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How can Australia improve
its primary health care
system to better deal with
chronic disease?
Background paper
This background paper has been prepared by McKinsey & Company. The paper is a not an
exhaustive literature review but rather a brief overview of a large subject area. It is neither a
comprehensive overview of all primary health care activities in Australia, nor a complete review of
all potential alternatives adopted internationally. It does not attempt to evaluate or compare
international approaches, nor does it recommend or endorse particular approaches for
implementation in Australia. Instead, it focuses on summarising alternative approaches and
providing international examples in order to provoke and inform discussions around the future of
primary health care in Australia.
i
Contents
Executive summary
1
Acronyms and glossary of terms
5
Definitions
9
Introduction
10
Chapter 1: The history of Australia’s primary health care system
12
1.1 Prior to 1984
12
1.2 Since 1984
12
Chapter 2: Opportunities to improve care for people with chronic disease
15
2.1 Quality of care
17
2.2 Consumer experience
19
2.3 Access to care
20
2.4 Cost and sustainability
23
Chapter 3: The dimensions of primary health care
28
Chapter 4: Primary health care governance and financing
31
4.1 Governance structure
31
4.2 Funding source(s)
37
4.3 Funding mechanism(s)
41
Chapter 5: Primary health care consumer interaction with the health system
48
5.1 Consumer segmentation
48
5.2 Medical homes and enrolment
54
5.3 Education and self-management
56
Chapter 6: Primary health care professionals
61
6.1 Clinical leadership
61
6.2 Workforce composition and roles
67
ii
6.3 Provision of care coordination
Chapter 7: Primary health care systems and processes
72
78
7.1 Digital health
78
7.2 Information transparency
84
7.3 Continuous quality improvement processes
88
7.4 Care pathways
91
Conclusion
93
Bibliography
94
iii
Executive summary
This background paper has two purposes: (1) to provide an overview of Australia’s primary health care
system, with a particular focus on people with chronic and complex diseases; and (2) to survey
potential alternatives to the current system that have been adopted internationally. It is important to
note that this background paper is neither a comprehensive overview of all primary health care
activities in Australia, nor a complete review of all potential alternatives adopted internationally. It
does not attempt to evaluate or compare international approaches, nor does it recommend particular
approaches for implementation in Australia. Instead, it focuses on summarising alternative approaches
and providing international examples in order to provoke and inform discussions around the future of
primary health care in Australia.
The primary health care system is typically a consumer’s main source of contact with health
professionals. It has four main purposes: (1) to coordinate care between different providers and
different parts of the health care system; (2) to provide the right care at the right time, ensuring
population health; (3) to provide cost-effective, community-based care, and in doing so minimise
hospital-based care; and (4) to act as a gateway to other services in order to ensure that they are only
provided when needed.1–3
Overall, Australia achieves excellent health outcomes, but in the coming decades, the primary health
care system will have to respond to the growing burden of chronic disease, which already accounts for
over 90 per cent of all deaths and is the leading cause of illness and disability in Australia.4
Opportunities exist to:
■
Improve the quality of care delivered to people with chronic diseases in order to
reduce clinical variation, improve people’s quality of life and reduce avoidable hospitalisations.
■
Improve consumers’ experience of primary health care, particularly with respect to
the coordination of team-based care and self-management.
■
Improve access to primary health care, especially out of hours and in rural and remote
areas.
■
Reduce the rate of health care expenditure (which is currently growing faster than the
national economy) to ensure that the system is economically sustainable.
Realising these opportunities requires changes in four areas of the primary health care system:
governance and financing, consumer interaction with the health system, the primary health care
workforce, and care systems and processes. Australia can be aided in this process by drawing on, and
learning from, the experiences of others in the international community, whose varied approaches can
inform discussions about the future of primary health care in Australia.
1
Primary health care governance and financing
■
Governance structure: Responsibility for primary and secondary care is assumed at both
the national and the regional level in Australia. This can result in cost shifting and makes it
difficult to identify and support the cross-sector needs of regional populations, particularly
those with chronic and complex conditions. To overcome similar issues, health systems around
the world are looking for ways to integrate primary and secondary care more closely, including
through combined governance structures (particularly at the local level) or pooled funding
arrangements.
■
Funding sources: The majority of primary health care in Australia is funded through
Medicare and patient contributions. Commonwealth and state governments provide additional
funding to support community health services. Private health insurers play an important role
in helping consumers meet some of the costs of services not funded through these mechanisms.
■
Funding mechanisms: More than 90 per cent of primary health care funding in Australia is
paid on a fee-for-service basis, with less than 10 per cent linked to quality of care (e.g. the
Practice Incentives Program). This system incentivises greater levels of service provision and
should, in theory, improve access. However, it does not incentivise population health outcomes
or value for money, and may encourage supply-driven demand. Other countries in the
Organisation of Economic Co-operation and Development (OECD)—including New Zealand,
Norway, the Netherlands, the United States, Italy, Sweden, France and the United Kingdom—
are opting for a blend of fee-for-service payments, payment for outcomes and capitation. While
meta-analyses of the different funding approaches are inconclusive, there are numerous
examples around the world where innovative funding models have contributed to improved
outcomes and consumer experience.
Consumer interaction with the health system
■
Consumer segmentation: Five per cent of people in Australia account for 28 per cent of
costs,5 and identifying these people ahead of time could facilitate earlier intervention, leading
to both improved outcomes and reduced costs. There are numerous examples of successful
systems that segment consumers based on need, either by enrolling the most high-risk
individuals in specific disease management programs (e.g., Torbay in the United Kingdom and
the Hospital Admissions Risk Program in Australia), or by comprehensively segmenting their
entire population and tailoring care for each group (e.g., Kaiser Permanente or the Care First
Patient-Centered Medical Home program in the United States).
■
Medical homes and enrolment: Consumers do not formally enrol with practices or
primary health care providers in Australia, and while most people do return to the same
general practice over time, there is no formal concept of a ‘health care home.’ Although the
current system offers a number of advantages, including simplicity and consumer choice,
medical homes may be an attractive option as they establish a non-binding agreement
2
(enrolment) between patients and health care providers to progress shared health goals. For
this reason, several other countries (including New Zealand, the United Kingdom, the United
States, Norway and the Netherlands) have adopted some form of enrolment scheme, often as
part of a wider suite of health reforms.
■
Primary health care education and self-management: Australia already has a variety of
programs to help people with chronic diseases learn about their conditions and manage their
own care. However, there are three areas in which Australia’s efforts could be expanded: (1) the
support and coaching provided by health professionals could be improved; (2) peer support
programs could be made more widely available; and (3) technology-enabled programs could be
improved in order to take advantage of effective, low-cost opportunities to engage people in
their own health care.
Primary health care professionals
■
Clinical leadership: Clinical leadership plays an important role in improving the
effectiveness and efficiency of health systems. Research in the United Kingdom and the United
States has demonstrated a strong relationship between the number of managers with a clinical
background and organisational performance. Australia can learn from the variety of
approaches to on-the-job leadership development implemented internationally.
■
Workforce composition and roles: Around the world, systems are looking for ways to
support people working ‘to the top of their licence’. Shifting responsibility for specific tasks to
health professionals who are appropriately trained to provide these services can free up
clinicians to focus on their principle role.
■
The provision of care coordination: In Australia, GPs or practice nurses usually perform
care coordination. One alternative approach is to appoint specialised care coordinators,
particularly for people with complex chronic conditions who require care from multiple
providers. Most of the patient-centred medical homes in the United States and a number of
integrated care systems in the United Kingdom have employed care coordinators to good effect,
as have a growing number of programs in Australia. These include the Diabetes Care Project,
the Connecting Care in the Community program in New South Wales, the Team Care
Coordination program in Brisbane Metro North, the Tasmanian Care Coordination for People
with Chronic Disease and Aged Care Clients Program, and Silver Chain in Western Australia.
Systems and processes
■
Digital health: Australia is building its digital health infrastructure through systems such as
the personally controlled electronic health record (recently renamed ‘My Health Record’) and
funding for telehealth consultations. It can continue to build its digital health capabilities by
expanding telehealth and mobile health, integrating remote monitoring devices into primary
3
health care, expanding integrated electronic medical records (EMRs) and providing decision
support through advanced clinical assistance tools.
■
Information transparency: Providing consumers or providers with transparency on clinical
performance and cost can improve the accuracy and quality of data and drive better service and
health care quality. However, despite ongoing advocacy for greater performance transparency
from organisations such as the Australian Commission on Safety and Quality in Health Care,
this has been difficult to achieve in Australia. There is almost no publicly available data about
primary health care clinical performance. Australia can learn a lot from other countries,
particularly the United Kingdom and the United States, both of which have been working
towards greater information transparency for a number of years.
■
Continuous quality improvement (CQI) processes. Australia has not implemented a
national CQI process in primary health care. There are a variety of CQI systems in Australia
(e.g., the Australian Primary Care Collaboratives and the Diabetes Care Project) and around the
world (in both private and public health systems) that could be further examined.
■
Care pathways: Although Australia has a multitude of general clinical guidelines, localised
care pathways are not universally available. The main alternative for Australia is to create
locally standardised care pathways for common chronic diseases, potentially enabled through
online decision-support tools that automate decision making on referrals and care planning. A
good example is Canterbury Care’s HealthPathways system in New Zealand, which now
includes more than 500 different pathways and has contributed to reducing acute and elective
hospital admission length of stays.
□ □ □
While Australia has a strong primary care system and achieves a number of excellent health outcomes,
significant challenges remain: chronic diseases are increasingly prevalent, health care costs are
growing faster than the national economy, and the best possible care is not always delivered. Australia
has an opportunity to find innovative solutions to these challenges, and in doing so, to meet the
emerging health care demands of the 21st century. It can be aided in this process by drawing on the
varied approaches adopted within the international community, all of which can inform discussions
about the future of primary care in Australia.
4
Acronyms and glossary of terms
Acronym
Definition
ABS
Australian Bureau of Statistics
ACI
Agency for Clinical Innovation
ACAT
Aged Care Assessment Team
ACO
Accountable care organisation
ACSQHC
Australian Commission on Safety and Quality in Health Care
AHP
Allied health professional
AMA
Australian Medical Association
AMSA
American Medical Student Association
ANAO
Australian National Audit Office
APCC
Australian Primary Care Collaboratives
APHCRI
Australian Primary Health Care Research Institute
CCG
Clinical commissioning groups
CDM
Chronic disease management
CLP
Clinical leadership programs
CMS
Centres for Medicaid and Medicare Services
CPM
Combined predictive model
CPOE
Clinical Point of Entry
CQI
Continuous quality improvement
CROM
Clinical reported outcome measurements
CVC
Coordinated Veterans’ Care
DAFNE
Dose Adjustment for Normal Eating program
DALYs
Disability adjusted life years
DCMS
Diabetes care management system
DCP
Diabetes Care Project
5
DGPs
Divisions of General Practice
DHBs
District health boards
DMPs
Disease management programs
DPM
Devon Predictive Model
DSM
Diabetes self management
DVA
Department of Veterans’ Affairs
ED
Emergency department
eLfH
Department of Health’s eLearning for Healthcare
EMR
Electronic medical records
EPC
Enhanced Primary Care
FFS
Fee for service
GDP
Gross domestic product
GHP
Geisinger Health
GP
General practitioner
HSCIC
Health and Social Care Information Centre
HWA
Health Workforce Australia
INWMML
Inner North West Melbourne Medicare Local
IT
Information technology
KP
Kaiser Permanente
LHD
Local health district
LHN
Local hospital network
MBS
Medicare Benefits Schedule
MLCF
Medical Leadership Competency Framework
MOU
Memoranda of understanding
NCQA
National Committee for Quality Assurance
NEHTA
National eHealth Transition Authority
NGO
Non-governmental organisation
6
NHIA
National Health Information Agreement
NHIF
National Health Insurance Fund
NHMRC
National Health and Medical Research Council
NHS
National Health Service
NMBA
Nursing and Midwifery Board of Australia
NPs
Nursing practitioners
NSW
New South Wales
PA
Physician assistants
PCEHR
Personally controlled electronic health record
PCMH
Patient-centred medical home
PCPHC
Primary Care Population Health Committee
PCTs
Primary care trusts
PFP
Physician Feedback Program
PHC
Primary health care
PHN
Primary Health Networks
PHOs
Primary health organisations
PIP
Practice Incentives Program
PLM
patientslikeme
PMEG
Peninsula Model Executive Group
PNIP
Practice Nurse Incentive Program
PPH
Potentially preventable hospitalisation
PREM
Patient reported experience measurements
PROM
Patient reported outcome measurements
QISP
Quality improvement support payments
QOF
Quality and Outcomes Framework
QPIs
Quality performance indicators
RACGP
Royal Australian College of General Practitioners
7
SIPs
Service Incentive Payments
SMOOTH
Safer medicines outcomes on transfer home
UHI
Unique Health Identifier
UQ
University of Queensland
WHO
World Health Organization
8
Definitions
This background document has adopted the following definitions.
Consumer: “Consumers are members of the public who use, or are potential users of healthcare
services. When referring to consumers, the Commission is referring to patients, consumers, families,
carers, and other support people” (Australian Commission on Safety and Quality in Health Care).6 This
document acknowledges the ongoing international debate about the term ‘health care consumers.’7
Primary health care: “Primary (health) care is first-contact, accessible, continued, comprehensive
and coordinated care. First-contact care is accessible at the time of need; ongoing care focuses on the
long-term health of a person rather than the short duration of the disease; comprehensive care is a
range of services appropriate to the common problems in the respective population and coordination is
the role by which primary care acts to coordinate other specialists that the patient may need” (World
Health Organization).2,8 This document acknowledges the difference between primary health care and
primary care and has adopted this comprehensive World Health Organization (WHO) definition of
primary health care.
Secondary care: “Secondary care is medical care provided by a specialist or facility upon referral by a
primary care physician. It includes services provided by hospitals and specialist medical practices”
(Australian Institute of Health and Welfare).4
Practice nurse: “Primary health care nurses work in a range of settings, each sharing the
characteristic that they are a part of the first level of contact with the health system. In Australia, those
settings can include community settings, general practice, domiciliary settings, educational settings,
occupational settings, informal and unstructured settings. Roles of the practice nurse include health
promotion, illness prevention, midwifery, antenatal and postnatal care, treatment and care of sick
people, rehabilitation and palliation, community development, population and public health,
education and research, and policy development and advocacy” (Australian Primary Health Care
Nurses Association).9
Nurse practitioner: “A nurse practitioner is a registered nurse educated to function autonomously
and collaboratively in an advanced and extended clinical role. The role includes assessment and
management of clients using nursing knowledge and skills and may include but is not limited to the
direct referral of patients to other health care professionals, prescribing medications and ordering
diagnostic investigations” (Australian Nursing and Midwifery Accreditation Council).10
Allied health: Allied health professionals “are autonomous practitioners; practice in an evidence
based paradigm using an internationally recognised body of knowledge to protect, restore and
maintain optimal physical, sensory, psychological, cognitive, social and cultural function; and may
utilise or supervise assistants, technicians and support workers” (Allied Health Professions Australia).11
9
Introduction
This background paper is intended to function as a supporting document for the Primary Health
Care Advisory Group’s discussion paper and has been authored by McKinsey & Company. It is
important to note that this background paper is not an exhaustive literature review but rather a brief
overview of a large subject area. It is neither a comprehensive overview of all primary health care
activities in Australia, nor a complete review of all potential alternatives adopted internationally. It
does not attempt to evaluate or compare international approaches, nor does it recommend particular
approaches for implementation in Australia. Instead, it focuses on summarising alternative
approaches and providing international examples in order to provoke and inform discussions
around the future of primary health care in Australia.
Primary health care is delivered in the community and is typically a consumer’s first and main source
of contact with their health care system. It has four main purposes:1–3
■
Coordinating care: Providing consumers with a central point of contact, which can
coordinate care from different providers and parts of the system.
■
Delivering the right care at the right time: Maximising overall health care system value
by providing evidence-based care at the right time, ensuring population health.
■
Delivering cost-effective care: Maximising overall health care system value by providing
low-cost care, with the intention of minimising more expensive, hospital-based care.
■
Gatekeeping: Acting as a gateway to other services in order to ensure that they are only
provided when needed.
Primary health care provides the foundations of the Australian health care system. There are more
than 26,000 general practitioners (GPs), 10,000 practice nurses and thousands of allied health
professionals who provide the first touch point for consumers.4,12,13 More than 80 per cent of
Australians visit a GP at least once within a 12-month period.14 In 2013–14, 133 million general
practice services were claimed through Medicare.15 In most health systems, primary health care
physicians control or influence around 80 per cent of health care costs.16 For example, although unreferred medical services account for only $10 billion of total health expenditure (7 per cent) in
Australia, GPs heavily influence pharmaceutical use (which accounts for 13 per cent of total
expenditure) and referred medical services (which account for 10 per cent of total expenditure). They
also play a role in minimising hospital services (which account for 38 per cent of total expenditure).17
In the United States, there is evidence that overall health is better in regions with more primary
health care physicians, and in regions where primary health care functions well.3 (In contrast, overall
health is worse where specialists predominate.18) In the United Kingdom, having one additional
primary health care physician per 10,000 population was associated with a 6 per cent decrease in
mortality.19
10
Managing the growing burden of chronic disease remains the biggest challenge for Australian primary
health care. Studies show that between 35 and 50 per cent of people in Australia have at least one
chronic disease.4,20 Just four chronic diseases account for 36 per cent of all health expenditure in
Australia.4 This paper therefore focuses on primary health care for people with chronic and complex
conditions. The paper has two purposes: (1) to provide an overview of Australia’s primary health care
system, and (2) to survey potential alternative approaches that have been adopted internationally. It
does not attempt to evaluate or compare these alternative approaches, and it does not provide any
recommendations about which alternatives should be considered for implementation in Australia.
This background paper is divided into seven chapters. Chapters 1 and 2 are designed to give the reader
high-level background information about Australia’s primary health care system, compared with its
peers in the Organisation of Economic Co-operation and Development (OECD). Chapter 3 outlines a
primary health care framework by describing the four dimensions of primary health care systems.
These dimensions form the basis for Chapters 4 to 7, which provide a more detailed overview of the
current system in Australia, as well as alternative approaches across the globe.
■
Chapter 1. The history of Australia’s primary health care system: An overview of the
Australian system and the policies and reforms that have shaped it.
■
Chapter 2. Australia’s primary health care outcomes and opportunities to
improve: How Australia compares across the four aims of primary health care (quality,
experience, access and cost), with a focus on specific opportunities to improve.
■
Chapter 3. The dimensions of primary health care: An overview of a framework that
describes primary health care systems and their structural alternatives.
■
Chapter 4. Primary health care governance and financing: An overview of the current
system in Australia and alternative approaches.
■
Chapter 5. Primary health care consumer interaction with the health system: An
overview of the current system in Australia and alternative approaches.
■
Chapter 6. Primary health care professionals: An overview of the current system in
Australia and alternative approaches.
■
Chapter 7. Primary health care systems and processes: An overview of the current
system in Australia and alternative approaches.
11
Chapter 1: The history of Australia’s primary health
care system
Despite multiple reforms over the past century, Australia’s primary health care system has retained
two core features: GPs as the central provider, and fee-for-service (FFS) payments as the dominant
funding mechanism. There have, however, been a number of important structural changes, including:
■
A shift from consumer self-funding to predominantly Federal Government funding.
■
An expanded role for professionals other than GPs, including allied health professionals
(AHPs).
■
Tighter regulation of training and registration standards for practitioners.
■
The emergence of local primary health care networks, with a trend towards a smaller number
of authorities covering a larger portion of the community.
■
The introduction of information technology (IT) and the beginnings of national eHealth
systems and standards.
1.1 PRIOR TO 1984
At the time of federation, primary health care was considered to be primarily the responsibility of
individuals, followed by state and local governments. In 1921, however, a federal Department of Health
was established, and in 1946, a referendum on social services paved the way for the Federal
Government to become increasingly involved in all parts of the health care system. A national health
insurance scheme with voluntary participation was introduced in 1950, and in 1975 universal
insurance was introduced (known as Medibank), which lasted until 1981.21 The organisation that would
later become known as the Royal Australian College of General Practitioners (RACGP) was established
in 1958, in the midst of these changes to the primary health care system.22 In 1968, a postgraduate
examination for GPs was introduced, followed by the introduction of a formal vocational training
program in 1973.23
1.2 SINCE 1984
Medicare came into being in 1984, and Australians have had universal access to subsidised or free
primary health care services ever since. In 1985, the Better Health Commission was formed to redirect
health policy to focus on prevention rather than illness.21 Since then, reforms to Australia’s primary
health care system have focused on three areas:
12
■
Funding: Various systems of consumer co-payment for primary health care services have
been introduced and then abandoned, most notably in 1991–92,24 and more recently in 2014–
15. Payment for performance in primary health care first appeared in a substantial way in 1999
in the form of the Practice Incentives Program (PIP).24 Funding specifically targeted at caring
for people with chronic and complex diseases was first introduced in 1999–2000 in the form of
Enhanced Primary Care (EPC) items in the Medicare Benefits Schedule (MBS), which later
evolved into Chronic Disease Management (CDM) items.24 Care planning and team care
arrangements are central to this funding.
■
Registration and training: Vocational registration for GPs was introduced in 1989 and
became compulsory in 1996.24 This was soon followed by the introduction of practice
accreditation standards in 1998, which became a requirement for receiving PIP payments in
2001.23 Practice accreditation remains voluntary.
■
Administration: The first formal primary health care system established Divisions of
General Practice (DGPs), which were introduced in 1992.24 By 2007–08, there were 110
DGPs.25 The DGPs were succeeded by Medicare Locals in 2010,24 61 of which existed by 2014.26
A transition from Medicare Locals to 31 Primary Health Networks (PHNs) is currently
underway.27 The PHNs will have wider mandates than the Medicare Locals, with six priorities
for targeted work: mental health, Aboriginal and Torres Strait Islander health, population
health, health workforce, eHealth and aged care.
