Is an annual GP fee the answer to paying for healthcare?

The uproar over the proposed $7 co-payment for bulk-billed general practice visits and pathology services raises questions about how we pay for healthcare more generally.

But serious discussion is urgently needed in regard to the billions that comprise the cake, rather than the thin icing of the new impost.

While I do it frequently, in my heart I know that there is little point in lamenting that Australia does not have a unified health financing system. It simply doesn't.

With the UK's NHS and managed care systems in the US such as Kaiser Permanente, the entire health budget is managed by a single health authority that can move money to where it is most effectively employed: hospital or community, prevention or care, private or public.

Instead, we in Australia have these compartments that each have their own lives to live, more or less independently. While that's not quite true, it is close enough.

Given the improbability of Australia shifting within the foreseeable future to a unified system of healthcare financing, we need to find small, doable things that achieve efficiencies (which, when defined properly mean effectiveness gains as well) where we can act.

A decade ago, I heard senior health service manager Dr Katherine McGrath, now consultant at KM Health Consulting Services, suggest that, given the rising tide of chronic illnesses that require continuing community-based care, it would be wise to consider a better way of funding services for these patients in general practice.

She suggested that an annual fee could be struck that would cover all the services provided by a GP.

Average fees are exactly that -- patients may require more or less service than the fee would cover but the end result should be even.

Of course, payment on this basis could be gamed, at least in theory, but there is hardly anything unique about that.

More positively, an annual fee might help those GPs who wish to develop and implement a preventive plan with their patients experiencing serious and continuing problems to do so.

Such a system could give more clinical freedom for the GP.

Dr McGrath made a second point: episodic, acute care is demonstrably well-managed within a fee-for-service system.

Occasional use of general practice would not need a system of payment based on repeated visits. Immunisation, common infections, even minor psychological upsets do not need continuing care.

"An annual fee might help those GPs who wish to develop and implement a preventive plan with their patients experiencing serious and continuing problems to do so."

The fee-for-service element of Medicare would remain unchanged.

This hybrid arrangement may be politically workable. A change to annual fee-for-service for chronically ill patients would need careful scrutiny to ensure that unforeseen side effects don't mean that it is more trouble than it is worth.

Such a proposal was advanced three years ago for the management of patients with diabetes in Australia and the results of pilot testing have not yet appeared.

The development of this method of payment would need careful handling and would be unlikely to succeed if imposed from above.

But it might enable the development of different ways of caring for these people, based more on their needs than now, with flexible arrangements about how they could be seen and when.

For example, a special channel for patients with chronic problems might be opened in a general practice where they simply turn up if they need help or reassurance.

It is possible that practice nurses and others could play an expanded role in their care. Recent US studies on the medical home -- a form of patient-centred general practice -- have been encouraging.

The debate about how much a patient pays at the time of receiving care vs how much they pay through their taxes when they are well will not solve our current set of healthcare financing challenges.

The current administration of Medicare is already dauntingly complex and the co-payment will add to that complexity.

We need to test new ways of paying for care in the community for patients with serious and continuing illness.

These forms of payment will serve patients and the profession best if they stimulate improved ways of providing care in continuity, new ways that come from imaginative thinking by the doctors who provide this care.

Their leadership is essential.

Professor Leeder is a member of the Menzies Centre for Health Policy at the University of Sydney, chair of the Western Sydney Local Health District Board and editor-in-chief of the Medical Journal of Australia.
 

Published Australian Doctor, 23 July 2014.

 

MJA CENTENARY – OPENING ADDRESS

Stephen R. Leeder

Editor-in-Chief

July 4^th 2014

The University of Sydney Great Hall

Welcome

This is a grand day and one to be savoured.  I am delighted to welcome you to the University of Sydney for this centenary celebration. I thank deputy vice-chancellor Professor Shane Houston for his warm and dignified welcome on behalf of the original custodians of this land, the Gadigal people of the Eora nation.

I also welcome Associate Professor Brian Owler, national president of the AMA, his predescessor Dr Steve Hambleton, Ms Anne Trimmer, secretary-general of the AMA and Ms Jae Redden, general manager of AMPCo. I also want to acknowledge  my editorial, journalist and production colleagues from the Journal and from MJAInSight, and our support staff in commercial development, human resources, finance, business development and information technology who work together to make the Journal a success.

