Stepping outside of health to be healthy

Published in  Australian Medicine, 2 September 2014.

How should we respond to the Ebola virus threat?

We Australians live in an exceptionally safe country compared with many others today (and compared with our own in times gone by) when it comes to serious infectious diseases.

Our immunisation programs have succeeded brilliantly against whooping cough, polio and the other diseases of childhood.

The basics of public health -- clean water and waste disposal -- are secure in urban and much of rural Australia. Huge gains in life expectancy have followed.

We no longer need the rituals and beliefs to comfort us as did families in Victorian England when the death of children from infections was commonplace. We are not a society facing the loss of 16 million deaths of combatants and civilians as happened in World War I, followed by about 50 million more who lost their lives from the larger scourge of H1N1 influenza in 1918.

Being unaccustomed to catastrophe, especially those due to infections, it is understandable that we are shocked and frightened by the current outbreak of Ebola virus in West Africa.

Well, even if we aren't ourselves, then at least a friend of mine is. This man, a retired, successful and highly intelligent businessman living in the north-east of the US, recently cancelled his summer holiday in the south of France.

You can read about the fascinating history and virology of Ebola on Wikipedia. The virus was named after the river in the Democratic Republic of the Congo (then Zaire) where it was first isolated in 1976. The current outbreak in West Africa is the first recorded for that area.

On 8 August, the WHO declared the outbreak to be an international public health emergency.

As of 21 August, the WHO reported there had been 2473 cases of Ebola virus in places such as Guinea, Liberia, Nigeria, and Sierra Leone, and 1350 people had died from the disease.

Infectious agents can kill in epidemics by being highly lethal and highly contagious. Highly lethal infections that are not contagious do not create epidemics.

Viruses that spread by airborne droplets such as influenza are highly contagious, but many forms of flu are benign because their pathogenicity is low.

It is only when a strain of influenza that has high lethality and is highly contagious -- such as the H1N1 influenza that followed World War I -- is circulating abroad that serious flu epidemics occur.

In the case of Ebola, there is high lethality associated with human infection. About half of the reported cases see the patient die due to massive cytokine disruptions to the vascular tree. But bodily contact, or contact with bodily fluids, is necessary for infection.

The Ebola virus does not mutate rapidly -- it's 100 times slower than influenza A and about the same as hepatitis B. If we could develop a vaccine, it would not be quickly out-of-date.

So what should we, in Australia, do? First, we need to ensure our surveillance strategies are sound and in place, concentrating especially on plane arrivals of people from West Africa.

Second, we need quarantined treatment facilities available to effectively manage cases.

Two US medical attendants, Kent Brantly and Nancy Writebol, who were exposed to Ebola while treating patients in Liberia were repatriated by air on 2 August to a special facility at Emory Hospital in Atlanta, built with the Centers for Disease Control. The US is thus taking seriously the possibility of treating patients with Ebola on its shores. So should we.

Third, we should, as a nation, contribute what we can to the advancement of scientific understanding of this threat, with an eye on antiviral therapy and vaccine development.

Australia's response has been appropriate to date, but we still do not have a national centre for disease control.

The surveillance networks that we have are generally adequate, but relatively informal and for a nation of our wealth, aspiring to international leadership, 'adequate' is not the word that comes to mind as an expression of appropriate ambition or responsiveness.

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 in Australian Doctor 26 July 2014 http://bit.ly/ZEx5FW

WHY CO-PAYMENTS ARE NOT ALL GOOD

In celebrating the one-year survival of the Abbott government former prime minister John Howard was reported to have asked why, if we have co-payments on pharmaceuticals, we should not have one on general practice. Five reasons stand out.  

First, the co-pays on prescription drugs stop poorer people from accessing to them. Ask general practitioners. Extending co-pays to general practice compounds rather than solves this problem.  

Second, seeing a doctor for a health worry is different to filling a script. A consultation with a doctor may dissipate the worry without further cost or action.

Third, a timely, uninhibited consultation for the first symptom – chest pain, let’s say – of a serious problem may save a life and nip the progress of a disabling illness. Co-payments diminish easy access for less affluent Australians to general practice

Fourth, a consultation may lead to preventive changes – quitting smoking, behaviour modification, stopping unnecessary medications – that are positive investments, not sunk costs.  Co-pays that inhibit preventive consultations diminish the chance of a healthy life.