While the Australian health care system has undergone important changes in recent decades, it will
need to continue evolving in order to keep up with changing burdens of disease, emerging
technology, changes in the health care workforce and innovations in medical practice. The following
chapter describes some of these changes and outlines opportunities for the system to better meet the
needs of people with chronic and complex conditions.
13
FIGURE 1.1
22,24,28–30
Australia has tried several measures to improve primary care
Medicare
introduced
(replacing
Medibank), bulkbilling restored,
and Medicare
Levy introduced
Co-payment
introduced
and then
abolished
after three
months
Establishment
of the
Australian
Divisions
of General
Practice
(ADGP)
1991-92
1984
Doctors
required to
have full
vocational
training prior
to entering
general
practice
1992 1996
Introduction of
Divisions of
General
Practice
(DGPs)
▪ Enhanced
▪
Primary Care
(EPC) MBS
items introduced
30% private
health insurance
rebate introduced
Chronic Disease
Management
(CDM) items
were introduced
to replace the
existing EPC care
planning items
19992000
2004-05
1997
1999
The Practice Incentives
Program (PIP) and
General Practice
Immunisation Incentives
Scheme replaced the
Better Practice Program
following
recommendations by
the General Practice
Strategy Review Group
2004
Australian
Primary Care
Collaboratives
(APCC)
Program
Phase I
2007
Medicare
Locals
established
Primary
Health
Networks
established
2010
2008-09
Introduction of
Broader
Health Cover,
giving private
health insurers
greater ability
to cover
services
2015
Funding for 36
GP
SuperClinics
14
Chapter 2: Opportunities to improve care for people
with chronic disease
Overall, Australia achieves excellent health outcomes. Across the OECD, for example, Australia has the
second highest life expectancy (83 years) and the fourth highest self-reported health score (85 per
cent) (Figure 2.1).31 Australia’s primary health care system also performs well in terms of disability
adjusted life years (DALYs) attributed to causes that can be addressed through primary health care.
Tobacco smoking, alcohol use, high-fasting plasma glucose, high total cholesterol, high blood pressure,
high body mass index, low bone mineral density, dietary risks and physical inactivity together account
for 0.11 disability adjusted life years per person in Australia—one of the lowest ‘primary health carepreventable burdens’ in the OECD (Figure 2.1). It must be noted, however, that health outcomes (and
medical access) among Aboriginal and Torres Strait Islander populations are disproportionately worse
than outcomes among non-Indigenous populations.
FIGURE 2.132–34
In 2012–13, for example, Indigenous people aged 15 years and over were 0.6 times as likely as nonIndigenous people to report “excellent” or “very good” health. Indigenous Australians were also 1.9
times more likely to have asthma, 1.2 times more likely to have heart and respiratory diseases, and 3.3
15
times more likely to have diabetes than non-Indigenous Australians.35 Life expectancy is also more
than 10 years lower for Indigenous Australians than non-Indigenous Australians.36
In the coming decades, the primary health care system will have to respond to the increasing burden of
chronic disease, which already accounts for over 90 per cent of all deaths and is the leading cause of
illness and disability in Australia.4 Today, more than 80 per cent of Australians are estimated to have
at least one chronic condition or risk factor,15 with hypertension identified as most common (affecting
26.3 per cent of Australians) (Figure 2.2). Australia has the highest prevalence of chronic disease
among OECD countries—followed closely by Hungary (70 per cent) and New Zealand (65 per cent)37—
and just four chronic diseases account for 36 per cent of all health expenditure in Australia:
cardiovascular diseases, oral health, mental disorders and musculoskeletal issues.21 The burden of
chronic disease is expected to increase in the coming years, driven by both an ageing population and an
increase in risk factors such as obesity and physical inactivity.38,39 In 2012, for example, the OECD
reported that Australia had an obesity rate of 28 per cent—the fifth highest rate of obesity out of 34
surveyed countries. (The United States, Mexico and New Zealand reported higher levels of 30 to 35 per
cent, and the OECD average was 18 per cent.40)
As the prevalence of chronic disease increases, Australia’s health care system will need to evolve to
meet growing population health needs and address rising health care costs, ensuring evidence-based
care is provided at the right time and in the right place. Opportunities exist to:
■
Improve the quality of care delivered to people with chronic disease.
■
Improve consumers’ experience of primary health care, particularly with respect to care
coordination and self-management.
■
Improve access to primary health care, especially out of hours and in rural and remote areas.
■
Ensure that the system remains economically sustainable by reducing the rate at which health
care costs are growing.
The remainder of this chapter discusses these opportunities in more detail.
16
FIGURE 2.2
15
2.1 QUALITY OF CARE
When compared with its OECD peers, Australia performs well in terms of life expectancy, overall
health and the burden of disease that can be prevented through primary health care (Figure 2.1).
However, there are three areas in which Australia could improve the quality of care it offers people
with chronic disease:
■
Monitor quality: At present, Australia has no systematic way of comparing quality across
primary health care clinicians, which makes it difficult to assess the quality of care received by
people with chronic diseases. Other countries have been much more proactive in this area. The
United Kingdom, for example, introduced comprehensive practice-level monitoring as part of
its Quality and Outcomes Framework (QOF),41 and in 2010, the Affordable Care Act introduced
public reporting of performance measures on quality and cost in the United States.42 While the
Australian Commission on Safety and Quality in Health Care (ACSQHC) has outlined practicelevel indicators for the safety and quality of primary health care, these have not been ratified
and they are not actively monitored or incentivised.43 For effective clinical governance, data
need to be collected more effectively at the practice level through the participation of clinicians.
■
Adhere to clinical guidelines: In 2012, the Care Track study highlighted that clinical
guidelines are often not followed in Australia, particularly for people with chronic health
conditions.44 For example, clinical guidelines were only followed for 63 per cent of people with
17
diabetes, and 38 per cent of people with asthma.44 Similarly, a recent study of over 7,000
people with diabetes in Australia found that 51 per cent of people with out-of-range cholesterol
were not taking hypolipidaemic medication, 53 per cent of people with out-of-range systolic
blood pressure were not prescribed anti-hypertensive medication, and only 35 per cent of
people had the components of an annual cycle of care recorded in their notes.5 The Diabetes
Care Project (DCP) also found that only 35 per cent of consumers participating in the project
had completed an annual cycle of care at baseline.5 Australia’s immunisation rates, which are
low relative to its OECD peers, similarly demonstrate that adherence to clinical guidelines
could be improved (Figure 2.3).
■
Reduce medication errors: A systematic review of Australian evidence demonstrated that
care is negatively affected by poor information sharing, and that some people suffer from
adverse drug events as a result.39 Indeed, 2 to 4 per cent of all hospital admissions were found
to be medication-related hospitalisations (i.e., caused by medications that should not have been
administered in combination), and this figure rose to 30 per cent among people over the age of
75. Three quarters of these medication-related hospital admissions were found to be potentially
preventable.39 In 2010, according to the Australian Bureau of Statistics (ABS), more than 5 per
cent of people aged 15 years and over reported receiving medication, medical care, treatment or
a test that caused harm or a harmful side effect at some point during the previous year.45
FIGURE 2.331
18
2.2 CONSUMER EXPERIENCE
Australians are generally happy with the primary health care they receive.46 According to the latest ABS
survey results, 72 per cent of people who saw a GP in the past 12 months reported that the GP always
listened carefully to them, 78 per cent reported that the GP always showed them respect, and 72 per
cent reported that the GP always spent enough time with them.47 Australians also have a high selfreported health score of 85.4 per cent, which places Australia fourth amongst all 34 OECD peers on
this measure.31
There are, however, three opportunities for improvement:
■
Engage more effectively with people with chronic conditions: According to
Commonwealth Fund survey results, Australia ranks fifth behind the United Kingdom,
Switzerland, the United States and Canada on consumer engagement. (Only 48 per cent of
people with long-term cases felt engaged in Australia, compared with 69 per cent of people in
the United Kingdom; Figure 2.4).48,49 While there are many self-management support
programs in Australia, it has been argued that these are not typically integrated or
coordinated.50
FIGURE 2.4
48,49
19
■
Improve communication between clinicians about consumers: A 2013 ABS survey
found that 14.3 per cent of people who saw three or more health professionals for the same
condition reported issues caused by a lack of communication between health professionals.14
People living in outer regional, remote or very remote areas of Australia were more likely to
report issues caused by a lack of communication between health professionals than those living
in major cities in Australia (18.6 per cent and 13.2 per cent, respectively).14,47
■
Improve the availability of health advice: According to 2014 Commonwealth Fund
survey results, Australia ranks seventh (out of 11 countries) on the self-reported availability of
chronic health advice, with only 65 per cent of people reporting that they knew how to get
advice.51 This suggests that when an urgent medical question arises, 35 per cent of consumers
in Australia either hesitate to call their GP or nurse or cannot get in touch with a health
professional.
2.3 ACCESS TO CARE
Australians generally have good access to primary health care, with more than 80 per cent of
Australians visiting a GP within a 12-month period.14 To a large extent, this reflects the availability of
bulk billing (i.e., government funding) for GP services, which is accessed in 82 per cent of GP
encounters.4 In terms of the average number of GP visits per person per annum, Australia is ranked
10th out of 24 of its OECD peers (Figure 2.5). Australia also has a high number of GPs per 1,000
people, compared to other OECD countries (Figure 2.5).31 It is worth noting that there is not a strong
link between having more GPs or GP visits and the quality of primary health care.
20
FIGURE 2.5
31
There are, however, three opportunities to improve access to care in Australia:
■
Provide greater access in rural and regional areas: The 2013–14 ABS survey found that
nearly one in three people living in outer regional, remote or very remote areas waited longer
than they felt was acceptable to get an appointment with a GP, compared with just over one in
five people in major cities.47 A comparison of rural and metropolitan Medicare Locals also
revealed substantially lower primary health care service utilisation in rural areas (Figure 2.6),
as well as substantial variation between regions in terms of utilisation of MBS-funded allied
health services (Figure 2.7), both of which may point to access and availability issues. In 2013,
for example, there was a 40-fold difference between the Medicare Locals that utilised MBSfunded allied health services the most and those that utilised these services the least. A report
by the Grattan Institute estimates that gaps in rural GP access, which have often persisted for
decades, can be eliminated by implementing internationally tested approaches. The first
approach involves training pharmacists (who are more easily accessible) to vaccinate against
disease and issue prescriptions.52 The second approach introduces physician assistants (PAs),
who can diagnose, prescribe and treat a wide range of health problems under the supervision of
a GP and, in doing so, lighten the workload of GPs.52 The Grattan Institute also argues that
these reforms are affordable; in 2011–12, for example, it would have cost $30 million to fill the
worst access gaps.52 In addition to these suggestions by the Grattan Institute, nurse
practitioners (NPs) are also improving access for rural and remote consumer care.53
21
FIGURE 2.6
26
Variation in primary care service utilisation in Australia
Annual number of primary health care services1 per person by Medicare Local, FY 2013
Brisbane
3
8
Sydney
Perth
ACT
Adelaide
Melbourne
1 Primary Health Services consist of a) GP and other non-referred attendances including Consulting Room and Residential Aged Care Facility
attendances; b) PIP Incentives related Services; c) Health Assessments; d) Mental Health Services; e) After Hour Services; f) Chronic Disease Related
Services; g) Other
FIGURE 2.7
26
Variation in MBS Allied Health service utilisation in Australia
Annual number of allied health visits per person by Medicare Local, FY 2013
Rural/Regional
Metropolitan
0.35
0.30
0.25
0.20
0.15
~40x
0.10
0.05
0
0
2
Kimberley - Pilbara
4
6
8
10
12
14
16
18
Cumulative population, millions
20
22
24
North Coast NSW
22
■
Provide greater access to out-of-hours primary health care (non-emergency
department): Australia ranks 9th out of 11 OECD nations in terms of non-emergency
department, out-of-hours care, with 46 per cent of people reporting access issues (Figure 2.8).
Researchers at the University of Wollongong also found an alarmingly high frequency of
emergency department (ED) presentations among people over 65 years of age where an
afterhours GP service would have been more suitable, but was avoided due to cost concerns.54
Access could also be provided in alternative ways such as via the phone, e-mail or telehealth.
■
Provide access to care in a more timely manner: Australia ranks 5th out of 11 peers in
terms of being able to book a GP appointment within 48 hours (46 per cent of people had
access issues) (Figure 2.8).49 People who cannot obtain timely access may choose to go to
hospital, where the cost of care is much higher, or to avoid care altogether, which often leads to
a deterioration in their condition.
FIGURE 2.8
49
2.4 COST AND SUSTAINABILITY
Australia’s health system is relatively expensive, and the current and predicted growth in cost is
unsustainable. While Australia performs better than most OECD countries in terms of health care
spending as a percentage of gross domestic product or GDP (ranked 8th out of 24 peers; Figure 2.9),
this is heavily influenced by its high nominal GDP per capita (Australia is ranked fifth in nominal GDP
per capita).55 When measured in absolute terms (i.e., health expenditure per capita in US dollars at
23
purchasing power parity), Australia is ranked 15th out of 24 peers (Figure 2.9), spending 34 per cent
more than New Zealand and 15 per cent more than the United Kingdom. Despite this, Australia only
spends 1.9 per cent of its health expenditure on prevention and public health services (per capita in US
dollars at purchasing power parity of 2005) and is ranked 19th out of the 22 OECD countries that
report on this metric (Figure 2.9).56
The rate at which costs are growing is also unsustainable. Since 1993, costs have risen at an average
rate of 8 per cent per year. This rate of increase is greater than Australia’s GDP growth, which means
that health care costs have risen from 7.3 per cent of Australia’s GDP in 1993 to 9.1 per cent in 2011
(Figures 2.9 and 2.10). This growth is primarily driven by hospital costs, although Medicare costs have
also increased.
Primary health care professionals are estimated to control or influence approximately 80 per cent of
health care costs, which means that they have an important role to play in ensuring that health
expenditure remains sustainable. There are two main opportunities to achieve this:
■
Target preventable hospitalisations for people with chronic disease. The rate of
potentially preventable hospitalisations (PPHs) reflects the appropriateness of Australia’s
primary and community health services, particularly for people with chronic diseases.57 PPHs
currently account for approximately 6.2 per cent of hospitalisations nationally (8.1 per cent in
public hospitals and 3.4 per cent in private hospitals),58 and Australia’s preventable
hospitalisation rate per 100,000 people for chronic diseases such as asthma, chronic
pulmonary disease, congestive heart failure and diabetes is higher than in the United Kingdom
and Canada (Figure 2.11).31 Indeed, while preventable hospitalisation rates in the United
Kingdom decreased by 10 per cent between 2008 and 2011, they remained relatively constant
in Australia over the same time period, despite the introduction of initiatives such as the
Enhanced Primary Care program (EPC). Overall, Australia ranks 13th for total preventable
hospital admissions per 100,000 of population, out of a group of 19 OECD peers (Figure 2.11).31
While there are some limitations around different data collection methods amongst this group
of countries, this nonetheless highlights a substantial opportunity for improvement for
Australia.
■
Ensure value for the money invested in primary health care for people with
chronic disease. There are opportunities to improve the value for money delivered by MBS
chronic disease funding, which includes care plan and team care arrangements. Funding for
these items increased at a rate of 25 per cent per annum between 2006 and 2014 and now costs
more than $848 million per year. There is substantial evidence that multidisciplinary care
plans, when designed and implemented properly, can improve outcomes for people with
chronic disease and can therefore reduce chronic disease expenses in the long term.59 In
Australia, however, this funding is not targeted at people with higher needs or higher chances
of hospitalisation, and it does not sufficiently incentivise long-term follow-up, both of which
are critical to reducing cost.5 Indeed, a prospective analysis of current chronic disease funding
found little to no relationship between the complexity of a person’s health care needs and the
24
amount of chronic disease funding they received.5 For example, people did not receive
substantially more resources if they had high HbA1c levels, systolic blood pressure or
cholesterol, or if they had multiple chronic diseases or were more likely to require
hospitalisation in the next year.5
FIGURE 2.9
31
25
FIGURE 2.10
60
FIGURE 2.1131
26
If Australia can improve the quality of care, consumers’ experience of care, and access to care, while
ensuring that the primary health care system remains economically sustainable, it will be better
prepared to meet the growing burden of chronic disease and the health care implications of an ageing
population. In order to identify where and how improvements can be made, Chapter 3 introduces four
critical dimensions of a health care system: governance and financing, consumer interaction with the
health system, primary health care professionals, and systems and processes. Chapters 4 to 7 then
discuss each dimension in detail, outlining how the system works in Australia across each dimension
and summarising alternative approaches that have been adopted around the world.
27
Chapter 3: The dimensions of primary health care
Primary health care is a multidisciplinary system that provides consumers with a first point of
contact and continuous care.61 There are a multitude of different frameworks for structuring primary
health care models,61–65 most of which build on Donabedian’s Model for Assessment of Quality of
Care. This model measures systems based on their structures, processes and outcomes.65
The framework for this paper is based on a review of other primary health care systems and different
health system models, with a focus on the structural and process components that are particularly
relevant to caring for people with chronic disease (Figure 3.1). It identifies 13 primary health care
model elements, which can be divided into four categories: governance and financing, consumer
interaction with the health system, primary health care professionals, and systems and processes.
While the components of this model are each discussed separately, they do not function in isolation.
Instead, they work together as part of a complex system, each affected by and affecting the other
components. Acknowledging these connections is critical to identifying an appropriate blend of
components that meets the specific needs of a health care system and is appropriate for its economic
and social context.
FIGURE 3.1
Primary care model elements
Governance structure
1
Governance &
financing
Funding source(s)
Funding mechanism(s)
Consumer segmentation
2
Consumer
interaction with
the health
system
Primary care
model
Medical homes and enrolment
Education and self-management
Clinical leadership
3
Health
professionals
Workforce composition and roles
Provision of care coordination
Digital health
4
Systems &
processes
Information transparency
Continuous quality improvement processes
Clinical pathways and care plans
28
■
Governance and financing: How primary health care systems are structurally organised
and the financial flows that enable them. This includes:
‒ Governance structure: The organisational management and governance structure of the
primary health care system and its integration with secondary and aged care.
‒ Funding sources: The means by which a primary health care system receives its funding,
including government, private sector and consumer sources of funding.
‒ Funding mechanisms: Methods of distributing funds across the primary health care
system and from payers to providers, including fee-for-service payments, payment for
outcomes, capitation and other methods.
■
Consumer interaction with the health system: The elements of primary health care that
determine how consumers relate to the system. This includes:
‒ Consumer segmentation: This identifies which people to focus on and determines how
resources are allocated.
‒ Medical homes and enrolment: The ability of consumers to enrol in medical homes,
which provide longitudinal care for a population of people.
‒ Education and self-management: Mechanisms to help consumers understand and
manage their conditions independently.
■
Primary health care professionals: The role of the health professional workforce in
primary health care, which is critical to the outcomes and sustainability of the system. This
includes:
‒ Clinical leadership: The involvement of clinicians in driving improvement and the
progression of primary health care delivery.
‒ Workforce composition and roles: The roles and responsibilities of general
practitioners, nurses, allied health professionals and specialists in primary health care
delivery.
‒ The provision of care coordination: The person(s) responsible for coordinating
communication and activities between consumers and health professionals, who may be a GP
or specialised coordinator.
■
Systems and processes: The organisational systems and processes that facilitate care
delivery, including information flows and performance reviews. This includes:
‒ Digital health: The systems and electronic tools that improve access and quality of care for
consumers, enable clinicians to make more informed decisions, enhance the connectivity
between primary and secondary care, or reduce costs for providers and payers.66
29
‒ Information transparency: The data captured by the health system and made
transparent to stakeholders, including health care professionals (for example, in relation to
how individual health care professionals deliver care in comparison with peer benchmarks)
and consumers (for example, in relation to their health and the way in which they interact
with the health care system).
‒ Continuous quality improvement processes: The methods and tools used to ensure
that the quality of care provided by primary health care professionals is continually
improving.
‒ Care pathways: The protocols used by health care professionals to standardise care across
consumers, with the aim of reducing variation between health care professionals.
□
□
□
The following four chapters focus on these four dimensions of primary health care: Chapter 4 focuses
on governance and financing, Chapter 5 focuses on how consumers interact with the primary health
care system, Chapter 6 focuses on primary health care professionals, and Chapter 7 focuses on
systems and processes. Each chapter discusses the different components of these dimensions,
outlining the systems currently in place in Australia and summarising alternative approaches that
have been adopted internationally.
30
Chapter 4: Primary health care governance and
financing
This chapter explains how primary health care systems are structurally organised and outlines the
financial flows that enable them. It is divided into three sections:
■
Governance structure: The organisational management and governance structure of the
primary health care system and its integration with secondary and aged care.
■
Funding sources: The means by which a primary health care system receives its funding,
including government, private sector and consumer sources.
■
Funding mechanisms: The methods of distributing funds across the primary health care
system and the flow of money from payers to providers, including fee-for-service payments,
payment for outcomes, capitation, and other methods.
4.1 GOVERNANCE STRUCTURE
Primary health care governance structures are the organisational constructs that enable
governmental bodies and professional associations to exert influence over resources, codes of
practice and care delivery.63 Primary health care governance structures are organised both at the
macro level (where national or regional agencies are responsible for policy, funding strategy and
enabling infrastructure) and at the meso level (where local agencies are responsible for
commissioning, linking and enabling the local primary health care sector).67 The core role of a
governance structure is to ensure that a health system has a strong sense of direction, efficiently
utilises resources, and responds to population needs by providing safe, cost-effective and high-quality
care.62 There is broad agreement that the best way to achieve this is to promote integration of
primary, secondary and aged care in order to maximise coordination between providers and optimise
resource allocation across the system.61,68,69
4.1.1 Australia’s system
In Australia, macro-level responsibility for primary and secondary care is divided between the
Commonwealth and state governments (Figure 4.1). The primary health care system is managed by the
Department of Health on behalf of the Commonwealth Government16 and is funded through
Medicare—automatic, universal health care insurance for all citizens and permanent residents.16 In
contrast, hospital-related health services are primarily managed and funded by state governments at
the macro level (through a combination of activity-based funding and grants) and by local hospital
networks at the meso level.