I acknowledge members of our Editorial Advisory Committee who give us strong and careful guidance and to our many colleagues who send material to us, our reviewers and our commercial sponsors.  I also thank our splendid array of distinguished presenters.

I am immensely grateful to Dr Richard Smith, a former editor of the British Medical Journal who has demonstrated in his subsequent global health career that there really is life after being an editor, who comes as our master of ceremonies for today’s symposium and this evening’s dinner.  Richard will shortly describe to us the order of proceedings.

The organisation of today has involved a joint effort by many members of our MJA team, especially Zane Colling and Mel Livingstone. Denise Broeren of Think Business Events, Laissez-faire Catering and DJW Projects for AV also deserve great appreciation.  And finally I want to acknowledge and thank our sponsors who have been generous in their support.

Origins

I want first to speak briefly about our origins as a journal then mention several high impact papers that the Journal has published, then consider what one hundred years of Journal publication means beyond the effects of individual papers.  I will conclude with a glimpse of where I believe the Journal is headed.

When I was approached about the editorship of the Journal 18 months ago, Steve Hambleton, who was then national president of the AMA and chair of the board of the publishing company, talked with me about an event to mark the one hundredth birthday of the Journal. 

I have wondered whether in approaching me Steve had in mind that I was of an age where I had a natural empathy for older things. Indeed I can boast of having read and contributed to the MJA for half its one hundred years – admittedly the latter half – so it’s true that I know a bit about it.   

The Medical Journal of Australia emerged in 1914. We can thank Dr Cumpston, the father of public health in Australia, whose achievements are celebrated in a wonderful book by Milton Lewis, the editor of our centenary supplement, for providing a short history of the ten principal forerunners of the MJA between 1846 and 1914. These were attempts to foster communication among the medical profession in the colonies. The Australian Medical Journal, the MJA’s immediate forerunner, operated impressively from 1856 to 1914.

Cumpston notes that in the absence of a medical Journal, medicos had to resort to newspapers to publish their views. He refers to an article published 110 years before the first issue of the MJA in the October 14, 1804 edition of, The Sydney Gazette and New South Wales Advertiser Australia’s first newspaper.

The article was by one Dr Thomas Jamison and was the first on a medical subject published in the public press of Australia.  Dr Jamison had a lot to say about smallpox vaccination in Australia.  He admonished parents who mistook chickenpox for smallpox.  “There is no smallpox here”, he said, “save for few cases spread among the natives by French ships anchored in Botany Bay”.

But he warned that it could come and ‘carry off nine-tenths of those affected’. “Look at the Cape of Good Hope”, he said, “on the same latitude as Australia, where smallpox is rife.”  He urged parents to have their children vaccinated because “the preventive qualities of the Cow Pock are incontrovertibly established; [and] it is attended by no sort of danger or external blemish.”   

”Therefore,” he thundered, (quote) “should parents delay to embrace the salutary benefit now tendered gratuitously and the vaccine be lost, the most distressing reprehensibility may accrue to them for their remissness in the preservation of their offspring, whose destruction heretofore may be reasonably apprehended to ensue from the smallpox should it ever visit this colony in a natural state.” This is a style cultivated by relative few contributors to the MJA today.  Jamison’s letter is able to be viewed in the University of Sydney Fisher Library archives.

Editors

I stand before you, the 16^th regeneration not of Dr Who but of the editor of the Medical Journal of Australia. The first three Doctors occupied 63 years of editorship. and passed the torch to the 13 of us who have followed.  But the 13 who followed, rather like the Australian cricket team often is in India, have not lasted long save for Martyn Van Der Weyden, who was a wag in the tail of the team, so to speak, for 15 years.  My immediate predescessor Annette Katelaris was editor for eleven months. Her contribution was both controversial and transformative.

High-impact publications

How should we judge the effect of the Journal? The social media savvy amongst us will know that clout is measured by clicks. For example MJA.com.au averages 400,000 clicks per month and nearly 200,000 from clickers who click and stick to read.

But citations remain the royal currency in Journals. In our centenary issue of the MJA, Dr Diana McKay, one of our medical editors, used the Web of Science citation analysis tool to examine popularity of articles published in the MJA from 1949 to 2014 by citation.