Fifth, many general practitioners in poorer parts of the country who entirely bulk-bill do not have the financial systems to raise fees.  The logistics of collecting and remitting a co-payment could drive them out of business.

Maybe the co-pays on pharmaceuticals are a public policy error that permits gouging of pharmaceutical prices and diminishes the search for efficiency in drug supply. Rather than asking where else we can impose a co-payment, the question should be, “We don’t have co-payments on general practitioner bulk-billed consultations, so why should we have them on prescribed pharmaceuticals?’

By way of postscript, the current debate about how much the Medicare levy contributes to health care costs is informed by figures from the federal minister that are all wrong.

ASSESSING VALUE BEFORE DEMOLISHING

In the current confusion in health that has followed from a swath of defunding, abolitions, co-payments and diminished Commonwealth funding, it is easy to lose sight of the needs of the individual patient. 

Typically and increasingly, the people who need our health care have a combination of problems such as diabetes and heart disease requiring concerted attention from hospitals, community nurses, general practitioners and community-based specialists. We do not have the firm evidence to say how best to do this, and hence in NSW the state minister for health, Jillian Skinner, has allocated $130m over 3 years to test out alternate ways of achieving this end.  Recently Medibank Private and other private insurers have expressed interest in testing strategies using community nurses to achieve the best alignment of care for our typical patient.

One of the casualties of the federal slashing has been what was called a Medicare Local, an organisation established by the previous government to create an environment of support for general practitioners and the long-term care of patients with chronic problems.  Their function was patchy, as expected from new entities, but where they worked they worked well. But the decision was taken recently to scrap all 61 and start again, with different, fewer entities called primary health networks.  Demolition and rebuilding is an expensive hobby.

In NSW, where we have 17 hospital districts or networks, there were 16 Medicare Locals.  While the match was imperfect, you get the drift.  In places such as western Sydney, fortune favoured us and the Medicare Local and the hospital district covered the same geographic area – from Mt Druitt to the Hills to Parramatta and Auburn.  Good things followed in coordinating care and hospitals and community practitioners learning to work together – for the good of the patient.

The document that evaluates the Medicare Locals concedes the value of a one-on-one relationship but envisions larger organisations combining the roles of smaller Medicare Locals.  What a pity. We know from past experience that the size of the NSW health districts is just about optimal – make them bigger and they are a managerial nightmare; make them smaller and you lose economy of scale.  Each has a degree of local identity and that identity is reflected in the Medicare Locals that serve the community especially when the overlap is complete.

If the federal minister wishes to experiment with how to meet the needs of the patient with chronic problems, why not leave NSW as it is and try out different models in other states such as Victoria that has no fewer than 90 hospital networks.  Or Queensland.  He has encouraged private insurers to experiment so why not his own ministry? 

Tearing up the crop before it has had a chance to bear fruit is expensive and wasteful.  Even more so with Medicare Locals.  Of course many of them can benefit from more energetic and focussed management, but there is no monopoly on that.  Let the plants grow.  We’ll find out soon enough whether the NSW model – one Medicare Local per hospital network – is the best way to go or whether we have been trumped by the Victorians again. 

Anyone seen general practice?

 Published in Australian Doctor 5 August 2014 Pages 22-23.  http://bit.ly/1ltc3nw



THE FUTURE OF MEDICARE AND MEDICARE LOCALS

The Conversation Conference

August 13^th 2014

Recently-announced proposed budget changes bear heavily on the future of Medicare and Medicare Locals (MLs).

 

The element in the budget that I wish to concentrate upon today is what’s happening with the 61 Medicare Locals.  I have been asked to address three questions:

• The argument for ML reform - what has and hasn’t worked and what changes are needed?
• Will the reform of MLs work or will abolition be the only answer? 
• What do we see internationally that could be applied within Australia to alleviate the problems with MLs?

The argument for reform of Medicare Locals

MLs have been reviewed both with regard to their function by John Horvath and specifically with regard to financial management by Deloitte.

As one might predict, the financial management of these entities was found to be immature and often below par. As well, much diversity of competence and performance was found in function among the MLs. General practitioners complained about being excluded from MLs.  Some feared that they will take over their work.

 

In any case the reviews proposed abolishing MLs and replacing them with Primary Health Networks – PHNs – that have rather similar functions.  Although the reviews proposed there should be fewer PHNs than MLs, it emphasised the value of having MLs and Local Health Districts – LHDs – or Local Hospital Networks – LHNs – relate closely to one another.  Contiguity was seen as a virtue.  How this will happen is not clear.  In NSW we have at present 17 MLs and 17 LHDs. As John Horvath observed in his review “to be effective, boundary alignment with Local Hospital Networks (LHNs) is critical for engagement” but of course this will not be possible at the PHN level unless there are more, not fewer, PHNs than there were MLs.