31
In 2009, the National Health and Hospitals Reform Commission argued that there was “widespread
dissatisfaction with the consequences of the split in funding responsibilities—the fragmentation of
services, perverse financial incentives that lead to underfunding parts of the health care continuum,
the duplication and administrative waste, and difficulties navigating a complex system.”70 The
Productivity Commission echoed this sentiment in 2015: “Australia’s health system is large,
fragmented and complex… [N]o single organisation has full responsibility for health, and in many
areas responsibilities overlap… [T]his can result in cost shifting, waste, gaps in service delivery, or an
unwillingness for any single party to take leadership for reform.”71 In the context of caring for people
with chronic diseases, the main drawback of this division in responsibilities is the risk that
preventative care will become deprioritised. For the Commonwealth Government, for example, it may
not make sense to fund preventative programs because it only receives downstream benefits through
reduced hospitalisations. At the same time, however, state governments’ ability to invest in prevention
programs is limited because they do not control critical primary health care levers, such as funding and
primary health care provider performance management.
In recent years, two main initiatives have been implemented to improve this situation. Firstly, activitybased funding for secondary care was introduced in 2014, and the Commonwealth now provides 45 per
cent of the cost of efficient growth (until 2017/18).72 This creates an incentive for the Commonwealth
Government to assist in reducing the volume of inpatient care through better primary health care
management. Secondly, the Commonwealth Government established Medicare Locals in 2011, which
were replaced by PHNs in July 2015.4 These meso-level organisations are responsible for improving
health care effectiveness and efficiency in their regions, with an immediate focus on developing
collaborative working partnerships with Local Hospital Networks (LHNs) and private hospitals,
consolidating services, and improving performance measures related to population health.73 In doing
so, they are expected to create formal joint board positions, local memoranda of understanding
(MOUs) and a commitment to collaborative approaches to care delivery.68
32
FIGURE 4.1
16
Organisation of the Australian health system
Macro
Meso
Micro
State /
Territory
Health
Departments
Department of
Health (DoH)
Strategic
direction
Local Hospital
Primary health
Networks
networks
Organizational
(LHNs)
(PHNs)
integration
Hospitals
Department of
Human
Services
(DHS)
Payments
for medical
services
(MBS)
Payments
for pharmaceutical
benefits
(PBS)
General
practices
4.1.2 Alternative approaches
It remains to be seen whether the introduction of activity-based hospital funding and PHNs can
overcome the challenges associated with coordinating primary and secondary care and increasing
Australia’s focus on preventative care for people with chronic disease. In the meantime, however,
Australia can draw upon the experiences of other health care systems and the structures they have
adopted for primary health care governance. Internationally, there are three main approaches to
primary health care governance:
■
Macro-level integrated governance structures
■
Meso-level integration with combined funding pools
■
Meso-level integration without combined funding pools
Macro-level integrated organisational structures
Some systems have a single, macro-level governance structure that spans both primary and secondary
care. This approach has two important benefits: (1) It makes it easier to standardise care delivery and
infrastructure (e.g., electronic health systems, accreditation systems, care pathways); and (2) it allows
systems to more easily optimise resource allocation across primary and secondary care.74 Systems with
33
this design have a strong incentive to invest in prevention services for people with chronic disease
because they receive the downstream benefits of reduced hospitalisation costs.68
One example of a large health system with a single, macro-level governance structure that spans
primary and secondary care is Kaiser Permanente (KP) in the United States. People in the United
States do not have a universal entitlement to health care and, unless they are eligible for state-funded
health insurance (i.e., Medicare for the elderly or Medicaid for people with low incomes), they must
make their own provisions. In this market-based system, KP is the largest non-profit private insurance
health plan and integrated delivery system of primary and secondary care in the United States, serving
9.4 million members.75 KP’s integrated system consists of three distinct entities: Kaiser Foundation
Health Plans, Kaiser Foundation Hospitals and Permanente Medical Groups.51 Kaiser Foundation
Health Plans offer comprehensive health care services for members, provided through exclusive
contacts with Kaiser Foundation Hospitals and Permanente Medical groups.76 The integrated model
aligns incentives for the payer and provider to encourage preventative, well-coordinated primary
health care, which in turn reduces secondary care costs. KP is one of the lowest cost systems in the
United States, and its health plans have been ranked the best in the United States for the fourth
consecutive year by the National Committee for Quality Assurance (NCQA) Health Insurance Plan
Rankings 2014–15.77
Another example closer to home is Australia’s Department of Veterans’ Affairs (DVA), which manages
the funding of both primary and secondary care for Gold Card holders (war veterans, war widows or
widowers and their dependants.)78 This single, macro-level organisational model means that the DVA
makes decisions about how to allocate resources to different services. For instance, recognising that
people with chronic disease were becoming an increasingly significant driver of hospital costs, the DVA
established the Coordinated Veterans’ Care (CVC) program in 2011, which aims to improve the
management of chronic disease for the 10 per cent most at-risk people with complex care needs.79 GPs
are offered financial incentives to enrol eligible Gold Card holders into the program and provide
ongoing comprehensive care, including care plans, dedicated nurse coordinators and tools for better
self-management.78,79 By June 2014, over 25,000 Gold Card holders had been enrolled.80 A 2013
interim evaluation report found improvements to potentially avoidable hospitalisation rates, better
self-management and social connectedness, and generally positive feedback from practices and Gold
Card holders.80 Final evaluations of the program are not yet publicly available.
While elegant in principle, this approach is not without its drawbacks, however. Firstly, it is
challenging to shift an existing system with separate governance structures to align with this model. (In
each of the examples described above, the governance model was adopted when the system was
established, thus avoiding this challenge.) The second drawback of relying on a centralised approach to
integrate care is that it may take the administration of care away from local organisations, which are
best positioned to understand the unique needs of resident populations. For this reason, New Zealand,
the United Kingdom and Canada are all shifting away from centralised governance towards tailored
regional approaches, built around meso-level agencies responsible for integrating care locally.81
34
Meso-level integration with combined funding pools
In some systems, integration has occurred at the meso level through the establishment of shared
governance models and pooled funding. These systems aim to push decision making closer to the
consumer, and they facilitate improved optimisation of resources across the primary and secondary
care systems. The pooling of funding also provides an incentive to invest in preventative care in order
to reduce downstream hospital costs.82–84
Examples of this approach can be found in the United Kingdom’s National Health Service (NHS). Prior
to the passage of the 2012 Health and Social Care Act, meso-level regional agencies (known as Primary
Care Trusts or PCTs) were accountable for funding 80 per cent of the country’s health services across
primary and secondary care.81,85 In the wake of the Health and Social Care Act, however, these PCTs
were abolished, and responsibility for funding was instead divided between the NHS Commissioning
Board (which funds primary health care and some specialised services) and Clinical Commissioning
Groups (CCGs), which fund secondary and community care. This created a situation similar to
Australia—a split between primary and secondary care governance—which has been widely criticised.85
To reduce the impact of this division in responsibilities, some parts of the United Kingdom decided to
pool funds from CCGs and local authorities (which fund social care) to create an integrated budget for
activities that drive integration across settings of care, including care planning, care coordination,
discharge management and rapid response services. In North West London, for example, the eight
CCGs agreed on a set of interventions that would be necessary to tackle the lack of coordination for
people with chronic conditions. They worked with the Commissioning Board and local authorities to
create a joint pool of funding, which included new investment and repurposed existing funding (such
as GP services for people with diabetes), to contract for these services. Implementation of this new
bundle of services in the Integrated Care Programme pilot led to a 4 per cent reduction in non-elective
admissions for consumers aged 75 and over between 2010–11 and 2011–12, compared with an 8 per
cent increase in non-elective admissions in non-participating practices.
New Zealand has also moved to enhance integration between primary and secondary care through
shared meso-level funding systems. New Zealand’s health model is primarily publicly funded and is
administered by the Ministry of Health, which funds 20 district health boards (DHBs) across the
country.16 Since 2001, the majority of the population (approximately 95 per cent) has voluntarily
enrolled in networks of self-employed providers, known as primary health organisations (PHOs),
which are funded by the DHBs. PHOs receive funding through capitation, which is adjusted for age,
gender, health status, utilisation of services and other health risk-related factors.16 While the overall
impact of the PHO program on the integration of care has yet to be determined,86 certain innovations
are already having an impact. In Auckland, for example, Counties Manukau District Health Board’s
20,000 Days Campaign focused on integrating local health organisations and individuals through 13
different community-based collaborations.87,88 Over the course of two years, the campaign exceeded its
target, reducing hospital bed days by over 23,000 through a combination of reduced admissions,
readmissions and average length of stays.87–89 In doing so, the campaign achieved significant financial
savings for Counties Manukau and greatly improved consumer empowerment and education. The
35
program attributes its success to five factors: common goal alignment, leadership support,
multidisciplinary teams from primary and secondary care, application of the Model for Improvement,
and structured milestones.87 The Safer Medicines Outcomes On Transfer Home (SMOOTH) initiative
estimated saving nearly NZD $300,000 per annum through the prevention of medication-related
readmissions.87 Counties Manukau has now shifted into phase 2 of the program (Beyond 20,000
Days), with a focus on implementing the collaboration changes permanently and expanding the
program.87
Meso-level integration was also introduced in Australia during the 1990s and early 2000s through two
rounds of coordinated care trials initiated by the Australian Government.90 The first round was divided
into nine trials, each testing whether incorporated pooled funds from existing programs, devolved
purchasing and formal care coordination could remove program barriers to clinical integration and
strengthen the role of doctors as gatekeepers to diagnostic and specialist services.90 For example, SA
Health Plus—the largest trial—aimed to provide new service delivery and funding systems for people
with chronic diseases by utilising fund pooling, structured care planning and consumer-centred care.90
This trial demonstrated improvements in health and well-being among some participants, but it did
not produce a sufficient reduction in hospital admissions to cover the costs of coordinated care. A
national evaluation of the first round of the trial found that outcomes did not improve and that higher
health service use and costs were incurred, although some participants reported a positive experience
and some care coordinators perceived that the trial benefitted their patients.90 The limited success of
the trial was believed to stem from its short timeframe and inappropriate measures and program
design.90 The second round of the trial produced better outcomes, suggesting that financial strategies
can drive improvements in particular consumer groups but are unlikely to improve outcomes without
linkage to clinical strategies.90
While examples such as these demonstrate the promise of meso-level integration with combined
funding pools, national rollout of the approach could be inefficient if it is not well coordinated. Local
organisations have to agree to cooperate and design their own models, which can be time consuming
and costly and may result in duplicated effort across regions. The lack of standardisation between
regions could also add to central administrative costs at the national level.
Meso-level integration without combined funding pools
Some systems try to achieve shared governance without pooled funding between primary and
secondary care—an approach that can be easier to negotiate between relevant agencies. However,
because this approach does not directly align incentives for different organisations to cooperate, it is
very difficult to implement successfully and in many systems has proved impossible.82
Australia has attempted to implement this approach in various pilot programs. In 2013, for example,
Inner-North West Melbourne developed a partnership between Inner North West Melbourne Medicare
Local (INWMML), two community health services and the Melbourne Health LNH.91 The arrangement
concentrated on building a collaborative approach to developing care pathways, chronic disease
36
management, afterhours access, advanced care planning and integrated mental health services.91 This
arrangement ultimately aims to reduce avoidable hospitalisations and improve care, but results on its
success are not yet available.91 Similarly, the Peninsula Model for Primary Health Planning is a
catchment-based partnership between local health organisations, hospitals and community care
organisations in Frankston and the Mornington Peninsula, Victoria.92 Although local governments,
LHNs and PHNs maintain responsibility for their own governance, each organisation actively endorses
and allocates dedicated resources to support the Peninsula Model.92 Strategic planning, monitoring
and coordination is managed by the Primary Care Population Health Committee (PCPHC) and the
Peninsula Model Executive Group (PMEG),92 and working group members from service providers
redesign services to improve coordination and outcomes.92 Currently, there are no formalised
evaluations of program results or effectiveness.
Locally led integration is also being trialled in New South Wales (NSW) as part of its integrated care
strategy.93,94 The four-year trial, which commenced in 2014, attempts to transform health care by
shifting focus from hospitals as the centre of care to a broader view that encompasses primary and
community care.94 Consumers are enrolled into the trial at three demonstrator sites in Local Health
Districts (LHDs) in Western NSW, the Central Coast and Western Sydney, where care delivery will be
co-managed by health professionals in primary and secondary care.94 Joint partnerships between
Medicare Locals and LHDs will focus on four concepts: shared care planning, IT infrastructure, care
facilitation and GP and consumer engagement.93,94 Results from this trial are not yet available.
4.2 FUNDING SOURCE(S)
Health systems can be funded through public financing, private financing, or a combination of the two.
Public funding (also referred to as national health insurance) is sourced through general government
revenues (taxation) or social health insurance contributions (compulsory contributions to health
financing).95 Private funding is sourced through private health insurance, independent out-of-pocket
contributions or social donations by charities.95 Systems aim to raise funds through the most equitable
and efficient combination of sources,95 but there is ongoing debate about the optimal mix of funding.96
Most OECD countries or developed health care systems adopt partial or full public funding in an
attempt to achieve policy goals of quality, cost and access (Figure 4.2), and there is some evidence to
suggest that this is a reasonable way of balancing efficiency and equity.61,95,96
4.2.1 Australia’s system
Taxation accounts for approximately 68 per cent of total health care expenditure, which is relatively
low in comparison with other OECD countries (Figure 4.2).16,31 Medicare, which supports access to
general practice and other medical services, is publicly funded through general taxation and a 2 per
cent means-tested income tax.31,97 In 2012–13, 82 per cent of GP services were bulk billed (i.e.,
practitioners billed Medicare directly without an additional charge to consumers).4 If primary health
services are not fully or wholly covered by Medicare (see Section 4.3.1 on how Medicare allocates
37
funds), the gap is funded through out-of-pocket contributions by individuals.97,17 In 2012, Australians
spent nearly $2.9 billion on primary health care out-of-pocket medical services expenses for ‘gap
payments,’ accounting for approximately 12 per cent of total out-of-pocket health care expenditure
(including pathology and imaging services).98 Other primary health care services (such as those
provided by allied health professionals) are supported by state and territory governments, nongovernmental organisations (NGOs), private health insurance or out-of-pocket contributions from
individuals.
Consumers have an option to purchase two different types of private health insurance: hospital cover
for inpatient services, or general treatment (also known as ‘extras’) for dental, physiotherapy and other
allied health services.99 Legislation in Australia prohibits private health insurers from covering general
practice services with an MBS reimbursement.4 This is contested by private health insurers, who have a
financial incentive to provide members with better preventative primary health care in order to capture
savings from reduced hospitalisations.71
FIGURE 4.2
31
Primary and secondary total health expenditure funding
Privately funded
%
Publically funded
14%
15%
16%
17%
19%
22%
23%
23%
30%
32%
34%
52%
86%
85%
84%
83%
81%
78%
77%
77%
70%
68%
66%
United States
Switzerland
Australia
Canada
France
Germany
Italy
Sweden
New Zealand
England
Norway
Denmark
48%
Note: % of total public funding calculated based on data extracted between 2006-2014.
Despite these regulatory restrictions, some private health insurers have attempted to provide their
members with benefits in primary health care. In early 2014, for example, Medibank Private trialled a
GP Access Program in selected Queensland clinics to improve members’ access to primary health
care.71 The program aimed to offer members guaranteed same-day appointments (if booked before
10am), fee-free consultations and afterhours GP home visits (conditional on location), avoiding any
38
breach of legislation by funding management services rather than reimbursing for care.100 Medibank
claimed that the initiative could improve outcomes, reduce avoidable hospitalisations and therefore
reduce insurance premiums.71 Later in 2014, Medibank also launched its CarePoint integrated care
trial, which aimed at improving clinical outcomes for consumers with complex or chronic diseases.71
4.2.2 Alternative approaches
Internationally, two alternative approaches are being implemented:
■
Create a prominent role for private health insurers in primary health care
■
Introduce mandatory co-payments for primary health care
A prominent role for private health insurers in primary health care
Determining the appropriate role for private insurers in primary health care is typically considered a
politically controversial decision because of the multiple economic and social trade-offs. Those who
support this approach claim that expanding the role of insurers in primary health care could
potentially lead to several benefits for consumers, both because it would enable insurers to become
more involved in coordinating effective care interventions, and because it would encourage greater
preventative care.71 This could be particularly beneficial for people with chronic diseases or complex
needs, given that insurers have an incentive to use primary health care in innovative ways to avoid
more expensive secondary care costs. Insurers also argue that by better managing primary health care,
premiums could ultimately be driven down to create a more stable private health insurance market.71
There are a number of examples of health insurers providing excellent primary health care around the
world. Intermountain, for example, is a health care system in the United States that consists of three
interdependent groups: Intermountain Health Services, Intermountain Medical Group and Select
Health (previously Intermountain Health Plans).101 Its private health insurance division, which covers
over 700,000 consumers, offers programs to help coordinate care and educate members about health
issues, which are usually targeted at consumers with more complex health needs.101 Members with
diabetes, for example, are assigned a nurse care manager to teach them about managing their
condition, identify available resources and help them navigate the health system.101 SelectHealth also
offers Member Advocates—a service that helps to match consumers with available doctors and
schedule appointments, and which offers seamless access to medical records, claims and health
information through its MyHealth online portal.101 Participants in Intermountain’s Diabetes Care
Management System (DCMS) program experienced statistically significant improvements in
performance metrics, including an increase of approximately 11 per cent in the number of consumers
receiving at least one annual HbA1c test, and an increase in the number of people with an HbA1c value
below seven (from 33.5 per cent to 52.8 per cent between 1998 and 2002).102
Although not an example of a private insurer, AOK—Germany’s largest public health insurance fund—
seeks to offer options to continuously improve services for its members.103 Structured treatment plans
39
for people with chronic disease, for example, involve disease management programs (DMP), scientific
monitoring and integrated quality management.103 Studies on the impact of these initiatives found that
DMPs improved health behaviours during the first two years of participation, including an increase in
the number of people quitting smoking (from 23 per cent to 32 per cent in Rhineland, and from 22 per
cent to 28 per cent in Hamburg) and changes in eating habits (among 80 per cent of participants).104
Positive consumer experience results were also noted. Fifty-six per cent of those involved in the DMPs
agreed that the quality of care had improved.104
While there are examples of insurers creating positive outcomes in primary care, expanding the role of
private health insurers in an Australian context typically raises several criticisms focused on equity of
access. Due to multiple market failures, health care markets tend to require regulatory assistance from
governments in order to protect consumer interests, create effective competition, and prevent the
creation of a two-tiered health system in which privately insured consumers receive privileged access
to care.71 Additionally, increasing the role of private health insurers to cover GP ‘gaps’ could artificially
inflate costs if the use of bulk billing decreases due to the transfer of cost from consumers to insurers.
This may make health care unaffordable for consumers in lower socioeconomic groups and could
create a ‘moral hazard’ effect, in which uninsured consumers are disproportionately disadvantaged by
changes.105 Insurers may also selectively seek lower risk consumers, creating access inequities for less
healthy consumers.
Mandatory co-payments for primary health care
Co-payment systems require people to pay a predetermined set amount (through out-of-pocket
contributions) each time they receive a health care service. Co-payment schemes for primary health
care in Australia are not new. In the post-Medicare era, co-payments were first introduced in 1991 but
were abolished after only three months. More recently, a $7 GP co-payment scheme was proposed by
the Australian Government but was abandoned in March 2015 following two unsuccessful attempts at
obtaining parliamentary approval.106
As this recent experience suggests, co-payments are often controversial. The arguments in favour of copayments for primary health care services are primarily economic, specifically that co-payments would
discourage unnecessary treatment and allow GPs to use their time more effectively for those who need
it.107 Critics, however, argue that co-payments reduce equality and access, which negatively affects the
long-term health of people with chronic and complex diseases or financial hardship.105
The RAND experiment—conducted in the United States in the 1980s—is the most comprehensive
evaluation of co-payment effectiveness. The study focused on the impact of co-payments on demand
for health services, the effects on appropriateness of care and quality, and the effects on health
outcomes.108 Participants in the experiment were randomly issued co-insurance arrangements (out-ofpocket contributions), ranging from free care to 95 per cent co-insurance.108 The study revealed several
clear findings. Firstly, utilisation of services was linked with co-insurance rates, with the use of medical
care decreasing as co-insurance rates increased.108 This decrease was notably caused by participants
40
withholding from initiating care, but it was not evident once consumers had entered the health
system.108 Secondly, the trial found that for the average participant, there was no statistically
significant difference in clinical outcomes by co-insurance rate, which indicates that higher coinsurance rates did not result in any negative health consequences.108 It is important to note, however,
that this was not consistent across all participants; among participants who were extremely poor or
sick, the top 6 per cent experienced better outcomes under a free plan than co-insured
arrangements.108
Since the RAND experiment, much of the literature has argued that co-payments have major flaws
relating to equity and access. Co-payments impose an additional financial burden on consumers,
particularly disadvantaged groups and people with chronic or long-term diseases,105 and financial
stress and the likelihood of facing financial difficulties increases by 46 per cent with each additional
chronic disease.105 Increasing the out-of-pocket cost of accessing primary health care may discourage
consumers from seeking necessary preventative care, or may prompt them to unnecessarily revert to
‘free’ secondary care, putting greater pressure on ED services. Although there is limited rigorous
empirical evidence on the long-term effects of co-payments, researchers generally believe that they
encourage a decrease in utilisation of otherwise cost-effective health care, limit entire system access
and discourage preventative care.105
4.3 FUNDING MECHANISM(S)
Funding mechanisms dictate the way money flows from health care payers to providers. They influence
service delivery and therefore impact quality, access, experience and cost performance outcomes.68,82
There are three main types of funding mechanism, each of which can be used separately or as part of a
blended payment system:
■
Fee-for-service payments. Providers are reimbursed based on the services they provide to
consumers, usually based on the time, effort or cost of providing the consultation. This system
encourages greater service provision and should, in theory, improve access. However, it does
not incentivise population health outcomes or value for money, and may encourage supplydriven demand.109
■
Capitation or population-based payments. Providers are paid a set amount per person,
per time period. The payments are often risk adjusted at a population or individual level, with
sicker consumer groups receiving higher funding. Capitated systems vary in the scope of
services they include. For example, some include only primary health care services, while
hospital costs and other downstream costs are covered separately. Other systems pay a fixed
amount to cover a person’s full health care costs. These systems transfer financial risk from the
payer to the provider and heavily incentivise providers to reduce hospital costs and other
health care costs. The main benefit of a population-based system is that it encourages providers
to focus on prevention and overall cost reduction. The disadvantages are that such systems are
more complex to operate and require sophisticated providers who are willing to take on risk.109
41
■
Payment for performance or outcomes. Providers receive payment for undertaking
certain practices or achieving a set of outcomes for their enrolled consumers, typically related
to quality, access, experience and productivity. The main advantage of this approach is that it
ensures that provider incentives are aligned with the system’s goals. The disadvantage is that
payment-for-outcome schemes are limited by data availability and can be difficult to design
without creating perverse incentives.109
There is no evidence to definitively suggest that one funding mechanism is superior to another. They all
involve trade-offs and can create potentially adverse consequences. As a result, systems around the
world adopt a range of different approaches, often blending different types of payments in an attempt
to find the optimal balance.