Safety

First ranked is the 1995 Quality in Australian Health Care Study by Ross Wilson, Bill Runciman, Bob Gibberd, Bernie Towler and John Hamilton, a reprint of which you will find in your symposium satchel. I am delighted that Bill and John are with us today.  I have heard them both lecturing recently and twenty years has only improved their vintage. 

Their paper demonstrated the shocking potential and moral imperative to improve the quality and safety of hospital care. It prompted the Australian Government to form the Australian Commission on Safety and Quality in Health Care launched in 2006. The Commission’s recommendations were written into legislation with the National Health Reform Act 2011. The paper also ignited international interest with replications of the study internationally, including by the WHO in developing countries.

Ulcers

Ranked 2^nd and 3^rd are two papers by Barry Marshall, a Nobel Prize-winner, on pyloric Campylobacter.

In our Centenary issue, Barry Marshall reflects on his work in an article titled “What does H pylori taste like?” He describes “the deliberate self-administration of Helicobacter pylori and the observation that it caused an acute upper gastrointestinal illness with vomiting, halitosis and an underlying achlorhydria.” 

He remembers the audacity of my predecessor as editor, Alistair Brass, and being (quote) “impressed by how far the MJA Editor was ‘sticking his neck out’ in allowing me to publish a hypothesis as to the cause of peptic ulcer”. Both of them lauded and lamented the beating the paper took from reviewers to get it into its final published form.

Lithium

The next most popular paper is probably the most widely recognised, described once as a “jewel in the crown” of the MJA. Professor John Cade’s article “Lithium salts in the treatment of psychotic excitement”, published in 1949, held the Journal’s most-cited paper position for decades. To this day, lithium retains “its royal status in clinical practice guidelines”. Gin Mahli, a Sydney psychiatrist, writes. “Lithium is arguably the best agent for the most critical phase of bipolar disorder, long term prophylaxis and as such it is the only true mood stabiliser. Put bluntly, it works”

These papers and many more have had good and immediate effects.  Some take a while.  Recently I read a paper written 60 years ago on drink-driving.  The writer, Dr F S Hansman who had an interest in the biochemistry of alcohol, had asked doctor-colleagues at what level of alcohol consumption did they consider their driving to be impaired.  “After two whiskies or less”, 90% of them said.  Dr Hansman found that this corresponded to a blood alcohol of 0.04.  It took 23 years before random breath testings using a standard of 0.05 became law.

Going deep, beyond the published papers

Beside recording scientific advances for immediate or deferred application, the MJA serves another splendid function.  The one hundred years of the Journal comprise a superb record or memory of medical achievement and of the people who made it happen. 

Hilton Als, an American novelist, theatre critic and staff writer at The New Yorker, gave a commencement address at Columbia University in NYC on May 21 this year to the graduating class of the School of the Arts. Als called his address Ghosts in Sunlight. You will find it in the July 10 issue of the New York Review of Books. 

Als’ address takes its title from an essay by Truman Capote published when he was 43.  Capote’s essay, Als told the graduating students, describes Capote’s experience on the set of the first film adaptation of his 1966 best-seller In Cold Blood. This was a non-fiction novel about the 1959 murders of Herbert Clutter, a farmer from Holcomb, Kansas, his wife, and two of their four children and the murderers.  Some of you may have seen the recent version of the film.

Ghosts in sunlight

Capote found his encounter with actors who were developing and forcefully portraying real characters from his book – victims and murderers – deeply disturbing.  Capote described how he felt he was watching ‘ghosts in sunlight,’ as the characters he had written about had come back to life.  

I doubt that we will find anything quite as exciting as In Cold Blood when we thumb through the archives of the Journal, but we can easily become absorbed reading the stories of the science and clinical practice and health policy of past years and as the characters come back to life in our imagination.

It can be disconcerting to revisit those memories, to revive the ghosts in the sunlight of our moment.  It can be disconcerting to read reviews of the science of ailments such as obesity that have hardly changed in fifty years and of other conditions, such as heart attack, that have changed radically.  Stories of sepsis in the pre-antibiotic era are frightening.  Yet understanding what progress we have made or failed to make can change us, change our views, and stimulate our imagination.