Perhaps to overcome the mismatch between PHN and LHNs, each PHN will have a board, informed by a Clinical Council and a Community Committee for each LHN.  These committees will oversee the functions that MLs provide at present though it is clear that PHNs will not have a service role other than exceptionally.  The Clinical Council is intended to give strong voice to general practitioners who reportedly have felt excluded from many MLs.

 A transition to PHNs may not involve much change providing they remain the same size as the MLs.  In Victoria where there are 90 or so LHNs, things are not clear. In any case funding to MLs will cease next year.  As John Horvath says in his report,  “The role of the PHN is to work with general practitioners, private specialists, LHNs/LHDs, private hospitals, aged care facilities, Indigenous health services, NGOs and other providers to establish clinical pathways of care that arise from the needs of patients (not organisations) that will necessarily cross over sectors to improve patient outcomes.”

 

The argument for a name change is quite acceptable.  ML is confusing.  The argument for abolition and then reconstruction rather than managing the process of development of laggard MLs and learning from the ones that are going well is less obvious.  There is no contestable policy visible, just a budget statement. 

What has worked?  In western Sydney the Western Sydney Local Health District (LHD) whose board I chair has worked with the ML on six projects and has another important one under way. The ML does not itself provide the service.  Rather, it coordinates and manages the players.

Indeed, the function that the ML has proved most useful in managing in partnership with the LHD is the increasing load of people with multiple serious and continuing illnesses has been to link their care between hospital and community.

Our district encompasses a population of nearly one million people, 40% of whom were born overseas.  We include Parramatta, Auburn, and Westmead, Blacktown and Mt Druitt and all places in between.  We have our share of older people and those living with economic disadvantage.  There are three major hospitals – Blacktown Mt Druitt – BMDH – Auburn and Westmead (WH), WH being the largest and BMDH being redeveloped to become a major tertiary centre.  Lots of hospital admissions are of people in crisis with their chronic illnesses.

With special sponsorship from NSW Health we are currently constructing integrated care programs for people with a chronic health problem – heart failure, chronic emphysema or diabetes.  We are doing this in partnership with our ML.  We are devising ways to centre care on the patient by brining into formal relationship general practice, community health services, hospital out-patient and community specialist acre and hospital inpatient services.

This is aided by limited use of electronic records.  It depends on good will and negotiation.  It also depends on formal affiliations between the ML and LHD because our sources of funding are different.

   

These projects do not account for all that the ML does.  For example it has also helped organise out of hours general practice services in western Sydney and has partnered several prevention programs. It is active as a provider of continuing education for general practitioners and those in training.  

Is abolition of the MLs essential?

There has been no recent suggestion to reform MLs, just abolish them.  Any restructuring in the health service comes at a huge cost and serious disruption and that should be factored into the argument for it.

 

I am not as familiar with all aspects of the performance of MLs as the review committees, but I am surprised that the proposal for abolition and then construction of a group of organisations of roughly the same function was not available for contest before it became an edict in the budget.  I personally don’t think that the function of the MLs warranted wholesale abolition. They were young and we had hardly a chance to establish them. That is my point of view.  I could be wrong, of course.

 

But the move to PHNs will be expensive and now we have private health insurers wishing to contract with the federal government to provide PHN services.  How this will serve public patients is unclear.  It is true that in the US managed care transacted by private insurers has often achieved good outcomes for integrated service delivery. But I cannot see how that could be provided in Australia with its divided financial arrangements between states and commonwealth, public and private patients.

So, to western Sydney.  Our district encompasses a population of nearly one million people, 40% of whom were born overseas.  We include Parramatta, Auburn, and Westmead, Blacktown and Mt Druitt and all places in between.  We have our share of older people and those living with economic disadvantage.  There are three major hospitals – BMD, Auburn and Westmead, WH being the largest and BMDH being redeveloped to become a major tertiary centre.  Lots of hospital admissions are of people in crisis with their chronic illness.  Before the ML there were active Divisions of General Practice.