4.3.1 Australia’s system
Australia’s primary health care system has predominantly used an FFS funding model for the last 30
years, and Australia is one of only three OECD countries not to use some form of capitation (Figure
4.3).16 Payments for health care services are listed in the MBS, which outlines over 5,700 items for
which a rebate can be claimed.110 These activity-based payments account for over 90 per cent of
primary care payments to providers.16
Australia also has an incentive system, which rewards clinicians for carrying out certain clinical
processes. The PIP or the Service Incentive Payments (SIPs) scheme reward completion of clinical
processes relating to asthma, cervical screening, diabetes, e-Health, GP aged care access, Indigenous
health, non-referred procedural services (e.g., obstetric delivery), prescriptions, rural loading and
teaching.111 Over 5,200 practices received PIP payments in February 2015, most commonly for eHealth (received by 93 per cent of practices), Indigenous health (received by 51 per cent of practices)
and teaching incentives (received by 22 per cent of practices).112 Typically, payments are made to the
practice, although they can also be administered through Service Incentive Payments (paid directly to
GPs) or rural loading payments (paid automatically to rural practices).111 It should be noted, however,
that the PIP and the SIP scheme represent less than 10 per cent of practitioner income.16 Practices can
also receive incentive payments of up to $125,000 per year for registered or enrolled nurses through
the Practice Nurse Incentive Program (PNIP).113 The scheme also offers financial incentives for the
employment of Aboriginal health workers, allied health professionals in rural areas, rural loading and
practice accreditation.113
The PIP has received mixed reviews. A 2008 evaluation of the program in relation to diabetes
treatment found that the HbA1c test (blood glucose test) was 15 to 20 per cent more likely to be
ordered if GPs participated in the PIP,114 which suggested that the scheme could influence behaviours
and positively improve care delivery.114 A 2013 study, however, found that the short-term increases in
diabetes and cervical cancer screening were observed across all practices, which meant that
improvements could not be conclusively attributed to the PIP.115 A 2010 review of the PIP, conducted
by the Australian National Audit Office (ANAO), also produced mixed results. Sixty-three per cent of
surveyed GPs believed that participation in the PIP benefitted quality of care or consumer access,116
42
and only 12 per cent of GPs rated the PIP as having no benefit at all on these metrics.116 The review also
found that the PIP encouraged modest improvements in general practice, such as greater use of
electronic patient records.116 However, nearly 80 per cent of surveyed GPs also claimed a slight or
significant increase in cost and work effort associated with the PIP.116 In addition to high compliance
and administrative costs for practitioners, other limitations of the scheme include low participation
amongst smaller practices and disadvantaged population areas.71
16
FFS
International funding compositions in primary care
Payments for outcomes
% based on approximate estimations
35%
33%
30%
15%
10%
5%
10%
80%
80%
England
Capitation
Sweden
FIGURE 4.3
25%
45%
5%
60%
70%
100% 100%
95%
90%
90%
20%
85%
10%
30%
30%
70%
20%
50%
37%
Netherlands
Italy
United States
New Zealand
France
20%
Denmark
10%
15%
Canada
10%
Switzerland
Japan
Singapore
Germany
5%
Australia
30%
35%
Norway
45%
Note: Both Canada (in some provinces) and New Zealand are in the process of extending hybrid models of health care funding
4.3.2 Alternative approaches
Evaluating payment models is challenging, and evidence on whether financial incentives improve
quality, access, experience and cost performance in primary health care is limited and inconclusive.
There are relatively few high-quality studies, and each scheme is different—both in terms of the context
within which it is implemented and the nature of the funding model intervention—which makes
comparisons between schemes difficult. As a result, a variety of meta-analyses have concluded that,
while there is evidence that funding models change provider behaviour, the impact of different systems
remains unclear.117–119 More research is needed to better understand their impact, and in the meantime,
any changes to funding models should “proceed with caution and incentive schemes should be
carefully designed and evaluated.”117
43
Despite this, however, a great deal can be learned by examining programs in different countries and
systems that have used new funding models to improve their performance. Three alternative models
are worth considering:
■
Payment for outcomes
■
Capitated or population-based payments
■
Blended models
Payment for outcomes
In many systems around the world, there is a growing trend towards outcome-based funding in order
to incentivise better quality care. Evidence for or against such funding remains inconclusive, however,
with two major reviews of payment-for-outcome schemes concluding that there is insufficient evidence
to either support or reject their adoption.117,120 Assessing the overall impact of these schemes is also
extremely difficult, because each study uses a different incentive design model, different levels of
remuneration and different implementation methodologies, all of which make it impossible to draw
meaningful comparisons. On an individual basis, however, there are a number of examples of
payment-for-outcome schemes that have made a difference.
In Massachusetts in the United States, one prominent example is Blue Cross Blue Shield’s voluntary
Alternative Quality Contracts (AQC), which aims to decrease spending growth and improve clinical
outcomes for consumers.121 The initiative now has 95 per cent of providers contracted through AQCs
(up from 25 per cent when the initiative was introduced), which utilise shared risk and saving
mechanisms and provide payment for outcomes for eligible provider groups.121 Initial evaluations
suggested that introducing AQC resulted in general improvements in quality.122 More recent findings
indicate that participants had lower spending for the 2009–12 period than comparable populations, as
well as an unadjusted increase of approximately 4 percentage points over control groups for measures
of chronic disease management.121
The United Kingdom’s QOF is also a useful example of a payment-for-outcome scheme. Introduced in
2004, the QOF represented a major change in the country’s primary health care funding,123 financially
incentivising GPs to improve quality, clinical processes and outcomes across 121 different indicators.123
However, it remains unclear whether the QOF can effectively improve outcomes and create
appropriate incentives for physicians, and supporting evidence remains inconclusive.117,124 Some
studies have found that reductions in mortality and improvements in quality of care were achieved
during the first year of implementation (see Section 7.3 on the use of QOF for continuous quality
improvement),124,125 but the QOF has also been criticised for failing to produce sustainable change,
adding unnecessary cost to primary health care, allowing practices to ‘game’ the system, and failing to
incentivise improvements to care beyond achieving targets.126
In France, a performance-based voluntary contract for GPs (known as le Contrat d’Amélioration des
Pratiques Individuelles, or CAPI) was introduced in 2009 to target improvements in quality of care and
44
efficiency.127,128 Sixty per cent of the reward payments relate to preventative care and chronic diseases,
while the remaining 40 per cent relate to medicine perceptions.127 Practitioners are paid an end-of-year
incentive, depending on their performance score against 16 indicators.127 Within four years of
implementation, nearly 97 per cent of GPs were participating in the initiative.128 An evaluation of the
program by the National Health Insurance Fund (NHIF) found modest improvements among
participants (relative to non-participants) between 2009 and 2012.129 The most notable improvement
occurred around diabetes management indicators, which revealed a 9 per cent increase in compliance
in relation to HbA1c tests among CAPI doctors, compared to a 4 per cent increase among non-CAPI
doctors.129
When implementing payment-for-performance schemes, however, three potential shortcomings
must be considered.120 Firstly, payment-for-outcomes schemes can create perverse incentives for
practitioners, resulting in several unintended consequences. For example, depending on how
payments are structured, providers may be incentivised to select only healthy people and avoid ill
people, or to disproportionately focus on incentivised care, while neglecting other important health
care issues. Secondly, schemes sometimes only reward practitioners who are already delivering highquality care, rather than driving improvements in quality. Finally, payment-for-outcomes schemes
are limited by their ability to accurately measure performance, which means that they require
information system infrastructure or timely administrative processes conducted by health
professionals.120,126 This is necessary to ensure that providers cannot manipulate data to falsely report
their performance.
Capitated funding
Most developed health systems have an element of capitated or population-based funding (Figure 4.3)
because capitation has a number of theoretical benefits. Primary health care physicians in capitated
systems have patient lists (see Section 5.2 on consumer-centred medical homes and enrolment), which
position them to proactively look after the needs of that population.130 The model also promotes
coordination amongst providers and incentivises joint solutions across health and social care to reduce
costs and provide preventative services.71 Furthermore, it encourages an investor-like mindset among
practitioners in order to drive population health outcomes.71 The benefits for payers include making
expenditure more predictable and transferring some financial risk to providers, which are better
equipped to manage that risk (although this depends on the size of the population covered and the
risk-adjusted amount).
Despite these potential benefits, reviews have concluded that there is insufficient evidence to
determine if capitated payments are better or worse than the alternatives.119 Again, it is difficult to
compare systems because they are so different, but there are a number of successful examples of
capitated systems that drive innovation and improve outcomes, particularly for people with chronic
disease. ChenMed, for example, is a family-owned private primary health care provider in the United
States that operates on a full capitation basis and focuses on lower socioeconomic populations and
older consumers with co-morbidities and complex care needs. (In 2011, approximately 73 per cent of
45
consumers had five or more chronic diseases.)131 Physicians are gradually introduced to risk-sharing
and performance management as they build experience with the system, and performance
management payments eventually account for 40 to 50 per cent of their earnings. In 2011, ChenMed’s
number of hospital bed days was 38 per cent lower than the average in the United States, while its
readmission rates were 17 per cent lower than the average.131
Kaiser Permanente (KP) is also commonly cited as an example of a successful capitation model that
improves health outcomes. The Permanente Medical Groups receive fixed capitated payments to
provide exclusive care to KP health plan members at Kaiser Foundation Hospitals and facilities.51 The
system therefore has a strong incentive to reduce overall costs, including investing heavily in primary
health care for people with chronic diseases in order to reduce hospitalisations and downstream
costs.51
Geisinger Health System is another integrated health system in the United States, which serves a
population of over 2.5 million people with a high prevalence of long-term conditions or complex needs,
most of whom are from lower socioeconomic groups.132 Unlike KP’s closed system, Geisinger has
adopted an open yet integrated system, in which care delivery is available to Geisinger Health Plan
(GHP) enrollees, as well as non-GHP consumers in the service area.132 Geisinger’s ProvenHealth
Navigator program—a patient-centred medical home (PCMH) model that utilises capitated payments
to cover all services—was found to reduce the total cost of care for all consumers by 7 per cent over a
four-year period (relative to projected costs).133
Although primary health care practitioners in the United Kingdom receive some payment for outcomes
through the QOF, the NHS has maintained a primarily capitated funding model.130 Capitation accounts
for approximately 80 per cent of payments, which are adjusted based on age, gender, consumer
morbidity and mortality, whether consumers are in nursing homes, consumer list turnover and a
market-forces factor.16 Payments are reviewed each quarter to ensure appropriate funding
allocations.16 In order to make capitation payments to GPs, all consumers are required to register with
GPs.16 Although it is difficult to directly link this capitation model with outcomes, several performance
metrics suggest that it is a well-functioning, supportive system. For example, amongst adults aged 65
and older, a self-reported Commonwealth Fund survey found that 32 per cent had no chronic
conditions, which is relatively high compared to other developed countries such as France (19 per
cent), Canada (17 per cent) and the United States (13 per cent).49 Similarly, 76 per cent of consumers
reported no care coordination problems in the past two years, which is also relatively high compared to
the United States (65 per cent), Norway (63 per cent) and Germany (59 per cent).49
However, capitation models do have several disadvantages if used in isolation. For example, capitation
creates little incentive for providers to increase the quality or quantity of their care because financial
incentives are fixed, regardless of their performance in these areas.71 From the practitioner perspective,
therefore, consumers are viewed as a source of cost, rather than revenue, as is the case with FFS
models. There is also a potential for under-servicing, particularly if practitioners avoid people with
needs that they believe are under-compensated for by risk formulas.71,134 Finally, there is a potential for
capitation models to limit consumer choice and create provider monopolies, depending on the design
46
of the model. This occurred in the United States in the 1990s, when capitated models became popular
and a number of large practice management companies emerged, which threatened the viability and
quality of care of other relatively small providers.134
Hybrid (blended) model
In reality, most countries around the world have a blend of different funding models (Figure 4.3). In
many instances, hybrid funding models are complex and politically and professionally challenging, and
they often require well-integrated systems. However, they can address some of the failures of singlebased funding models such as pure FFS or pure capitation.135 There are three useful examples of
blended models: the model adopted by the Australian Diabetes Care Project and the models adopted in
New Zealand and Canada.
In Australia, the Diabetes Care Project trialled a blended funding model that utilised FFS, flexible
funding based on risk stratification, quality improvement support payments (QISP) and salaried care
facilitators.5 Enrolled participants were grouped based on five identified risk strata (see Section 5.1 on
consumer segmentation), and funding payments were made directly to practices based on identified
grouping on a population basis, similar to a capitation-style method.5 Providers were able to determine
how funding was then allocated within the practice to GPs.5 Practices also continued to receive FFS
payments by claiming standard MBS items.5 Additionally, a QISP was paid to practices for achieving
improved clinical outcomes (HbA1c) and adhering to clinical processes, and based on consumer
experience metrics.5,135 Evaluations of the project suggested that the funding model enabled greater
innovation, encouraged a more consumer-centred approach to health care and contributed to
improved clinical outcomes.5
Since 2009, New Zealand’s funding model has shifted towards blended payments, combining
capitation, co-payments and targeted FFS.135 Capitation covers a portion of GP services and consumers
contribute co-payments for the remainder.16 This shift has facilitated a better provider mix of
multidisciplinary team members delivering care, greater consumer enrolment and accountability for
provider behaviour, and more accurate information on population demographics.135 The transactional
nature of GP consulting remains unchanged due to the continuation of FFS payments, which represent
a significant proportion of practitioner income.135
Over the past decade, Canada has also undergone primary health care transformation to reform its
funding model, moving towards blended funding arrangements including FFS, capitation, salaries or
targeted incentive payments.135,136 In 2002, 59 per cent of practitioners received 90 per cent or more of
their income from FFS payments. By 2007, this had declined to 48 per cent.136 In Ontario, a 2011 study
of Family Health Groups found that the new blended model (relative to the FFS model) increased
practitioner productivity, reduced referral rates and tended to treat moderately more complex
consumers.137 Despite the growing evidence base, however, research that suggests that blended funding
models improve quality of care delivery remains limited.136
47
Chapter 5: Primary health care consumer interaction
with the health system
This chapter discusses the elements of primary health care that determine how consumers interact
with the system. It is divided into three parts:
■
Consumer segmentation: This identifies which people the system should focus on and
determines how resources are allocated.
■
Medical homes and enrolment: The ability of consumers to enrol in medical homes, which
provide longitudinal care for a population of people.
■
Education and self-management: Mechanisms to help consumers understand and
manage their conditions independently.
5.1 CONSUMER SEGMENTATION
Consumer segmentation (or risk stratification) allows practitioners to provide tailored care based on
predictions of future health care needs or the clinical severity of particular groups of people.138 Finding
ways to tailor care for different groups and focus resources where they can make the most difference is
important for ensuring the sustainability and effectiveness of the health care system.139,140 In Australia,
for example, the most expensive 5 per cent of people with diabetes account for 28 per cent of total costs
(including MBS, PBS, hospital and allied health costs), while the next 15 per cent account for 29 per
cent of total costs.5 If Australia can find a way to identify these people ahead of time and intervene
early, it could be enormously beneficial in terms of avoided illness and reduced overall costs.
5.1.1 Australia’s system
To date, consumer segmentation in primary health care in Australia has been limited. The Towards a
National Primary Health Care Strategy discussion paper broadly identified consumers with chronic
diseases and co-morbidities as a priority for the future primary health care system, highlighting a need
for it to be “well integrated, coordinated, and providing continuity of care, particularly for those with
multiple, ongoing and complex conditions.”141 At present, however, Australia does not systematically
group people into different segments based on an assessment of their future health care needs. Instead,
the primary health care system supports tailoring care for people with chronic diseases through CDM
items available under Medicare. These items are available for people with chronic conditions—defined
as “one that has been (or is likely to be) present for six months or longer”—and they fund general
practitioners to create individualised care plans and team care arrangements.142 In 2013–14, CDM
items represented over 5.6 million services and $587.6 million in benefits paid—a 16.4 per cent growth
in services since 2012–13.143 These items also fund up to five individual and eight group allied health
48
visits for eligible people. It is up to clinicians to decide who should receive these benefits and what care
they should receive.144 However, as discussed in Section 2.4, a recent study of their use among people
with diabetes suggests that they are not well targeted to those who are likely to need them most.
5.1.2 Alternative approaches
There are three main ways in which consumer segmentation or the tailoring of care can be applied in
health systems:
■
Programs for specific cohorts of high-risk individuals
■
Systems that perform comprehensive segmentation of populations and tailor care accordingly
■
Population-based funding systems that allocate funds based on projected needs
Programs for specific cohorts of high-risk individuals
The simplest way to segment and tailor care is to identify a single group of high-risk individuals and
enrol them in programs designed to address their needs. Such programs tend to allocate additional
resources to these people, usually on the basis of achieving benefits in reduced secondary health care
costs in the future. As such, these programs often focus on reducing the number and duration of
hospital episodes for people enrolled in the program.
One example of this can be found in South Devon and Torbay in the United Kingdom. Predictive
modelling using the Devon Predictive Model (DPM) is used to identify the top 0.5 and 5 per cent of
consumers at risk of unplanned hospital admission in the next 12 months.145 Lists of these consumers
are reviewed to identify those most suitable for proactive case management and admission to a ‘virtual
ward,’ in which they receive intensive assessment, coordination from a case manager and support for
their home health needs.145 Consumers are ‘discharged’ from the virtual ward once they have been
stabilised. An evaluation of the program found that emergency admissions and lengths of stay
decreased in 2010 and 2011 for these high-risk consumers.145 Health professionals working in the
virtual wards also reported improved motivation and communication between teams, as well as a
greater focus on protocol compliance.145
This approach was also utilised by Evercare—a managed care program in the United States, in which
high-risk individuals (i.e., those living in long-stay nursing homes and most prone to requiring
secondary care) were assigned Nursing Practitioners (NPs), who worked alongside other primary
health care physicians to provide regular monitoring, structured health assessments and training.146
The intention of the program was to decrease instances of hospitalisation through more intensive
primary health care. Studies showed that the incidence of hospitalisations among Evercare residents
was half that of the control group, and that each NP saved, on average, an estimated $103,000 a year in
hospital costs.146
49
Another example is the Pfizer approach, which uses telephone systems to monitor and refer consumers
at the highest risk of requiring both planned and unplanned secondary care.147 These individuals are
contacted proactively by dedicated telephone support nurses to assess their condition, refer specialist
care, educate them on self-management and monitor their condition.147
In Australia, a successful example of this type of approach is the Hospital Admissions Risk Program
(HARP) in Victoria. This government initiative was developed in the late 1990s in an effort to better
manage demand for secondary care, targeted at people with chronic diseases who frequently use
hospitals.148 The HARP coordination model is based on Kaiser Permanente’s chronic care framework,
which focuses on providing intensive care coordination for high-risk consumers, while lower risk
consumers participate in health programs with a greater focus on preventative care. A 2005 evaluation
found that participants in HARP demonstrated 35 per cent less ED attendances and 41 per cent fewer
hospital days over a 12-month period.148 Between 2007 and 2010, 13 HARP Better Care of Older People
(BCOP) trials were piloted, resulting in a 64 per cent reduction in hospital utilisation and a 55 per cent
reduction in ED presentations. From July 2010, BCOP was rolled out across Victoria.148
Other Australian trials have also started to experiment with this type of program. For example,
Medibank Private and the Victorian Department of Health launched a trial called CarePoint in 2014,149
which focuses on 2,200 Victorians with multiple chronic and complex conditions and a history of high
service utilisation (i.e., adults with four or more admissions in two years, or two or more admissions
within a three-month period in the last six months). The model builds on the central role of the GP or
physician in care assessment and planning, and features home monitoring, care navigation and an
electronic care plan and patient record. Results will be available in late 2017.