I hesitate to answer questions from well-intentioned inquirers when they ask which papers in the Journal changed medical practice.  It is a perfectly proper question, and I have referred already to a list in the centenary issue of the Journal of the ten most cited papers. 

But above and beyond those papers with their tangible achievements and changes to how we do things, though, is the marvellous artistic process, the alchemy, by which the stories and memories and encounters contained in those hundreds of thousands of pages came about.  This is the story behind the story, if you will.

The hard work of science

Scientific achievement as recorded in the MJA is always hard won. I spent 1963 working with John Pollard on a neuroscience research project at this university in the pharmacology department as part of a BSc(Med). We were in search of the elusive transmitter substance between the optic nerve and the lateral geniculate body in cats.

We did not find it. Indeed when we presented our finding of a stimulant in extracts of sheep optic nerves that made smooth muscles twitch and which we could not characterise and wondered if this was the transmitter it didn’t work. 

When we presented our findings at a neuroscience conference, Sir John Eccles chaired our session and told the audience that a colleague had found a similar substance in extracts from his socks after a brisk game of tennis.

In returning to complete my medical degree I recall opening Cecil’s textbook of medicine and thinking “Every line in this book represents a research worker’s life.”  The ghosts were clear in the sunlight. 

In the commencement address I have been referring to, Hilton Als quotes Caribbean-born writer Jean Rhys who said that: “she considered her writing to be the tiniest stream. But without those streams, there would be no ocean, and if there is no ocean there is no shore, and if there is no shore there is no place for our ghosts to gather in the sunlight, those artistic forebears who wave us back to dry land when a project seems beyond us and we lose our way, which is at least half the time.”

Neils deGrasse Tyson,

an astrophysicist and science communicator at the Hayden Planetarium at the American Museum of Natural History in NYC, in his TV series Cosmos puts it another way: “Science is a cooperative enterprise, spanning the generations. It's the passing of a torch from teacher, to student, to teacher; a community of minds reaching back to antiquity and forward to the stars.” It is the background culture and society of medicine and medical research that you will find in the MJA that can be as informative and stimulating as individual papers and articles.

Lessons from the ghosts

The ghosts of the practitioners and scientists can change us, too, even now, even when we know that past proposals were often wrong, that many of the lines of inquiry led nowhere really.  They can help us toward humility; they can help us see how we, too, like the authors of the pages that we turn, are creatures of our time. 

They can make us tolerant of the false starts, of the well intentioned failures, even of the pomposity of our colleagues.  (‘What’s good for doctors’, opined the first editorial in the MJA, ‘is good for the community!’ Ahem!)  Ghosts can also frighten us: Capote writes about having to take a bottle of scotch to bed to obliterate the ghosts of the characters of his book from his consciousness.

When all of the issues from 1914 the MJA are digitised, as we plan them to be when we have raised the $70K for that purpose (hint, hint), exploration of the past and encounters with its ghosts in the sunlight will be a possibility for all, anytime, anywhere. 

Glimpsing the future

Today we celebrate a unique record of medical memory in Australia that stretches back 100 years.  This can be a day to renew our quest for sounder medicine, for safer and better patient care, for new insights into preventive possibilities and indeed to recognise and manage our own humanity and frailty and proneness to error with gentle acceptance.  The ghostly values can warm and correct us and set our hearts racing.

The MJA has a bright future if we maintain our deep respect for science, for imagination and humane concern for our patients, the profession, and society and indeed for everyone in the organisation that contributes to the Journal.  As we look to possible futures of the Medical Journal of Australia, we need to be open to the unbidden, the unplanned, and the serendipitous that is never completely captured in a strategic plan. 

We are in the middle of the most exciting explosion of knowledge in human history, with multiple media to communicate and sift it. These dynamics will affect the form and style of the Journal and even its ethics. The format of the Journal will need to become more attuned to contemporary ways of communicating, the content more flexibly responsive to the needs of our diverse readership through electronic tailoring and streaming of content to them where and when they need it.  Already we have a substantial presence in the social media and this will grow.

To remain a trusted instrument of record, where contemporary medical knowledge and reflection is written carefully and history is recorded, that will require all our skill and imagination about new and efficient ways of communicating through multiple media. 

That is what we at the Journal are committed to doing and we thank all of you for your continuing support as we move into our next century.