With special sponsorship from NSW Health we are currently constructing integrated care programs for people with a chronic health problem – heart failure, chronic emphysema or diabetes.  We are doing this in partnership with our ML.  We are devising ways to centre care on the patient by brining into formal relationship general practice, community health services, hospital out-patient and community specialist 

acre and hospital inpatient services.

This is aided by limited use of electronic records.  It depends on good will and negotiation.  It also depends on formal affiliations between the ML and LHD because our sources of funding are different. The features of this relationship that have meant it is a success so far as it has developed that I can identify include: 

1.  Managerial commitment and compatible, mature personalities of the executives of both LHD and ML – both share a belief that collaboration is feasible and desirable and a common goal of contributing to the health of the district.    

2.  Overlapping geography.  This is important in preventing dual loyalties and administrative confusion.  There is no space for playing one master LHD or ML off against another.  Although successes have been achieved in some MLs where there are more than one per LHD, reports of conflicts and sub-optimal performance are common.  We lobbied hard to have the ML boundaries set to be the same as those of the LHD and have never regretted it. 

3.  A common foe – the rising tide of chronic illness. 

Has this arrangement been optimal? When it comes to integrated care the answer is no, because factors we know to be critical in the achievement of integrated care are missing. But whether this is ground enough for abolition – especially when the proposed replacement does not, it seems to me, promise more that would enable truly integrated care to be provided – is extremely thin.

International models of relevance to MLs and PHNs.

If we take the fundamental task of MLs or PHNs to be to integrate care for patients with chronic illnesses, then we should look at overseas models.  Where integrated care works to reduce inappropriate use of hospitals there is one payer as at Kaiser Permanente’s managed care for six million Californians, and many of the McKinsey-supported projects in the US and the UK. Complete electronic data systems are used to assess clinical performance and health outcomes, guidelines and a keen interest is expressed in professional standards for all practitioners, with rewards and sanctions for achievement or non-compliance. The Veterans Affairs services in Australia bear close scrutiny as a model in this regard.  Pull any of these pieces out of the integrated care structure and the whole thing collapses.  I know of no examples of successful 

integrated care that have been unmanaged.

We have none of these necessary arrangements.  These qualities of successful integrated care are not within the power of general practice or a ML or PHN to achieve whether embedded in a Commonwealth-funded arrangement or a private insurance set-up given the way Australia funds health care though separate silos.  The initiatives needed to change this belong with the major state and federal health bureaucracies.

 

It is true that growing interest has been expressed by private health insurers in the PHNs and where they might play a role.  For example, Medibank and the WA and Victorian governments have proposed a trial of intensive care coordination 3000 patients with complex and chronic health problems. 2000 of the patients would be covered by Medicare and 1000 would in addition be privately insured.  Community nurses would ensure all patients are seen by their general practitioner within seven days of hospital discharge.  The interventions proposed have elements found in most efforts to integrate care and are not dissimilar to those found partially in many MLs. It is not clear whether the proposals can extent to what is successful in Australia through the VA or in the US through managed care.

So we have the foundations through the LHD-ML liaison to provide more appropriate care for people with chronic illnesses but no superstructure.  To drive towards optimality requires a common funding stream, tighter management of the process and a set of quality performance goals that carry incentives and sanctions.

These features are recurrent in the successful models of integrated care with which McKinsey and Co, a consultancy, have established in the US, England and Europe.  They are similar to what the King’s Fund, a health service think tank, in London also articulate, though in the NHS integrated care has not worked as well as hoped.  Tough, but if you want it to work, observe what the ingredients are where it does work.

The way forward

Integrated care is a necessary revision to the current model of disjointed care because chronic illness is coming to dominate our health care agenda and this cannot be done with optimal success when components of care are disconnected.

 

In moving to PHNs to replace Medicare Locals we can expect a year or more of disruption due to transitions and it remains to be seen what management assistance will be provided to the agencies, presumably including private insurers and existing successful MLs and maybe even LHDs/LHNs that contest to provide the services of a PHN.

 

The positive thing is that the need for integration is clearly recognised as is the role of the general practitioner.  These are good omens.  I do not know what process the federal government proposes to use to implement its approach to PHNs – we can only wait and see.  This is not an era in our political history where policy – either its formation or action that might be based on it – is obvious or strong.  But we can hope that gains made by many fledgling MLs will not be lost.

 

A call to action in the July 26 edition of the Lancet is especially apposite.  “Primary care needs to be reshaped to truly function as the most important pillar for people-centred health and well-being in the 21^st century. Primary care leadership needs to wake up and start a revolution.”

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.