Systems that perform comprehensive segmentation of populations and tailor care
accordingly
A more sophisticated approach is to segment whole populations into different groups and tailor care
(and resource allocation) for each group. The advantage of this approach is that it can be expanded to
include many more people than the focused disease-management programs described above. Typically,
these systems target the highest risk people using similar models of care to those described above. In
addition, however, they provide structured programs for people who are relatively well but at risk of
future health problems (due to long-term conditions such as diabetes or heart disease), or who have
risk factors such as high blood pressure or cholesterol.
There are various examples of this in action around the world. Perhaps the most well-known example
is the Kaiser Permanente risk pyramid, which stratifies the population with chronic conditions into
three groups and offers differentiated levels of intervention for each group across primary and
secondary care.150 Level 1 covers people with relatively manageable chronic conditions (65 to 80 per
cent of the population), who receive normal primary health care with supported self-management.150
Level 2 covers people with chronic conditions who are considered unstable or at risk of deterioration
(15 to 30 per cent of the population), who receive structured support through specialist care
50
management.150 Level 3 covers people who have highly complex needs and/or are frequent users of
unplanned secondary care (5 per cent of the population). This group receives active case
management.150 A 2003 study found that after adopting the Kaiser model, there was a 6 per cent
decline in medical visits within the trial group and 5 per cent fewer telephone calls to doctors.151 An
unpublished report by the NHS, meanwhile, found that Kaiser Permanente’s focus on integrating
services, using intensive primary health care to reduce hospitals admissions, and actively managing
consumers reduced the number of bed days required for leading causes of admission (asthma,
bronchitis, COPD and stroke) by 75 per cent among people over the age of 65.152
Another example from the United States is the Care First Patient-Centred Medical Home (PCMH),
which also utilises a whole-population approach to risk stratification. Introduced in 2011, the PCMH
program uses a Wellness/Illness Pyramid to determine five cohorts of members likely to have high
future costs (Figure 5.1).153 The pyramid is based on an Illness Burden Score for each member, which is
calculated based on the member’s individual claims history.153 Each of the five segments has a tailored
care approach, ranging from low to basic intervention for “healthy” consumers (Band 5) to high-touch,
individually tailored care delivery for consumers with multiple long-term conditions (Band 1),
consumers with “catastrophic conditions” (Band 2), or consumers “at risk for multiple chronic
conditions” (Band 3).153 For example, the top 2 per cent of consumers by risk (those with complex, endstage diseases or major traumas) are assisted with advanced coordination of care or home health
services and are provided with case managers.153 However, there is usually limited scope for PCMH
programs to assist these consumers, who are typically cared for by specialists, and the programs
instead focus on Bands 2 and 3, which include the next 28 per cent of consumers with multiple chronic
diseases.153 A review of each individual consumer in these bands is used to determine who will benefit
most from care plans or other interventions. These consumers are reclassified and assigned into
clusters, and evidence-based clinical guidelines are then applied to each cluster. Members in these
bands all receive periodic screening and preventative services, with a focus on risk mitigation.153 This
model enables CareFirst to understand cost patterns and predict resource requirements for consumers’
unique care needs.153 In 2012, after the initiative had been in place for two years, results from the
PCMH demonstrated overall savings (against projected costs) of approximately US $98 million.154
In Australia, a similar approach was implemented as part of the DCP. In this trial, funding levels were
tiered by risk, with resources directed to consumers for whom the greatest benefit could be realised.5
The enrolled population was divided into five groups, based on metabolic indicators (current HbA1c
levels, blood pressure and cholesterol levels), health status (whether or not they had complications
related to diabetes) and whether they had been recently been diagnosed with diabetes (Figure 5.2).5
Funding for general practices and allied health professional consultations was then tiered so that those
in the highest risk groups received more resources. Decision-support software suggested tailored care
plans for each group of consumers, with those in the high-risk groups receiving more intensive support
and coaching. The DCP trial found that combining an improved IT platform, continuous quality
improvement processes and innovative funding models based on risk stratification had a significant
impact on improving clinical outcomes.
51
In order to implement risk stratification systems such as these, it is important to develop effective ways
of predicting a person’s risk level. A well-known model is the combined predictive model (CPM), which
is used in the United Kingdom. This risk stratification tool places consumers into four segments, based
on their relative risk of unplanned hospital admission in the next 12 months.155 Consumers in the top
0.5 per cent segment are predicted to be 18.6 times more likely to have an emergency department
admission than the average population.155 Most of these models require a data set that links primary
health care, hospital care and ideally social care data at the consumer level (although this can
sometimes be challenging to obtain).156 A review of the CPM found that including GP practice data, in
addition to secondary care data, significantly enhanced the ability to identify long-term conditions and
understand the necessary clinical interventions for risk groups.155
Historically, obtaining such data has proved difficult in Australia due to fragmented consumer-level
data sets, but a number of initiatives are underway to resolve this. For example, the NSW Agency for
Clinical Innovation (ACI) is currently developing and testing risk stratification tools for use in
integrated care strategies,94 and will be testing various risk stratification approaches at several
locations over the next 6 to 18 months.94 The program focuses on developing consumer selection
approaches and selection methodologies in order to redesign NSW’ Chronic Disease Management
Programme.94
FIGURE 5.1153
PCMH risk stratification of consumer population pyramid
Share of
population
Rank by care band and approximate total cost per patient
Share of
costs
32%
2%
~$40,000
Catastrophic
conditions
8%
Multiple long term
conditions
At risk of long term
conditions
Stable
Healthy
28%
~$10,000
24%
20%
$3,000
$1,000
$300
20%
10%
50%
6%
52
FIGURE 5.2
5
Population-based funding systems that allocate funds based on projected needs
Internationally, many countries adjust funding distribution for population-based payments based on
predicted risk.157 While this is not strictly a formal consumer segmentation method, it does adjust
resource allocation to populations based on risk, and clinicians are then free to tailor individual care
based on their own assessment of need. In these countries, resources are typically allocated on the
basis of age, gender, previous utilisation of services, health status (which can be defined by the
number and severity of health issues), or other related components (such as socioeconomic
background, demographics) that may affect the risk status of consumers (Figure 5.3).158
53
FIGURE 5.3
158
Adjustments used for capitated funding payments
% of surveyed
countries1,
Adjustment used for capitation
Not used for capitation
2014
Adjustments
26%
47%
47%
63%
74%
53%
53%
37%
Utilisation
of Services
Gender
Health Status
Other2
1 Surveyed countries include Canada, Chile, Czech Republic, Estonia, Hungary, Ireland, Israel, Italy, Netherlands, New Zealand, Poland, Portugal,
Slovak Republic, Slovenia, Spain, Sweden, Switzerland, Turkey, United Kingdom
2 Not listed
5.2 MEDICAL HOMES AND ENROLMENT
Some primary health care systems have chosen to build their care models around a single ‘health care
home,’ where people enrol with a single provider, which becomes their first point of care and
coordinates other services around the consumer.159–161 Proponents of this system argue that it improves
care coordination, reduces duplication and enhances accountability.160 Enrolment is a pre-requisite for
population-based funding (Section 4.3) and payment-for-outcome schemes (Section 4.3), as well as
comparing provider performance (Section 7.2), because these mechanisms all require the ability to
associate a particular population with a particular provider.
5.2.1 Australia’s system
Australia does not have a formal system for consumer enrolment, and people seeking primary health
care are free to attend any primary health care provider.160 In practice, 67 per cent of consumers always
see the same GP, and an additional 25 per cent may see a different GP but always attend the same
practice.162 Nevertheless, there is no formal accountability for ongoing management, and GPs are
frequently not aware of how they perform relative to other health professionals.130
54
5.2.2 Alternative approaches
Many health care systems around the world have implemented consumer enrolment systems. In most
cases, this is voluntary, although it is mandatory in the United Kingdom and the Netherlands if people
are to receive publicly funded health care.
One example that is particularly relevant for Australia is New Zealand’s PHO program. Prior to 2001,
New Zealand did not have primary health care consumer enrolment. Like Australia, care was provided
on a fee-for-service basis, and consumers could move between providers as desired. In 2001, however,
New Zealand set up PHOs, and providers and consumers were given the option of signing up.163,164 For
providers, this meant adopting standardised electronic medical records, switching to a populationbased funding model and supplying data to a central agency on outcomes and quality of care for their
enrolled population.125,163 For consumers, it meant registering with a PHO and using it as their single
point of primary health care. New Zealand financially incentivised uptake,164 with providers receiving a
one-off signing fee (to cover the cost of necessary IT equipment and process redesign), as well as a fee
for each person enrolled.125,163 Consumer incentives included a reduction in fees for GP visits and
prescriptions. These financial incentives contributed to over 95 per cent of New Zealanders signing up
to a PHO.165 The program has been linked with an increased focus on quality improvement (including
clinical facilitation) and improved data collection, data quality and feedback to member
practitioners.164
People are also able to voluntarily enrol in health care homes in the United States. An increasing
number of health insurers offer PCHMs as part of their efforts to reduce overall costs and improve the
quality of care. These represent a new model of organising primary health care, with a focus on: (1)
providing comprehensive care for an individual’s physical and mental health care needs, which often
requires the co-location of physicians, nurses, pharmacists, social workers, educators and care
coordinators; (2) gaining a deep understanding of the consumer; (3) coordinating between secondary
care and allied health; (4) improving access through technology and enhanced in-person hours; and (5)
ensuring quality and safety through CQI, decision-support tools, and robust data collection.
Examples of PCMHs include HealthTeamWorks in Colorado; CareFirst BlueCross BlueShield in
Maryland, Washington, D.C. and Virginia; Intermountain in Utah; and HealthPartners in Michigan.166
PCMHs typically use a blended, three-part payment model, which consists of a monthly, risk-adjusted
care coordination payment; a visit-based, fee-for-service component; and a performance-based
component for delivering on defined quality and efficiency goals, which is generally funded through
secondary care cost savings.167 Although peer-reviewed studies on the impact of PCMHs have returned
mixed results, a 2015 meta-review of the existing literature showed favourable results for reducing
cost, reducing utilisation of hospital and ED services, improving clinical outcomes and enhancing
consumer satisfaction. The Illinois Health Connect program, for example, achieved annual Medicaid
savings of 6.5 per cent, an 18.1 per cent reduction in its adjusted hospitalisation rate, a 5.0 per cent
reduction in its adjusted emergency department visit rate, and an 85.8 per cent user recommendation
rate.168
55
In Norway, enrolment is with an individual GP, rather than a practice, and consumers are free to
choose in the open market. Since 2001, the social security office has carried out the enrolment process,
which is governed through the Regular Practitioners Scheme. Consumers can change their GP a
maximum of twice in a 12-month period, but there is a legislated right to request a second opinion.160
While the program is optional, over 98 per cent of the population have enrolled with a GP. Two thirds
of GPs are happy with the program, and the number of people who are very happy with the primary
health care system rose from 32 per cent before the program was launched to 44 per cent three years
into its rollout.169 Concerns about potentially perverse incentives in Norway have been raised in the
academic literature (e.g., incentivising long patient lists and rationing consultations), but research has
concluded that both concerns are unfounded.170
In the Netherlands, insurance funds require consumers to enrol with a GP to receive care. Consumers
are only enrolled with one GP, but they can change physicians within their assigned practice. The
funding model is mixed, with practices receiving €54 per year, per consumer, as well as €9 for each
consultation.160 Enrolment is managed via an electronic registry, which also supports financial
administration of the system. Similarly, consumers in the United Kingdom have to go through a
mandatory enrolment process in their area of residence to obtain an NHS number. Once assigned to a
GP, consumers can change to a new practice without notifying their prior GP or practice.160 While
drawing a causative link between enrolment mechanisms and consumer outcomes has not been
attempted in the United Kingdom or the Netherlands, an article published by the Commonwealth Fund
suggests that continuity of care in the United Kingdom and the Netherlands has been facilitated
through consumer enrolment in a single general practice. 160
Australia has experimented with consumer-centred medical home models. The most recent example is
the DCP, which gave people with diabetes the option of enrolling with a general practice. The practice
then received population-based and outcome-based payments, as well as regular reports on the
progress of their enrolled population.5 Nearly 8,000 people from 154 general practices signed up to the
project during the six-month enrolment period.5 Enrolment was slightly skewed towards sicker people,
possibly as a result of higher financial incentives for those with out-of-range metabolic indicators or
comorbidities.5
5.3 EDUCATION AND SELF-MANAGEMENT
To achieve sustainable improvement in health outcomes, people with chronic diseases must take an
active role in their health management and care. Education and self-management programs aim to
empower people by providing information and teaching them skills and techniques to improve their
ability to take care of themselves. There is ample evidence that these programs can improve people’s
clinical condition and quality of life.171,172 Surveys also consistently show that consumers want more
information about their health conditions and treatment options, as well as the skills to self-manage
their condition.71 Consumer education and self-management are especially beneficial for those with a
chronic condition, where only the consumer can be responsible for his or her day-to-day care over the
lifetime of a condition.
56
The advent of digital technologies in the last decade makes it possible for people to take a more active
role in their care by making it easier to find information, self-monitor a condition, interact with other
people with the same condition and receive support to make better decisions. This trend is already well
established—a study of 13 developed and developing countries found that nearly 9 out of 10 people
have used the internet to find health information and advice71—but it is set to accelerate in coming
years.
As health care becomes increasingly focused on long-term conditions, behavioural change in
consumers will become increasingly important.173 Health care professionals must ensure that they
engage consumers (rather than treating them as passive recipients of care) and encourage them to selfmanage some of the aspects of their chronic disease.174 To facilitate this, consumer engagement and
experience should be emphasised during clinical training.175
Over the past 30 years, governments throughout most OECD countries have encouraged consumers to
contribute to the planning and development of health services by setting standards for consumer
feedback mechanisms. These feedback mechanisms, in turn, enhance customer engagement,
encourage customer awareness and increase levels of self-education.176
5.3.1 Australia’s system
The national approach to health literacy is led by the ACSQHC. This includes a national statement and
guidance on implementing and integrating health literacy for clinicians, consumers and health
administrators. Through this approach, the ACSQHC aims to encourage a variety of different
organisations to think about what they can do to address health literacy across health, education and
social services.177
Australia has many education and self-management programs for people with chronic diseases. These
include government-funded initiatives such as the National Diabetes Services Scheme178—which
provides subsidised access to diabetes-related equipment and information on managing diabetes—and
state-level initiatives, such as the Diabetes Self-Management (DSM) initiative in Victoria. The DSM
initiative funds the delivery of services that aim to assist people with type 2 diabetes to improve their
capacity to manage the condition, prevent diabetes complications, and improve their health and wellbeing.179 Recently, the Australian Government’s Sharing Health Care Initiative also explored whether a
range of community education interventions for people with chronic diseases were suitable for scaleup.180 NGOs also provide a range of programs. Dose Adjustment for Normal Eating (DAFNE), for
example, is a program for people with type 1 diabetes, which has been shown to improve blood glucose
control and improve quality of life.181
The MBS also contains a number of items that support consumer education and self-management. For
example, people with chronic diseases are eligible for care plans and team care arrangements, which
set goals and activities for consumers and their care teams. People can also receive up to five individual
visits and eight group visits to allied health professionals, such as dieticians, diabetes educators,
57
exercise physiologists and podiatrists, all of whom provide education and coaching on managing
different conditions.182,183
5.3.2 Alternative approaches
While Australia already provides a great deal of support to people with chronic disease, there are three
areas in which Australian efforts could be expanded:
■
Peer support programs
■
Technology-enabled education programs
■
Provider-led education and self-management programs
In addition to the three areas described in this section, Section 7.1 describes five digital tools that can
be applied to support people with chronic disease, including (1) telehealth and mobile health tools; (2)
remote monitoring devices; (3) electronic medical records (EMRs); (4) team-based software; and (5)
decision-support engines.
Peer support programs
These programs match two or more people with the same chronic disease so that they can provide
coaching and support to one another. There are a number of academic studies that demonstrate that
peer support programs can provide significant clinical and psychological benefits by targeting specific
behaviours and consumer empowerment.184 For instance, telephone or face-to-face peer support
programs have been shown to significantly improve blood glucose control in people with diabetes,185
while online peer support programs can improve knowledge, social support and people’s selfefficacy.186 Many peer support programs, however, focus on a single disease, which can present a
challenge for people with multiple chronic diseases.187–189 To date, there are few interventions that
provide peer support for people with multiple chronic conditions.184 For this reason, evidence
demonstrating the effectiveness of peer support programs for people with multiple chronic conditions
is limited and needs to be further explored.184,190 Research indicates that interventions that focus on
particular conditions in people with multiple chronic conditions may be the most effective way of
offering consumer education.184 The current trend towards peer support programs that focus on a
single disease could be related to funding sources and guideline development, both of which
predominantly focus on single diseases. One approach to providing cost-effective access to peer
support programs is to create online consumer communities, such as patientslikeme (PLM), which
allows consumers to share information on their health experiences and the organisations that support
them (Figure 5.4).191 The self-reported benefits of PLM include a better understanding of the condition
(reported by 58 per cent of participants), greater control over the condition (reported by 50 per cent of
participants), reduced side effects (reported by 27 per cent of participants), and improved adherence to
clinical guidelines (reported by 27 per cent of participants).191
58
FIGURE 5.4
191
Technology-enabled education programs
Opportunities created by the digital world are beginning to transform consumer education and selfmanagement.
One approach to engaging and educating consumers involves adopting a fully implemented platform
that enables consumer education and chronic disease self-management, such as Kaiser Permanente’s
My Health Manager (which is linked to Kaiser’s EMR system, HealthConnect).51,192 Innovations include
the ability to take online health assessments and access health information remotely. HealthConnect
and My Health Manager have improved consumer behaviours and led to better health outcomes. A
study of Kaiser members in Hawaii, for example, found that the number of office visits by consumers
fell by over 25 per cent between 2004 and 2007. 51,192
There are also several international examples that illustrate the role mobile health can play in
preventing chronic disease or treating consumers with chronic conditions. One trial, for example,
provided evidence that regular support messages sent by text message helped people to quit smoking
in the short term.193 Similarly, findings from a mobile phone-assisted diabetes self-care pilot
program194 demonstrated that consumers engaged in the program valued the mobile phone case
manager system highly and used hospital services less frequently (both ED visits and subsequent
hospitalisations).194 Consumers who engaged in a mobile health study in the United Kingdom also
reported good compliance and better access to self-management interventions.195
59
Provider-led education and self-management programs
People with chronic diseases are often poorly engaged in managing their condition,196 and there is
significant variation in the quality of care and the support they receive to do so.197 People with complex
or multiple chronic diseases (especially those who are older) may be best supported by tailored
education provided through their health professionals.188
There are several provider-led education and self-management programs available internationally,
many of which are worthy of consideration. The Expert Patients Programme (EPP), for example, is a
comprehensive self-management program for people in the United Kingdom living with one or several
chronic conditions. While GPs retain overall responsibility for managing care for people with multiple
chronic diseases, the EPP provides complementary support for consumers by increasing their
confidence, improving their quality of life and helping them to manage their condition more effectively.
For example, the program offers advice on coping with pain, extreme tiredness and feelings of
depression; provides relaxation techniques and exercises; and offers guidance on healthy eating,
communicating with family, friends and health care professionals, and planning for the future.198 While
the program has been shown to improve consumers’ confidence, there is no evidence to date that the
EPP has reduced hospitalisations.199
In the United States, different primary health care providers have successfully adopted different
techniques to deliver provider-led education to people with multiple chronic diseases.188 Some of the
most commonly used techniques include: (1) increasing consumer participation in care through
collaborative goal-setting, using motivational interviewing (MI) as a counselling approach (which has
been shown to be effective in engaging consumers);200 (2) improving communication with consumers
using techniques such as consumer activation through skills training (e.g., coaching consumers to take
a more active role in the clinic visit) and pre-visit questionnaires;201 202 and (3) fostering and engaging
consumers in behaviour change. One tool that can be applied to achieve behaviour change is the
Chronic Disease Self-Management Program, developed by Lorig et al., which includes content on
exercise, symptom management, managing negative emotions, health care professional to consumer
communication, nutrition, fatigue management, and other topics applicable to people with multiple
chronic diseases.203
60
Chapter 6: Primary health care professionals
The role of the health professional workforce in primary health care is critical to the outcomes and
sustainability of the system. The following chapter focuses on:
■
Clinical leadership: The involvement of clinicians in driving improvement and the
progression of primary health care delivery.
■
Workforce composition and roles: The roles and responsibilities of general practitioners,
nurses, allied health professionals and specialists in primary health care delivery.
■
Provision of care coordination: The person(s) responsible for coordinating
communication and activities between consumers and health professionals (who may be a
general practitioner or specialised coordinator).
6.1 CLINICAL LEADERSHIP
Clinical leadership is central to achieving effective, efficient and sustainable health care for people with
chronic disease.204,205,206,207–212 Clinically trained managers bring many advantages to the system,
including an ability to understand clinical challenges, proficiency in communicating with clinical staff,
and credibility amongst the clinical workforce.204 Research in the United Kingdom and the United
States, for example, found a strong relationship between the number of managers with a clinical
background and performance,204 and organisations that increased the number of clinical leaders over
time saw the greatest improvement in management scores.
Health systems need to encourage clinical leadership among health professionals at all levels and in all
positions.207,213 Creating a sense of shared responsibility and providing opportunities to drive
improvement across all health care professionals can facilitate and encourage effective teamwork and
communication.214 Encouraging and supporting clinical leadership amongst nurses has been identified
as particularly important. Davidson et al. (2006) have argued that nurse leaders are needed at every
level of leadership and should be involved in strategic planning, mentorship and leader
responsibilities.215 Health Workforce Australia has similarly highlighted that nurse leadership is
fundamental to productivity improvements, developing positive workplace cultures, and workplace
retention.216
6.1.1 Australia’s system
Clinical leadership was identified as one of five system concerns for sustainability in the National
Health Workforce Innovation and Reform Strategic Framework for Action 2011–2015.217 The report
suggested five strategies for creating sustainable leadership in the health system, including developing
a nationally consistent leadership framework, working with regulators and accreditation authorities to
incorporate leadership competencies into education, and directly working with clinical leaders.217
61
Australian health professionals can access Australian-based and international leadership development
programs. For example, the Clinical Excellence Commission has been running annual External Clinical
Leadership Programs (CLP) in New South Wales since 2007,218 which now attract approximately 300
health professionals each year.218 Practitioners receive training to help them understand effective
governance, core leadership competencies required for health care, and strategies for generating a
culture of continuous improvement, safety and quality.218 Although there has been no formal
evaluation of the program, participant feedback indicates that it represents a worthwhile investment in
personal development.219
Leadership programs have also been adopted in some Australian universities. Edith Cowan University
in Western Australia, for example, introduced a leadership program as part of the extracurricular
studies organised for fourth-year nursing students.220 The program focuses on foundational leadership
knowledge, and pairs participants with leader mentors from local health organisations.220 Initial
results demonstrated a positive shift towards effective and open communication among participants,
as well as improved leadership confidence and personal and professional growth, although the longterm program benefits have not yet been measured.220 In 2010, the University of Queensland (UQ) also
introduced a leadership training program, offered jointly by the UQ School of Medicine and UQ School
of Business.221 High-performing students accepted into the program study three courses in strategy,
human capital and leadership, accumulating credit towards a graduate certificate in executive
leadership.221 To date, there has been no formal research or evaluation of the performance of
graduating students.
While the availability of clinical leadership programs is encouraging, an evaluation of these programs
by Health Workforce Australia (HWA)212 found that leadership opportunities disproportionately favour
physicians over nurses and allied health professionals. The evaluation also identified a number of
design shortfalls in leadership programs.212 Only 20 per cent of programs, for example, incorporate
forms of action delivery, and only 10 per cent offer mentorship support or in-situ training.212
The Australian Primary Health Care Research Institute has recommended the establishment of a
national primary health care clinical leadership development program, tied to the achievement of
specific service changes and improvement.222 At the most basic level, programs like this can begin to
shift health professionals’ mindsets and opinions on leadership and its critical role in improving
outcomes.223
In 2013, HWA released its ‘Health LEADS Australia’ leadership framework, with the goal of creating a
people-focused health system that is equitable, effective and sustainable (Figure 6.1). Health LEADS is
designed to be the national reference point for all health care professionals; all health care
organisations; all national, state and territory agencies; and all training and academic bodies. The
guiding principles of the Health LEADS Australia framework are: 1) ownership of leadership by all
individuals in health care, and 2) the perpetual need for personal and professional development at all
levels to shape the future of Australia’s health system. It is intended that, over time, Health LEADS
Australia will be supported with further tools, stories, networks and programs.224
62
FIGURE 6.1
224
6.1.2 Alternative approaches
Internationally, two interventions have been adopted to improve clinical leadership:
■
Leadership education for those in training
■
On-the-job leadership training and programs
Leadership education for those in training
University curricula and postgraduate training programs provide a foundational opportunity to deliver
leadership skills and knowledge to health professionals. Running educational programs on leadership
as part of a university degree exposes students to leadership skills, allows students more time to
develop these skills before formally joining the workforce, and helps to motivate and encourage
students to become more enthusiastic about clinical leadership.221,225
Some countries have taken a lead in promoting clinical leadership among trainees. In the United
Kingdom, for example, the NHS has developed a Medical Leadership Competency Framework (MLCF)
to be used in undergraduate and postgraduate medical training curricula. The framework consists of
five core domains (Figure 6.2), and expectations around knowledge depth and competence are
determined by career stage and progression.214 The framework has been used to support leadership
curricula in undergraduate medical schools in the United Kingdom and has been integrated into 58
63
specialty curricula of the Medical Royal Colleges and Faculties for postgraduate studies.214 It has also
been incorporated into the Department of Health’s eLearning for Healthcare (eLfH) project (known as
LeAd) to provide postgraduate trainees with leadership resources.214
In the United States, clinical leadership education for medical students is decentralised to medical
associations (such as the American Medical Association and the American Medical Student Association
[AMSA]), industry bodies and individual medical schools, all of which offer various leadership
development programs. The American Medical Association, for example, provides online modules,
leadership positions, scholarships and fellowships for medical students,226 while AMSA offers sixmonth mentorship and leadership courses for medical and pre-med students.227 Individual medical
schools offer mentorship, shadowing opportunities and leadership conferences, such as the Leadership
Development Program at John Hopkins Medicine.228
Despite the prevalence of such programs, a systematic review of leadership training in 24
undergraduate medical curricula across the United States, the United Kingdom, Canada, Switzerland,
Sweden and Israel found that curricula did not generally influence student behaviour or deliver
quantifiable results (for cost, quality or efficiency metrics).229 The review did, however, highlight some
common design choices: 71 per cent adopted longitudinal programs, and 46 per cent catered to both
preclinical and clinical students. Only 28 per cent employed clinical faculty to run the programs.229
FIGURE 6.2
214
On-the-job leadership training and programs
64
On-the-job opportunities can be created for primary health care professionals to develop leadership
and management skills through formal clinical leadership programs, secondments to clinical
improvement projects and internal leadership support (e.g., mentorship or celebration of leader
achievements).
Kaiser Permanente’s leadership development program illustrates how leadership initiatives can
facilitate improved outcomes in health organisations. In the late 1990s in Colorado, KP redesigned its
leadership development program for physicians, explicitly positioning clinical leadership at the
forefront of its strategy for improving consumer outcomes230 and collapsing traditional barriers
between clinicians and managers. As Swanwick and McKimm (2011) explain, “Clinicians are actively
encouraged to take on senior management roles, and quality improvement projects are seen as
internally generated rather than externally imposed.”231 Five years after these changes were
implemented, consumer satisfaction in Colorado had increased, staff turnover had fallen dramatically,
and net income had risen from zero to $87 million.230
The ChenMed model of care provides unique vocational leadership development for its physicians. Its
medical centre layout (modelled after an ambulatory intensive care unit) encourages physician-led
collaboration with other medical staff, and physicians are required to attend morbidity and mortality
meetings three times a week to share case examples and encourage peer review.232 Physicians are also
given mentorship and research opportunities and are required to develop business acumen.232 The
ChenMed model has received widespread praise and has produced higher adherence rates (compared
to traditional drug treatment plans), lower hospitalisation rates and industry-leading net promoter
scores from consumers.232
In the United Kingdom, the NHS has emphasised that leadership is critical to providing safe, highquality care. The NHS Leadership Academy focuses on leadership development and change
management and is based on a new model for leadership, which highlights nine dimensions of
leadership behavior (Figure 6.3). This model informs the clinical leadership programs and tools that
are available to health professionals and organisations.233
65
FIGURE 6.3
234
The Darzi Fellowships (part of the London Leadership Academy), for example, are based on this model
and provide cohorts of clinicians in the early stages of their careers with 12-month fellowship posts
designed to develop their capabilities as clinical leaders.235 Over 200 fellows have been allocated posts
through the program, with cohorts expanding from medical trainees in secondary care specialties to
clinicians from all disciplines and in primary and secondary care.235 A 2011 evaluation of the program
found that it had a significant and positive impact on fellows’ growth, knowledge and mindsets.235
Although it is not possible to link organisational or system-wide outcomes to individual fellows, the
review indicated that there had been positive impacts in both areas.235
Other regions have adopted different approaches. For example, North West London—the United
Kingdom’s biggest integrated care trial—introduced a Change Academy initiative, which includes the
Transformational Leadership Program. The program is aimed at operational and clinical leaders and
offers five core modules over the course of a year, which focus on creating “whole system” vision,
problem solving, change strategy and influence models, using information to improve outcomes and
sustaining change.
Encouraging health professional engagement and participation with these programs remains a
problem, however. Overcoming this challenge will require clinicians to become more interested in
clinical leadership and managing organisations.230 Programs need to be easily accessible and functional
for practitioners, and systems may need to incentivise health professionals (either financially or by
other means) to participate in leadership activities or training.
66
6.2 WORKFORCE COMPOSITION AND ROLES
The composition of the health professional workforce has important implications for the quality,
accessibility and financial sustainability of the health system.62 Generally, it is acknowledged that
health care systems should enable different groups to perform at the top of their skill level, utilising the
full extent of their training and education (known as working at the ‘top of their licence’).236 This
improves people’s access to qualified professionals and increases economic efficiency by having the
least costly person perform a given function, freeing up more qualified personnel to concentrate on
tasks where they can add the most value. Although primary health care provision has traditionally been
the responsibility of general practitioners, an increasing demand for care and increasing recognition of
the roles and capabilities of allied health and nursing disciplines have prompted a shift in
accountability to other health professionals in some health systems.237–239
6.2.1 Australia’s system
Australia’s primary health care workforce consists of GPs, nurse practitioners, nurses and allied health
professionals. GPs represent approximately 48 per cent of the health practitioner workforce in
Australia,16 and in 2012, there were approximately 26,000 registered GPs across the country, which
equates to 112 full-time equivalent GPs per 100,000 people.4 Despite increases in absolute supply,
population growth and working patterns meant that there was no change in full-time equivalent GPs
per capita between 2007 and 2012 (unlike specialist physician numbers, which have been growing
steadily) (Figure 6.4).240 In contrast, while the number of nurse practitioners remains relatively small
(there are currently 1,214 NMBA-endorsed nurse practitioners in Australia), there has been a 10-fold
increase over the last three years.241,242 The number of practice nurses in Australia has also grown
significantly, tripling from 3,255 in 2003–04 to 10,759 in 2010–11 (Figure 6.5),12 and there were over
126,000 allied health professionals across multiple practitioner types in 2012, including psychologists
(23 per cent of allied health professionals), pharmacists (21 per cent) and physiotherapists (19 per
cent).13 However, the health workforce is not evenly distributed across Australia. For example, there
are approximately 137 GPs per 100,000 people in major cities, compared to approximately 87 GPs per
100,000 people in remote or very remote areas.240 The Department of Human Services offers four
programs to incentivise greater provision of services in rural areas, including the General Practice
Rural Incentives program, the HECS Reimbursement Scheme, the Rural Procedural Grants Program
and the Rural Locum Education Assistance Program.243 Despite these initiatives, it remains
challenging for people in remote communities to access health services.
67
FIGURE 6.4
240
Growth in medical practitioners in Australia, 2007-12
Employed medical practitioners FTE (40 hour week) per 100,000 population
CAGR1
2007-12
302
300
69
60
4%
284
279
272
Specialists-in-training
52
50
Specialists
115
114
121
123
128
2%
General practitioners
112
108
112
110
112
0%
2007
2008
2009
2011
2012
51
Note: 2010 data not available
1 Compound Annual Growth Rate
FIGURE 6.512
Growth in practice nurse numbers in Australia, 2003-04 to 2010-11
Estimated total number1 per 100,000 population
+17% p.a.
41
46
49
43
36
30
25
16
2003-04 2004-05 2005-06 2006-07 2007-08 2008-09 2009-10
2010-11
1 Numbers based on an estimate, by Divisions, of the number of practice nurses working in their catchments, calculated to per capita based on
population statistics
68
Consistent with their growth in numbers, the role of practice nurses in Australia has expanded in
recent years, facilitated by changes in MBS items for nurses, financial incentives (discussed in Section
4.4.2 on the PNIP) and support from the Commonwealth’s Nursing in General Practice Program.244
Practice nurses can currently claim six MBS items on behalf of a GP, including the Healthy Kids Check,
follow-up services with Indigenous people, monitoring support for people with chronic diseases,
antenatal services and telehealth items.245 A growing body of literature suggests that practice nurses
can play a critical role in managing workforce supply and improving the quality of care and consumer
experience.244,246,247 A 2009 study by Phillips et al., for example, identified six roles for practice nurses,
including carer, organiser, quality controller, problem solver, educator and agent of connectivity.244
Despite common acceptance of practice nurses in each of these roles, the study suggests that GPs do
not recognise nurses as educators or problem solvers.244
Allied health professionals are another major component of Australia’s primary health care workforce
and are responsible for providing direct care to consumers through diagnosing, rehabilitating and
monitoring health care.248,249 The use of allied health services has grown rapidly. In 2013–14, for
example, 4.8 million individual allied health services were provided, and $257.5 million was paid in
benefits—a 16.7 per cent growth in services from 2012–13.143 Sixty-one allied health MBS items can be
claimed by a limited number of eligible allied health professionals, including Aboriginal health
workers, audiologists, chiropractors, diabetes educators, dieticians, exercise physiologists, mental
health workers, occupational therapists, osteopaths, physiotherapists, podiatrists, psychologists and
speech pathologists.250 Most of these items are only available to consumers who have been placed on a
Chronic Disease Management Plan (‘care plan’) and Team Care Arrangement by their GP.
In addition to the above, roles for nurse practitioners (NPs) and physician assistants (PAs) are also
emerging. Both roles have existed overseas for several decades, but remain relatively new in
Australia.251–254
6.2.2 Alternative approaches
Discussions about ideal workforce composition and potential roles have been occurring for a number
of years in Australia and overseas, particularly because of the unequal distribution of health care
professionals across remote and urban settings.255,256
Two approaches that could be considered for Australia in this context are:256
■
Expanding the scope of traditional roles to operate to “top of licence”
■
Expanding and scaling up new and emerging roles
69
Expanding the scope of traditional roles
Bodenheimer and Smith (2013) argue that for most systems, creating new health professional roles will
not be sufficient to address physician supply shortages.257 Instead, strategies such as empowering
licenced personnel, expanding the role of registered nurses or pharmacists, creating opportunities for
non-licenced health professionals, introducing consumer self-management of care and adopting
technology to increase capacity have been suggested.257
Role redesign has been used in several systems around the world to manage supply shortages and
costs, and to improve effectiveness and efficiency. In 2001, for example, the Changing Workforce
Programme (CWP) established 13 pilot sites within NHS organisations in the United Kingdom, focused
on four main areas of workforce change: (1) skill mix changes, achieved by shifting tasks up or down a
hierarchy, usually through role substitution; (2) job widening, achieved by expanding the
responsibilities associated with different roles, or by merging the roles of two different individuals; (3)
job deepening, achieved by enriching the content of roles to include more significant, substantial
responsibilities; and (4) new role creation, achieved by forming a new position.258 Examples of role
redesign include extended roles for nurses, technicians, welfare rights assistants, health care assistants,
laboratory assistants and pharmacy assistants.258
In 2004, role extension and redesign was listed by the NHS Modernisation Agency as the 10th element
in the 10 High Impact Changes for Service Improvement and Delivery report, which focused on
opportunity areas for administrative and clerical roles, assistant practitioners and advanced
practitioners.259 One successful example of this was the Accelerated Development Programme, in
which 49 Trusts and GP services worked to reduce doctors’ administrative burden by enhancing the
role of medical secretaries to include greater responsibilities for consumer co-ordination, and by
increasing IT use. Doctors in participating organisations reported between 0.5 and 15 hours of extra
time per week, per doctor (an average of 2.75 hours), resulting in extra capacity to see between 4 and
27 additional people per week.259 The benefits of role extension and redesign include improvements to
service delivery, consumer experience, clinical outcomes and career opportunities for staff.259
Expanding and scaling up new and emerging roles
Expanding and scaling up new and emerging roles may represent another solution for supply
imbalances. Two roles have recently been introduced to Australia: nurse practitioners (NPs) and
physician assistants (PAs). These roles are different; most notably, NPs are licensed professionals,242
while PAs are unregulated.52,260,261
NPs are educated to a master’s degree level, and their role includes the direct referral of consumers to
other health care professionals, prescribing medications and ordering diagnostic investigations.262 NPs
have been introduced (or are being considered for introduction) in approximately 70 countries,252
including the United States, the United Kingdom and Canada, where strict licencing requirements
apply.252
70
There are approximately 1,210 endorsed NPs practising across Australia,242 compared with 200,000
licensed NPs in the United States,263 where NPs recently celebrated 50 years of role development.251 In
Australia, NPs were initially part of the hospital environment (particularly in emergency departments
and hospital diabetes clinics), but in late 2010 they were introduced into primary health care and given
limited access to the PBS and MBS.264 One study from the United Kingdom showed that consumers
were generally more satisfied with care from nurse practitioners, compared to general practitioners.265
Research has also found that nurse practitioner consultations were significantly longer and consumers
reported being provided with more information, with no notable differences for the other outcomes
studied.265 Another study in the United States concluded that fully integrating the contributions and
skills of all primary health care practitioners and, specifically, the contributions of nurse practitioners
is a vital policy step towards achieving high-value health care.266
As with the NP role, the PA role was developed in the United States over 50 years ago in response to
clinician supply shortages.253,267 PAs have since been introduced to primary health care in other
developed systems, including Canada, the Netherlands and the United Kingdom.267,268 Evidence on
PAs’ contributions to primary health care is limited and mixed, and large knowledge gaps make it
difficult to evaluate the benefits and risks.267 However, a study of consumer perceptions of PAs in the
United States found that while half of the respondents would prefer a physician as their primary health
care provider, 49 per cent of respondents would (in a theoretical scenario) opt for a PA or nurse
practitioner, or would have no preference. Respondents’ rationales for this preference varied, though
most related to greater accessibility, lower cost, perceptions of more personalised care and positive
prior experience.269 Findings from one literature review suggested that PAs may be particularly well
suited to rural health practices because of their diversity, cost efficiency and broad range of skills.270
This has also been suggested by the Grattan Institute (see Section 2.3).52 In Australia, O’Conner and
Hooker (2007) have suggested introducing PAs to primary health care. For example, PAs could be
integrated into practices alongside GPs or into rural practices, or could fill designated positions in
Aboriginal and Torres Strait Islander communities.268,270 This was also acknowledged by the
Productivity Commission, which suggested that physician assistants could diagnose, perform
examinations, prescribe medicines, make referrals and perform other tasks currently performed by
general practitioners.71
A common concern is that care quality will be compromised if less qualified people perform certain
tasks.256 It is challenging for policy makers to determine which activities are appropriate for different
health professional roles, and continuous monitoring is often necessary.256 It is also necessary to
ensure that appropriate training and standards are in place for all health professionals (discussed in
Section 5.4 on training and standards). Inter-professional barriers may also limit the expansion of nonpractitioner roles. These barriers are underpinned by assumptions about the roles and capabilities of
nurses and allied health professionals, as well as the traditionally hierarchical relationship between
doctors, nurses and allied health professionals.271 Although cultural shifts are hard to achieve,
challenging these assumptions is critical to successfully expanding the role of health professionals.
71
6.3 PROVISION OF CARE COORDINATION
The term ‘care coordinator’ is used interchangeably with several other titles, including care/case
manager, care facilitator, health coach, care navigator, and ambassador. Some literature distinguishes
between these positions,272–274 but for the purposes of this document, they are discussed collectively as
care coordinators. The core responsibilities of a care coordinator are to manage communication
between stakeholders (including GPs, nurses, allied health professionals and specialists); organise care
(e.g., scheduling appointments, reminders); and support consumers as they navigate health care
systems (e.g., educating consumers on which health professionals to see, explaining processes). Care
coordinators are particularly beneficial for consumers with complex needs, such as co-morbidities or
chronic diseases, many of whom require care delivery from multiple practitioners across the health
care system.274–276 In aged care, care coordination facilitates support for older people who wish to
continue living at home but need support to do so.
The Commonwealth Fund’s National Scorecard argues that a lack of appropriate care coordination
increases costs, undermines effective care and increases safety risks and quality risks for consumers.277
Care coordination can play an important role in reviewing the appropriateness of services, and can be
set up at arm’s length from practices and providers of health services. Two elements of the care
coordination role should not be confused: its practice-based care coordination role, and the case
management role (as used by insurers such as motor accident and work cover schemes).
6.3.1 Australia’s system
In Australia, GPs are traditionally considered to be primary health care coordinators for consumers.
Approximately 59 per cent of Australian practices employ an additional care coordinator for
consumers with serious chronic diseases, but this percentage is much lower than in countries such as
New Zealand (68 per cent), the Netherlands (73 per cent) and the United Kingdom (78 per cent).278
Between 2012 and 2016, approximately three million people (roughly 16 per cent of the population
aged 15 or above) received care from three or more health professionals for the same condition.279 Of
these consumers, approximately one third did not receive care coordination assistance from a health
professional (either a GP, a medical specialist or a nurse).4 Additionally, 21 per cent of all adults aged
65 years and older self-reported at least one care coordination problem in the past two years.280
6.3.2 Alternative approaches
Although coordination roles have existed in many systems in some capacity for some time, the care
coordinator role is still maturing,281 and there is a growing body of literature that focuses on how a care
coordinator can make care more proactive, rather than reactive.273,276,282,283 Although there are many
models for providing care coordination, this section focuses on having a dedicated care coordinator.
The nature of this role can vary considerably depending on several factors, including:
■
Intensity of care: There are various degrees of care coordination, ranging from basic
administration through to intensive clinical interventions. In the United States, for example,
72
Indiana’s Care Select care coordination program delivers care management for low-need
groups primarily via telephone, while high-need consumers with multiple chronic diseases
receive intensive, in-person care coordination.284 Risk stratification tools can be used to
identify groups of consumers that require higher levels of intervention and tailored support
from care coordinators (discussed in Section 5.1 on consumer segmentation).140 Due to the
relatively high cost of a dedicated care coordinator, it is generally more efficient for care
coordinators to focus on a sub-set of high-risk, high-cost consumers.283 The intensity of care
required by these consumers will usually dictate the number of people cared for by a care
coordinator.
■
Type of care: Systems should consider the type of coordination this role can offer: clinical,
administrative, or both. Clinical responsibilities include assessing (and regularly checking)
consumer health performance and needs, developing and enforcing care plans, facilitating
communication between health care providers and providing self-management education.274
(Responsibilities do not include activities such as interpreting test results, making diagnoses or
prescribing treatments). Alternatively, care coordinators can adopt a more administrative
approach, helping consumers to navigate the health system, organising the scheduling of care
services and following up on care plans.274
■
Appropriateness of coordinators: Coordinators may come from a variety of backgrounds,
including clinical work, social work, counselling, management and others.274 The American
Medical Association suggests that the care coordinator role should be filled by professionals
with clinical, financial, administrative or social experience, or with a background in
education.285 The dominant model in many systems suggests nurses fill coordinator roles, but
there is ongoing debate about the most appropriate candidates for care coordination.
Care coordinators can improve consumer experience by building strong, empowering relationships
with consumers. These relationships can then be utilised to address consumer distrust and cynicism
towards health systems, which can often lead to non-compliance with treatment or plans.273
Coordinators can also address language and cultural barriers, providing customer service that timepoor health professionals are often unable to deliver.273 Disadvantaged populations that receive
services from care coordinators report improved continuity of care and are more likely to complete
prescribed treatments.273
Despite these advantages, health professionals need to be conscious of the extent to which care
coordinators are utilised throughout the system. If multiple system levels (e.g., primary health care,
secondary care, community care) develop their own care coordinator roles, there may be too many
coordinators without clear, distinct roles, creating additional complexity and burdens for
consumers.286
Several international health systems are already using care coordinators:
■
The Community Care of North Carolina PCMH program provides service to 14 local networks
across the state.284 In an effort to improve quality of care and reduce costs, case managers are
73
employed by these networks, and are responsible for assisting practices in identifying high-risk
consumers, providing disease management education, assisting coordination of care for access
to services, and collecting performance management data.284,287 Some large practices employ
full-time, on-site case managers, while some smaller practices share a care manager.284 Initial
evaluations of the PCMH found that targeted care management interventions (amongst other
factors) helped to achieve significant savings, particularly for high-risk consumers.287
■
In the United Kingdom, the borough of Torbay has introduced health and social care
coordinators within each primary health care team. Their role is to liaise with members of the
team to arrange the necessary care and support, while acting as a single point of contact for
consumers.288 Coordinators have access to both health and social care records, which provide
them with all the relevant details about consumers’ conditions and care, and which help them
to identify complex, unstable and intermediate care cases within their zone. This enables them
to work closely with nurses, allied health professionals and social care staff to arrange and
modify care packages and proactively coordinate care with the multidisciplinary team.288
Although coordinators are not professionally qualified, they are expected to work closely with
professional staff.288 The integration of health and social care in Torbay has had a significant
impact: Hospital bed days decreased by 3 per cent between 2007–08 and 2010–11, and the
average length of stay was approximately 20 per cent lower in Torbay, relative to its peer
strategic health authority, South West.
■
Aetna is a complex care management program, which operates in California and focuses on
Medicare Advantage consumers. Case managers are responsible for approximately 1,000
consumers each, although the majority of their time and effort is focused on the top 20 per cent
of consumers (i.e., the high-risk consumers, who typically have five or more chronic conditions
or complex needs).289 Case managers are integrated into practices and work closely with the
care team. An evaluation of the program found 24 per cent fewer hospital admissions and 39
per cent fewer long hospital stays (greater than 15 days) for participants in the program,
compared to unmanaged Medicare consumers, exclusive of denials.289
■
BlueCross BlueShield PCMHs have introduced designated care coordinators across the United
States. For example, the CareFirst PCMH introduced a complex case management program,
which provides members with a case manager who is responsible for navigating medical care
services, assisting in the development of treatment plans, and providing education on care
options and community health services.290 To date, there has been no formal review of the
program to evaluate its clinical and cost impact.
■
Geisinger Health Plans utilise nurse care managers as care coordinators and embed them in
primary health care practices to provide support to the multidisciplinary team.291
Responsibilities include consumer education, referrals to community health care services,
coordination of ongoing self-management of care, follow-ups, home assessments and
evaluations of long-term care.291 The degree of care intervention for consumers varies based on
74
risk stratification. For example, low-risk consumers receive self-management education, care
plans, and follow-up phone appointments,292 while high-risk consumers receive more frequent
phone check-ups, referrals and reviews of care plans.292 Evaluations of the care coordinator role
are not publicly available.
To date, several initiatives have been launched in Australia to create care coordinator roles in both
primary and secondary care, starting with the Australian Care Coordination Trials in the 1990s (see
Section 4.1.1). Examples of other initiatives are outlined below.
■
In New South Wales, a chronic disease management program (CDMP), Connecting Care in the
Community, focuses on consumers with complex care needs and high risk of hospitalisation.293
A 2014 evaluation of this CDMP found that participation in the program was associated with a
decrease in planned acute service use and an unexpected increase in unplanned acute service
use.294 However, regression to the mean (as a result of the evaluation design) makes it difficult
to evaluate the real impact of the program.294
■
The Cancer Institute NSW also funds care coordinator positions. Care coordinators are
responsible for coordinating consumer care across services, delivering consumer-centred care,
and providing information and education to consumers.295 A 2011 evaluation of cancer care
coordinators found them to be effective in improving care, particularly consumer experience.295
The evaluation also found that coordinators were particularly important in ensuring timely,
appropriate referrals for support services.295
■
In Queensland, the Metro North Brisbane Medicare Local runs a Team Care Coordination
program, which provides consumers with a team of registered nurse coordinators responsible
for supporting GPs and the care plan team and providing follow-up services.296 Although no
formal evaluations of clinical benefits have been conducted, initial feedback from participants
has indicated positive consumer experiences and attitudes towards the initiative.296
■
Since 2012, Tasmania Medicare Local (through the Tasmanian Health Assistance Package
[THAP]) has supported the Improving Care Coordination for People with Chronic Disease and
Aged Care Clients Program (the Care Coordination Program). This program is responsible for
several coordination activities, including assisting with access to services, education, tools and
resources for self-management, medical records, communication between health professionals,
care plans and feedback. These services are provided by qualified health workers (either nurses
or other qualified health professionals). The program aims to target four main chronic disease
types: (1) neuro-degenerative disorders (NDD); (2) chronic obstructive pulmonary disease
(COPD); (3) type 2 diabetes; and (4) cardiovascular disease (CVD). Care coordinators may also
access a flexible funding pool, which can be used to access goods or services to improve
consumer care (such as specialist services, transport, equipment and medical aids, or
community-based services). Although no formal evaluations have been undertaken, the
program is expected to benefit approximately 10,000 people per year once fully operational.297
75
■
The Care Coordination and Supplementary Services (CCSS) Program was introduced in 2009
as part of the Commonwealth’s Indigenous Chronic Disease Package (ICDP).293 The CCSS
program—which focuses on referred Aboriginal and Torres Strait Islanders with at least one of
five target chronic diseases—has now been rolled out across the country. As part of the
program, a qualified health worker (either a specialist nurse or an Aboriginal and Torres Strait
Islander health worker) functions as a dedicated coordinator, responsible for assisting with
care support and navigation of the health system.293 A formal review of the CCSS is being
undertaken in 2014–15.298
■
Facilitators were also engaged as part of the Australian DCP to facilitate communication
between multidisciplinary care teams, offer holistic care to participants and provide a central
contact point for consumers and health professionals.5 Their main responsibilities included
reviewing consumer data, booking case calls, scheduling and managing the availability of allied
health professionals, educating consumers and supporting GPs and nurses.5 Care facilitators
were independently funded by the DCP Project Management Office, which introduced an
additional diabetes care expense per consumer, per annum. Only one of the trial’s intervention
arms utilised care facilitation, and this group was the only group to experience improvements
in outcomes.5
■
Medibank Private’s CareFirst chronic disease management program, introduced in 2014,
utilises care navigators as part of its aim to improve population health and service utilisation.299
Teams based in call centres are responsible for helping members organise appointments and
navigate care logistics.299 A formal evaluation of this program has not yet been conducted.
■
Silver Chain is an example of comprehensive care co-ordination for older people. It offers to
coordinate care at home and bring in the following elements of care: health needs (including
nurse visits, rehabilitation, physiotherapy, and wound care); everyday wellness (including help
with showering and grooming, getting dressed and managing medication); and everyday
household tasks and community connections.300 Silver Chair also offers co-ordinated
restorative health care programs at home through the Home Independence Program (HIP) for
older consumers, and the Personal Enablement Program (PEP) for those leaving hospital.
These programs have been proven to reduce the likelihood of using more comprehensive
personal care services, limit the likelihood of being unable to live at home, limit hospital
admissions and reduce the occurrence of death in older people within five years of joining the
program.301
Care coordination can also play an important role in reviewing, at arm’s length, the appropriateness
of services provided by GPs and primary health care practices.302 Current domestic examples of this
include the Department of Veterans’ Affairs, private health insurers, and motor accident and work
cover schemes. As part of the Department of Veterans’ Affairs Coordinated Veterans’ Care Program
(CVC), for example, community nurses from a contracted community nursing provider coordinate
treatment services as per the GP’s care plan, but also regularly assess, review, update and renew
76
consumer care plans, factoring in their appropriateness.303 When dealing with motor accidents and
work-related injuries, care coordinators typically help people with severe injuries find the most
appropriate treatment options, while case managers coordinate administrative requirements and the
insurance assessment. In New South Wales, for example, care coordinators and case managers are
provided by the NSW Lifetime Care and Support Authority.304
While care coordination at arm’s length from GPs has the advantage of reviewing the appropriateness
of care, markets dominated by private sector insurers (such as the United States) engage in ongoing
debate about the legitimacy of private insurance companies providing equitable care coordination.305
77
Chapter 7: Primary health care systems and processes
The following chapter discusses the elements of primary health care systems and processes. It is
divided into four parts:
■
Digital health: The systems and electronic tools that improve access and quality of care for
consumers, enable clinicians to make more informed decisions, enhance the connectivity
between primary and secondary care, and reduce costs for providers and payers.66
■
Information transparency: The data captured by the health system and made transparent
to stakeholders, including health care professionals (for example, in relation to how individual
health care professionals deliver care compared to peer benchmarks) and consumers (for
example, in relation to their health and the way in which they interact with the health care
system).
■
Continuous quality improvement processes: The methods and tools used to ensure that
the quality of care provided by primary health care professionals is continually improving.
■
Care pathways: The protocols used by health care professionals to standardise care across
consumers, with the aim of reducing variation between health care professionals.
7.1 DIGITAL HEALTH
Five digital health tools are increasingly influencing the way in which primary health care is provided:
■
Telehealth and mobile health tools. Telehealth refers to the delivery of health services via
telecommunication technologies, including phones and videoconference platforms. This can be
as simple as a remote GP consultation or as sophisticated as facilitating robotic surgery
between facilities over vast distances.306 Mobile health refers to the use of mobile technologies
to deliver health care services, such as health education, disease prevention, diagnostics,
treatment advice and prescription dispensing and refills.307,308 Together, these tools enable
better coverage for consumers in remote locations and rural Australia, consumers who face
mobility challenges, and consumers who are active in leveraging mobile devices to manage
their health and wellness. Both technologies provide fast and interactive access to the health
system.
■
Remote monitoring devices. These devices give consumers, particularly those with chronic
diseases, the ability to self-manage their condition. People with chronic conditions
disproportionately benefit from remote monitoring.309
■
Electronic medical records (EMRs). EMRs enable the full integration of consumer data
across primary, secondary and community care settings.4 Linking EMRs and improving
information exchange leads to enhanced communication, better quality of care, reduced
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medical errors, more consistent adherence to guidelines, more effective monitoring of
immunisation rates and increased staff productivity.174 However, studies have shown that the
return on investment for EMRs is often not immediately positive, and can be difficult to
quantify. This is attributed to both the cost of EMR systems (which typically cost more than the
paper systems they replace) and the delayed impact of stronger data linkages on quality and
cost of care, which are often not realised immediately.310–313
■
Team-based software. This supports the provision of integrated care for people with chronic
diseases by making it easier for a multidisciplinary team of GPs, practice nurses and other
health care providers to coordinate their work.
■
Decision-support engines. These harness global advances in medical research and
knowledge to assist health care professionals in making informed decisions (for example, when
administering medications).314 Decision-support engines have proven effective in preventing
adverse drug events and are likely to become increasingly prevalent health care tools.315
Collectively, digital health tools can improve the quality of health services and reduce costs.62 They also
provide opportunities to track health conditions and their treatment over time, which is particularly
important when treating people with chronic diseases who often have extended treatment times.316
7.1.1 Australia’s system
Australia has a long history of investing in digital health and embedding it within the broader health
care system, at both the national and the state level. In 1993, the National Health Information
Agreement (NHIA) came into effect,317 and the Australian Government has since supported primary
health care practices in implementing IT systems, electronic medical records and digital health
through the Better Practice Program and (from 1998 onwards) the PIP.
Since 2000, Australia’s system has undergone four major changes:
■
In 2000 and 2003, respectively, HealthConnect and MediConnect were established to leverage
different health systems in Australia and trial initial standards for the implementation of
EMRs.
■
In 2005, the National eHealth Transition Authority (NEHTA) was created to drive digital
health initiatives, supported by both the Federal Government and state governments.71
NEHTA’s purpose is to lead the uptake of health systems of national significance, and it has
been building the foundations for a national EMR since 2010.318 NEHTA has established
documentation and recommendations for terminology and secure messaging standards; made
progress in encouraging vendor support for including specifications and standards in releases
of their software products; established the elements of My Health Record; and collaborated on
establishing the Unique Health Identifier (UHI) proposal.318 The Australian Commission for
eHealth will replace NEHTA in July 2016.319
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■
In 2011, the Australian Government introduced the specialist telehealth initiative, with the dual
aims of improving access to health services and up-skilling health professionals in rural and
remote locations. The initiative included payment of a $6,000 incentive for joining, a $60
service incentive for specialist telehealth consultations, and a $20 telehealth bulk-billing
incentive. These amounts were paid in addition to the usual MBS consultation schedule.320 The
telehealth initiative also provided financial incentives to eligible residential aged care services
to enable participation in telehealth consultations with specialists, consultant physicians or
consultant psychiatrists. While the financial incentives ceased in June 2014, health care
professionals continue to receive higher Medicare benefits for telehealth services.321 To date,
the Australian Government has not introduced incentives for telepharmacy services or
telehealth to the home in the primary health care setting.322
■
In 2015, the Australian Government launched the personally controlled electronic health
record (PCEHR, recently renamed My Health Record). By May 2015, approximately 2.25
million people and over 7,700 health care practices had registered to participate in the system,
although utilisation of the records by health care professionals remains variable.
Despite these major transitions, opportunities exist to expand the use of digital health elements.
Firstly, Australia still relies heavily on physical health care, with limited scope for—and uptake of—
telehealth and mobile health consultations.307,321 This is especially true in rural areas, where
educational and administrative uses of telehealth are strong, but the use of telehealth technology for
clinical applications has been limited due to bureaucratic and procedural barriers, as well as
participant hurdles.323
Secondly, limited subsidies for remote monitoring devices have restricted consumers’ ability to selfmanage their chronic conditions. For example, while the MBS funds insulin pumps, continuous
glucose monitoring devices and sensors are not currently available for subsidy.324 Finally, although
financial incentives have been introduced to encourage practices to use EMRs, actual activity around
electronic medical records has been limited. Approximately 2.25 million people have registered, but
only 1,727 specialist letters have been written, and only 30,300 consumers have viewed their
records.325 There has also been limited uptake of clinical decision-support tools beyond those
integrated into clinical information systems.326
7.1.2 Alternative approaches
Australia can draw upon a number of international approaches to digital health in order to:
■
Expand online, telehealth and mobile health
■
Achieve greater integration of remote monitoring devices in primary health care
■
Expand integrated EMRs
■
Use team-based care software
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■
Provide decision support through advanced clinical assistance tools
Expanding telehealth and mobile health
Several international examples demonstrate the value of telehealth in the public and private sectors.
■
Public sector: In the United Kingdom, the Airedale NHS Foundation Trust pioneered the use
of telehealth technologies to support integrated care outside the hospital environment,
including aged care homes. This reduced hospital admissions from care homes by 35 per cent,
accident and emergency attendances by 53 per cent, hospital length of stay by 11 per cent, and
total bed days by 50 to 60 per cent.327,328 In Canada, telehealth consultations have been
introduced in various primary health care settings. A detailed study of 190,000 clinical sessions
found that telehealth consultations led to improved access, quality (for example, improved
disease management and health coordination), and productivity. Consumers in rural locations,
for example, participated in 94,000 clinical sessions and saved C$70 million in travel costs,
while 25 clinicians saved 496 days of health care professional travel and avoided $20 million in
inpatient costs.329
■
Private sector: In the United States, WellPoint’s LiveHealth model provides both telehealth
and mobile health tools, which offer consumers advice without having to see a doctor.330
Consumers can communicate with doctors in real time and choose health care professionals
based on geographic location and language preference. Other providers in this sector include
DrThom in the United Kingdom,331 which offers a photo upload service for visible problems,
and Zoomcare in the United States,332 which provides consumers with diagnoses, treatment
plans and prescriptions through e-visits. Kaiser Permanente has also successfully expanded its
mobile offerings, with a study in northern California attesting to positive growth and impact
trajectories for its mobile health applications (which comply with the Affordable Care Act).333
At Kaiser Permanente, care delivery has now expanded well beyond office visits, and by 2013,
secure e-mails accounted for 33 per cent of primary health care consumer encounters.334
Achieving greater integration of remote monitoring devices
Remote monitoring devices measure vital statistics and levels, facilitate real-time or delayed review by
health care professionals, and are effective tools for health management, disease prevention, diagnosis
and treatment advice. Using such tools, health care professionals can remotely monitor and manage
the health of people with chronic conditions such as heart disease (through wireless electrocardiogram
sensors and a mobile phone), diabetes (through a glucometer and insulin pump), and asthma (through
a spirometer).335 iRhythm’s Zio Patch, for example, is a single-use patch (powered by Amazon’s cloud
computing software) that provides continuous heart monitoring for 14 days and assists in the diagnosis
of arrhythmias. Zio detects 57 per cent more arrhythmias than standard techniques, and referring
health care professionals confirm that the Zio service aids in a definitive diagnosis 90 per cent of the
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time.336 Wearable monitoring devices, such as the Lively watch, can reduce the number of consumers
who do not recover from a fall (62 per cent of people do not recover if help does not arrive within an
hour),337 while monitored people incur 75 per cent fewer costs compared with unmonitored people.338
The Lively watch also provides an emergency button to call an ambulance and can monitor daily
activities including taking medication, using the shower, walking (steps per day), and opening the
fridge door.339 Quietcare is a similar solution that uses sensors in people’s homes, passive monitoring
and data analytics to interpret a consumer’s daily activity levels, providing notifications to family
members or other designated caregivers when those patterns change (e.g., as a result of deteriorating
dementia).340
Several studies have demonstrated the benefits derived from integrating remote monitoring devices
into care pathways. For example, a study of people participating in the Alere Heart Failure Program in
the United States documented a 69 per cent reduction in hospitalisations and a 60 per cent reduction
in costs after only one year.341 A study of people using the Accu-Chek Complete Glucometer and
modem, meanwhile, documented a 14 per cent improvement in compliance with target glucose levels
for monitored consumers after six months.341 Finally, a meta-analysis of 15 reviews published between
2003 and 2013 indicated that, in combination, home telemonitoring interventions reduce the relative
risk of all-cause mortality and heart failure-related hospitalisations, when compared with usual care.
Expanding integrated EMRs
EMRs enable the integration of databases across primary, secondary and community health care
settings. Expanding the use of EMRs on a system-wide basis (including the private sector) facilitates a
comprehensive approach to gathering consumer data, which in turn facilitates targeted allocation of
funding and other resources for the benefit of consumers. EMRs enable health professionals and
consumers to better ‘connect the dots’ in a health journey, leading to improved care.316
In the United States, Kaiser Permanente’s personal health record (known as My Health Manager) is
directly connected to its HealthConnect consumer platform. This platform provides members with
access to their health information 24 hours a day, seven days a week, as well as health management
tools, which they can use to e-mail their health care professionals, schedule appointments and refill
prescriptions. Kaiser Permanente’s EMR is used by Kaiser’s approximately nine million members,
facilitating communication between members and health professionals (who also have access to the
latest treatments to ensure members receive the right care at the right time). It has reduced
ambulatory care visits by over 20 per cent, and there has also been a 26 per cent reduction in the office
visit rate, a 25 per cent reduction in the primary health care visit rate, and a 21 per cent reduction in
specialty care visits since the EMR was introduced.75
While Kaiser Permanente provides an excellent example of an effective EMR, a study from McGill
University has shown that although primary health care professionals can realise a positive financial
return by implementing EMRs, benefits are typically not achieved in the short term.311 In the long
term, however, evidence suggests that stronger data linkages improve the quality of health care and
82
reduce costs, thereby mitigating the cost of EMR implementation. Indeed, a research study that
examined the benefits of EMRs at the practice level concluded that achieving a return on investment is
a realistic goal even for smaller practices, although it noted that much of the return on investment
consists of efficiency gains and increases in revenue.310
EMRs also deliver non-financial benefits. Geisinger—an integrated health care provider in the United
States—has established an EMR system that improves the targeting of treatments, information
transparency, clinical decision making and adherence to protocols, as well as reducing variation in
care.132 In the United Kingdom, VitruCare supports consumers through internet-delivered services,
offering personalised support for creating a self-care plan and converting clinical data (i.e., the EMR)
into actionable information. The care plan is then discussed with the consumer’s GP and put into
action. VitruCare’s features have made it easier and more convenient to track progress on a personal
care plan (for example, a smartphone can be used to enter data), and consumers report that VitruCare
has helped them to achieve health objectives such as weight loss.342
Team-based care software
Team-based software has been shown to assist multidisciplinary teams in treating people with chronic
diseases, and Australia, the United Kingdom, the United States and other countries have introduced
team-based software with some success.
In Australia, software called cdmNet has been extensively trialled as part of the Australian
Government-funded Digital Regions Initiative. This trial found that cdmNet could better integrate care
for people with chronic disease and make it easier for a team of GPs, practice nurses and other health
care providers to manage both chronic care and prevention. The effectiveness of cdmNet is evidenced
by: (1) improved clinical outcomes for people with diabetes;343 (2) improved quality of care, measured
by adherence to best practices; (3) improved systematic care;344 and (4) increased review and follow-up
ratios.343
cdmNet was also trialled as part of the DCP. When combined with funding incentives, it proved a
successful tool for driving clinical outcomes in group two of the DCP trial. It did not change clinical
outcomes by itself, however, due to modest uptake among practitioners in group one of the trial.5
Other software with similar functionalities is available in Australia, including MMEx software (which
was trialled through the University of Western Australia’s Centre for Software Practice)345 and Extensia
(which uses a combination of the RecordPoint and EPRX systems).346 Globally, there are hundreds of
software providers offering team-based medical software.
In the United States, most team-based software applications align with Health Information Exchange
(HIE) guidelines. HIEs have been established in several health networks and states throughout the
United States,347 and have been shown to increase collaboration between different levels of care
(although studies have only been conducted on a small scale to date).348 Standards similar to those
developed by the HIE also exist in many European countries, including the United Kingdom349 and
83
Germany,350 where health care professionals and practices have a choice of selecting from multiple
software providers.
Decision support through advanced clinical assistance tools
Computers can help health professionals make diagnoses and select treatment choices. The advantage
of decision-support engines is that they can process large amounts of information and search it
quickly, exhaustively and quantitatively. 351 IBM Watson is a useful example of a clinical decisionsupport system (CDSS) that uses cognitive technology to provide holistic diagnoses. It provides
diagnoses by evaluating a clinical situation against a multitude of scientific journals, using natural
language processing, hypothesis generation and evaluation, and dynamic learning to generate a list of
responses ranked in order of probability.352 IBM Watson is currently being tested in the Memorial
Sloan-Kettering Cancer Center (MSK) and has a successful diagnosis rate of 90 per cent for lung
cancer, compared to just 50 per cent among human doctors.353 Clinical Point of Entry (CPOE) is
another decision-support system that has been tested and reviewed multiple times. In Boston, for
example, the CPOE tool was used to assess whether incidences of adverse drug events could have been
avoided. A total of 180 adverse drug events occurred in 141 consumers, 75 per cent of which were found
to have been preventable had the CPOE decision-support system been implemented. 354
7.2 INFORMATION TRANSPARENCY
Australia has the potential to improve the efficiency of its health care system by improving the capture
and storage of data, as well as the dissemination and transparency of data to stakeholders, including
health care professionals and consumers. Public reporting on care outcomes and consumer behaviour
has had mixed results. It has been shown to improve the accuracy and quality of data,71 and improving
transparency can also drive better service, both because consumers use the information to make
decisions about their care, and because health professionals use the information to continue to
enhance the quality of care they provide.71 There is also evidence that engaging consumers in their own
care improves consumer experience and contributes to successful outcomes.4,71,355 However, a 2011
Cochrane review on the impact of public releases of performance data on behaviours and care
outcomes showed that the evidence was inconclusive (although the study was based on a review of four
North American trials, which differed from one another in methodology and outcome indicators,
making comparison difficult).356
7.2.1 Australia’s system
Any consumer who has registered for the national My Health Record has access to their health
information, including MBS and PBS data, discharge summaries, event summaries and, in some cases,
a shared health summary (if curated by a relevant health professional).357
84
Historically, however, providing consumers with transparent information on provider performance
and cost has been challenging in Australia. Private insurer nib Insurance faced opposition from
industry groups when it first published ratings of health care specialists on its ‘whitecoat’ website, and
from the Australian Medical Association (AMA) when it attempted to establish a ratings site in 2011.358
Despite this opposition, nib Insurance later re-launched its whitecoat website (whitecoat.com.au),
which now provides publicly available contact details and ratings information (via a ‘Comparative Cost
Score’ and a ‘Likelihood to Recommend Score’), as well as comments about customer service
experience.359
A limited amount of primary health care data for consumers is also published on the My Healthy
Communities website—a public website that allows consumers to compare their PHN with others
across Australia, based on general health outcomes, use of services, and overall experience with health
services, expenditure, and GP care. Specific information on individual primary health care
professionals is not available, however, and the data currently provided is from 2009 to 2013 only.360
There is ongoing advocacy for greater transparency, and in 2012, the Australian Commission on Safety
and Quality in Health Care reiterated the need for greater transparency for consumers and funders as
part of the national primary health care strategy.361
7.2.2 Alternative approaches
There are four areas in which information transparency can be provided:
■
Information transparency for providers
■
Information transparency for consumers about providers and health care professionals
■
Cost transparency for clinical decisions in primary health care
■
Public data transparency to enable vendor-led innovation
Information transparency for providers
Capturing and analysing data on quality, experience and cost helps providers (e.g., individual
practices) develop an objective understanding of their performance, which encourages selfimprovement.362
In the United Kingdom, comprehensive practice-level performance data are published in three ways:
primary health care statistics are published on the Health and Social Care Information Centre (HSCIC)
website;41 quality outcomes are published through the QOF, which also governs incentivisation;41,363
and consumer feedback is published on the NHS Choices website.364 The comprehensiveness and ready
availability of performance data in the United Kingdom means that feedback from both payers and
consumers can be quickly addressed at the GP practice level. Performance data are also used for
benchmarking and incentivising quality and outcomes under the QOF, which forms part of the general
medical services contract between providers and the government.127 The QOF contains over 120
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indicators, which cover clinical processes for managing particular conditions.41 Most of the QOF
evaluation studies indicate that the initiative has reached most of its objectives,363 and there has been a
notable performance increase for most of the clinical indicators.364
The QOF has had its critics, however. A particular concern relates to the lead times for developing
performance indicators. A comprehensive review of evidence is needed to validate these indicators, and
critics fear that indicators may be superseded by the time they are implemented. It has also been
suggested that the incentives are counterproductive (as discussed in Chapter 4).41 Regular reviews of
the QOF are mitigating these concerns, and there is regular consultation between payers, providers and
consumers to continuously improve the QOF framework.127 While few health systems include
consumer feedback in performance metrics for providers and health care professionals, the NHS has
also incorporated a ‘Friend and Family’ test into the NHS Choices website, which asks consumers
whether they would recommend their GP practice to friends or family.364,127
In the United States, there are hundreds of individual feedback schemes.127 In the public sector, which
is governed by the Medicaid and Medicare schemes, performance data are provided to both providers
and consumers.127,365 The Centres for Medicaid and Medicare Services (CMS) also publishes provider
data through its website and holds regular seminars for health care professionals to improve
performance and compliance with set quality metrics. The CMS’ Physician Feedback Program (PFP),
meanwhile, provides comparative performance information to health care professionals and medical
practice groups in order to improve the quality and efficiency of medical care provided to Medicare
consumers. In the private sector, performance data are often not publicly available. Despite this,
however, integrated private online platforms have started to rate physician practices, and providers
like Kaiser Permanente and ChenMed report quality metrics and physician ratings as part of their
continuous quality improvement programs.366
Information transparency to consumers about health professionals
Increasing information transparency for consumers about health professionals involves a bidirectional sharing of information, allowing the consumer to see information about a health care
professional’s performance and quality, and to provide feedback/ratings for the health care
professionals they see.
There are several international examples of health care systems with increased transparency around
health care professional performance. In the United Kingdom, for example, the NHS Choices
information service provides consumer ranking for GP practices, including rankings on working hours
and location, the range of services offered and appointment scheduling systems.364
In the United States, ZocDoc allows consumers to compare doctors online and book online or inperson appointments. A recent study on ZocDoc highlighted the increasing importance of consumer
reviews, demonstrating the following: 1) an increase of half a star in a ZocDoc rating (on a scale of one
to five stars) leads to a 10 per cent increase in the likelihood that a physician will fill an appointment;
2) health care professionals with a higher number of reviews have a higher likelihood of filling an
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appointment; and 3) consumer ratings capture consumers’ visit experience and the educational
differences of health care professionals.367
Cost transparency for clinical decisions in primary health care
Cost transparency for consumers includes making the prices of investigations and prescriptions
apparent at the time of ordering.
In the United States, Medicare and Medicaid (CMS) have released over 1,800 data sets, which include
statistics on Medicare spending, costs, utilisation, and quality at the state, hospital referral region and
county level. CMS releases include information on the quality performance of hospitals, nursing
homes, and other providers like small practices.368 In 2014, CMS released data on Medicare payments
for services provided by 880,000 health care professionals, including the number and type of services
provided by each physician, the average allowed payment, and the average Medicare payment paid to
health care professionals. In 2015, CMS released data on physician utilisation and announced that
entrepreneurs and innovators would receive full access to Medicare data. Releasing the data set is
expected to inform consumers’ and insurers’ provider choices, and to ultimately reduce variation in
health care professionals’ fees.368 To date, the data release has been successful in focusing attention on
specific examples of high-cost services, and the data release has since been expanded.368
Public data transparency to enable vendor-led innovation
Numerous companies in the United States have become innovators in digital health care, driven
primarily by the CMS data releases.369 Innovative new companies that leverage open data sets include:
■
Sensentia—a mobile application that anticipates and automates the inquiry system process of
any health insurance company370
■
Kuveda—an online platform that provides options in personalised cancer therapy to consumers
and health care professionals371
■
RowdMap—a tool that enables users (primarily payers, providers and researchers) to view and
analyse benchmark data from hospitals, physicians and geographies372
■
Carevoyance—a platform that maps physicians across the United States, based on financial
information, prescription activity, consumer interaction and other physician relationships373
■
HealthyMe—a consumer engagement and intervention web platform and mobile application
that supports population health management for newly discharged consumers, as well as those
who might be at risk of chronic conditions (for example, diabetes)374
■
Proteus Digital Health—a company offering a medicine adherence program through an
ingestible sensor ‘pill,’ which combines the capabilities of wearable, mobile and cloud
computing technologies.375
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7.3 CONTINUOUS QUALITY IMPROVEMENT PROCESSES
Continuous quality improvement (CQI) processes help a system to iteratively identify barriers to
improvement, implement changes, and measure impact. Although there are numerous CQI models,*
they all aim to improve quality of care, and they typically include discussions about performance
outcomes amongst health care professionals, followed by idea-generating sessions to identify
continuous improvement opportunities, both for the individual practice and the system as whole.125,71
They have been shown to decrease variation in care quality;125 improve consumer care and
satisfaction;125 increase efficiency;125 encourage closer cooperation and teamwork among primary and
secondary care professionals, departments and health networks;51 increase job satisfaction among
staff;376 and decrease treatment complications.212,377
CQI processes and performance management tools can be implemented at all levels of the primary
health care system, including the federal level, state level, PHN level, practice level and individual
health care professional level.125 In primary health care, CQI has typically been attempted in large
institutions and non-clinical domains, where it has motivated considerable efforts to refocus health
care delivery. At the practice level, quality improvement faces unique challenges because of the
diversity of consumers and problems, the small scale of many practices, and the low volume of specific
conditions.378,379 However, a trial with 44 primary health care clinics in the United States identified
three factors as critical to successfully implementing CQI processes in primary health care
environments: (1) create a deep understanding of CQI among health care professionals, nurses and
administration; (2) complete all the steps of the CQI process; and (3) create opportunities to discuss
the process as a team.380
The lack of data on care processes and outcomes in primary health care is an on-going problem for
applying evidence-based practice. CQI approaches have the potential to address this challenge by
facilitating the use of local-level data, whilst utilising suitable standardised data sets that are available
system-wide.381
7.3.1 Australia’s system
To date, Australia has not implemented a national CQI process in primary health care. However, the
new PHN performance framework plans to provide a mechanism to monitor and improve primary
health quality and performance.324,27 The framework will include three tiers of performance (national,
local and organisational) and use existing data collections where possible, and the performance
information on all PHNs will be made publicly available.324 Combined with publicly available
guidelines, reporting performance outcomes allows PHNs to benchmark themselves against one
another and identify areas for improvement.
* Examples in health care include FADE (Focus, Analyse, Develop, Execute), PDSA (Plan, Do, Study, Act),
Lean Six Sigma and Total Quality Management.
88
Any CQI system developed in Australia will need to include consumer feedback. ‘Standard 2’ of the
National Safety and Quality Health Service (NSQHS), developed by the Australian Commission on
Safety and Quality in Healthcare (ACSQHC), requires that 1) Australian health organisations and
systems establish governance structures to form partnerships with consumers and carers; 2)
consumers and carers are actively supported to participate in designing care; and 3) consumers are
included in the ongoing monitoring, measurement and evaluation of health system performance.
Similarly, the Royal Australian College of General Practitioners (RACGP) sets out several criteria to
ensure consumer collaboration, of which one is called ‘patient feedback.’ This outlines five indicators
for GP practices: 1) processes for seeking and responding to feedback from consumers; 2)
establishment of a complaints resolution process; 3) a process to actively seek feedback about
consumers’ experiences of the practice every three years, using a validated consumer experience
questionnaire or specific method approved by the RACGP; 4) an ability to demonstrate improvements,
where progress has been made in response to analysis of consumer feedback; and 5) provision of
information to consumers about practice improvements made as a result of their input.
7.3.2 Alternative approaches
Continuous quality improvement processes can be implemented in a number of different ways in
public health care systems at the national, local and practice level. There are also examples of CQI
programs that have been successfully implemented in the private sector, some of which span across
primary and secondary health care.
Capio—a leading pan-European health care provider, which offers a broad range of health care services
through its hospitals, specialist clinics, and primary health care—has made CQI the core of its
business.382 Capio’s approach is centred on regular quality improvement reviews, which drive better
treatment outcomes and reduce care-related injuries. Capio argues that quality, in turn, enables higher
productivity and reduces per capita cost, which means that the existing budget can be spent on
providing health care to a larger number of consumers. Capio’s model consists of three steps: analyse
performance indicators, implement changes, and measure outcomes. Measuring outcomes is a teambased effort and is integrated into the overall clinical governance. The system is reinforced through
three sets of quality performance indicators (QPIs): clinician-reported outcome measurements
(CROM); patient-reported outcome measurements (PROM); and patient-reported experience
measurements (PREM) (Figure 7.1).382
Capio applies its CQI models across primary care units, specialist clinics, local hospitals and emergency
hospitals. Through its integrated approach, Capio can provide the right care environment at the right
level for consumers, avoiding costly and unnecessary hospitalisations.382
89
FIGURE 7.1
382
Capio’s 4-step systematic quality model
Outcome
Quality Performance Indicators (QPI)
CROM = Clinical Reported Outcome
PROM = Patient Reported Outcome Measurements
PREM = Patient Reported Experience Measurements
Continuous
development
builds
medical
excellence
Quality
drives
productivity
Process
Follow up
Activities and
process targets
Training
and internal
recruitment
build expertise
and continuity
Create an
organization
for continuous
initiatives
and
improvements
Mirror
operations
in simple
and clear
reporting
Quality plan
Improvement of working
methods that are
measurable, resourceset, has an owner and a
time table
Modern medicine
Good information
Kind treatment
Nice environment
and adequate
equipment
Process measurements
In Australia, a number of programs have tested CQI processes, including the Australian Primary Care
Collaboratives (APCC), the DCP, and the Lowitja Institute’s recommendations for a national CQI
framework for Aboriginal and Torres Strait Islander primary health care.
The APCC is delivered by the Improvement Foundation and is a federally funded program. It brings
together primary health care practitioners in a field-and-forum setting to deliver bite-sized,
incremental quality improvements in processes using their proprietary ‘Model for Improvement.’ Since
2004, the APCC program has helped over 3,000 practitioners improve clinical outcomes across a range
of issues, including access and care redesign, diabetes, coronary heart disease, chronic obstructive
pulmonary disease, and Indigenous health.383 Results have been positive, including a 70-fold increase
in the number of Diabetes Risk Assessments completed by 37 participating practices.383
The DCP trial implemented a CQI process between the National Program Management Office and
primary health care organisations, and between primary health care organisations and general
practices. The CQI process consisted of six steps: (1) define a common performance dashboard and
goals; (2) understand performance; (3) diagnose issues; (4) agree remedial actions; (5) plan and
execute actions; and (6) follow up on progress. While CQI processes on their own did not significantly
change practices, combining CQI processes with alternative funding models improved clinical
outcomes.5
Funding for quality improvement in the Aboriginal and Torres Strait Islander primary health care
sector started in 2002 with the introduction of Continuous Improvement Projects. To date, however,
these efforts have lacked national coordination, prompting a September 2014 recommendation to the
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Department of Health for a national CQI framework for Aboriginal and Torres Strait Islander primary
health care.384
7.4 CARE PATHWAYS
Care pathways are “an integrated source of information on referrals, specialist advice, diagnostics, GP
procedure subsidies and consumer handouts, all of which have been collectively agreed by health
professionals from across the health system”385 and can be used to populate care plans for individuals.
Care planning is particularly important when facilitating appropriate care for consumers with chronic
diseases or complex needs.386 While pathways are mostly implemented at the meso and micro level,
they could potentially be established for a whole segment, such as rural and remote health care.323
7.4.1 Australia’s system
While Australia has a multitude of general clinical guidelines, localised care pathways are not
universally available. The National Health and Medical Research Council (NHMRC) provides a
collection of clinical guidelines via a free-to-access online portal,387 and there are currently 213
NHMRC guidelines for GPs and 49 guidelines for allied health professionals. A further eight guidelines
for primary health care are currently under development.388 Guidelines are also available from multiple
organisations, often covering the same conditions, which can create confusion and variation in care
between providers. Both NSW Health and the South Australian Department of Health, for example,
provide guidelines for managing acute asthma in children. There are also six separate guidelines for
type 2 diabetes.388
7.4.2 Alternative approaches
The main approach is to create locally standardised care pathways for common chronic diseases. In
New Zealand, for example, Canterbury Care’s HealthPathways is a web-based information portal,
which supports primary health care professionals to plan care through primary, community and
secondary health care systems.385 The system provides information on referrals, specialist advice,
diagnostics, GP procedure subsidies and consumer handouts,385,389 and has been designed around a set
of locally agreed best practices. With almost 500 pathways in existence, GPs can now tackle rare cases
more easily.390 Rolling out HealthPathways has reduced both the acute and elective medical length of
stay in secondary care by 13 per cent and 6 per cent, respectively.391
The system has been generally well received by health professionals, with 80 per cent of primary health
care professionals now using HealthPathways more than six times per week.392 Between 90 and 95 per
cent of primary health care professionals consider the system easy to use and a valuable tool for the
improvement of care, and approximately 50 per cent reported that it had improved their relationships
with consumers and hospital clinicians. Approximately 60 per cent of hospital clinicians reported
improvements in referral quality, triage and working relationships with general practices since the
91
introduction of HealthPathways.385 There are, however, concerns about the size of the website and its
prescriptive nature, and the platform has increased the duration of consultations.
Standardised, locally tailored care pathways have also been trialled in Australia. Canterbury’s
HealthPathways, for example, are currently being rolled out in approximately 25 per cent of Australian
PHNs,389 including Hunter & New England,393 the Mid & North Coast in New South Wales, and Perth
Central & East Metro PHNs in Western Australia.394 (In the Hunter PHN in New South Wales, a
customised version of HealthPathways389 has been rolled out to suit local conditions.) While
comprehensive evaluations of these platforms have yet to be conducted, the first study of
HealthPathways in Australia suggests that it has strengthened relationships between GPs and
secondary care specialists.389 The benefits of the HealthPathways platform stem from its process of
engagement with the entire health sector, including specialised community groups, allied health
professionals, GPs, local hospital network representatives and specialists, which creates an opportunity
for dialogue and increased communication between professionals and sectors.389 The ‘Map of
Medicine’ platform—a European alternative to Canterbury’s HealthPathways—is also currently being
rolled out in the Metro North PHN in Perth.
The DCP also trialled standardised care pathways for people in different risk groups, which were
incorporated into care plans by general practices. The pathways contributed to changing referral
patterns, significantly increasing the number of people who saw diabetes educators, exercise
physiologists and dieticians.5
92
Conclusion
Australia’s health system already achieves excellent health outcomes in many areas. In the coming
decades, however, health systems in Australia and around the world will need to adapt and evolve in
order to navigate the changing health care demands of the 21st century, including a growing burden of
chronic disease and rapidly increasing health care costs.
As this paper has demonstrated, there are a number of ways in which Australia could organise and run
its primary health care system for people with chronic disease:
■
Governance and financing: Alternatives include better integrating primary and secondary
care governance structures, introducing new funding sources and incorporating new funding
mechanisms.
■
Consumer interaction with the health system: Alternatives include adopting strategies
to segment consumers in order to tailor resource allocation and care pathways, improving care
coordination (particularly for people with chronic diseases) by introducing health care homes,
and increasing consumer empowerment by expanding education and self-management
programs.
■
Primary health care professionals: Alternatives include strengthening clinical leadership
and governance, expanding the roles of health care professionals other than GPs, and
introducing specialised care coordinator roles.
■
Systems and processes: Alternatives include expanding Australia’s digital health
infrastructure, improving information transparency, implementing continuous quality
improvement processes, and creating locally standardised care pathways for common chronic
diseases.
Australia can be aided in its efforts to make improvements in these areas by drawing on, and learning
from, the experiences of others in the international community. This paper has summarised the main
approaches adopted by other countries around the world, and it is hoped that these examples provide a
useful foundation for discussions about the future of primary health care in Australia.
93
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