Download Models of General Practice - General Practice Registrars Australia

Models of General Practice
Dr Graeme Doherty
MBBS (Syd), BSc(UQ), FRACGP, DRANZCOG
State Medical Director
Queensland
Independent Practitioners Network
Models of General Practice
My GP career…….
- Born, raised and educated on Gold Coast
- Graduated Sydney University 1981
- Joined Family Medicine Program 1982
- Commenced General Practice in Charleville (South Western Queensland) 1983
- Established own practice on Gold Coast 1986 ( then semi-rural ) & still practising as a GP
- Merged with another similar sized practice in Ashmore for economies of scale 1993
- Awarded FRACGP & DRANZCOG 1991
- Current position of State Medical Director (QLD) Independent Practitioners Network
- Have worked in a variety of general practice models
- VMO at 2 local private hospitals and Hopewell Hospice
- Quality Assurance Examiner for RACGP Fellowship Examination
- External Clinical Teacher for General Practice Training Queensland
- Former Regional co-ordinator /nodal educator RACGP Training Program Gold Coast /Logan
region 1993– 2001
- Former academic appointment Bond University Medical Program 2005 – 2011
- Held various positions on local professional bodies – GCDCP / GCLMA
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Models of General Practice
Current Australian GP landscape
DOHA workforce statistics 2014 -15
• Almost 33 000 practising GPs
• Making up 22 000 FTE
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Approximately 40 % female
Approximately 50% aged 45 - 65
• 110 FTE GPs per 100, 000 people
• 5.8 visits per head of population
Models of General Practice
Practice Demographics
• Approximately 7500 practices nationally
• 2400 Solo GP practices
• 3050 practices with 2 – 5 FTE
• 2050 practices with > 6 FTE
Models of General Practice
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Number of solo GPs has halved in the last decade
~ 50% GPs currently work in practices with > 5 FTE doctors
~ 18% of GPs work for corporate companies
Average size of practice is 5.2 FTEs
Fewer home & after hours visits by traditional general practices – after
hours co-operatives /public and private hospital ED
 ? Increasing trend by residential aged care facilities to seek services of
one practice to provide care to all residents in urban communities
 Variety of billing methods –universal bulk billing / mixed billings /
totally private billing (often discounted for pensioners & HCC holders)
Models of General Practice
Solo GP
 Works alone in owned or leased premises
 If owned – local government regulations / town planning /
parking availability etc / maintenance
 Usually without Practice Nurse / Manager
 Minimal staff overheads
 ? Sources locum or closes for leave / illness
 Locum – continuity of patient care but expensive
 Closure – no continuity of patient care
 Responsible for entire practice management
 On retirement is practice saleable / goodwill?
Models of General Practice
Small Group Practice
 Less than 5 FTEs
 Usually with a Practice Nurse and / or manager
 Usually GP- owned Partnership (all equal) vs Associateship
(differences –fixed and variable costs) / Employee –agreed wage
(benefits) / contractor usually incorporated with ABN –usually % of
billings (no benefits no leave entitlements and responsible for own
superannuation and ATO)
 Purpose-built or leased premises – same constraints as solo GP
 Allows continuity of care
 Often able to provide extended hours
 Small staff with or without Pathology collection service
 Still has responsibility for practice management
Models of General Practice
Medium Group Practice
 More than 5 FTEs
 Practice Nurse / Manager support
 Ownership – single GP principal , Partnership, Associateship who
solely or collectively provide management / Corporate / co-located
within pharmacy
 Premises owned (local government regulations) or leased
 Employees without financial interest – agreed salary / incorporated
contractor
 Pathology collection service
 Allied Health services
Models of General Practice
Large Group Practice
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10 GPs plus
Practice Nurse Practice Manager support
Ownership – GP, partnership, associateship, corporate, +/-pharmacy
Purpose built Centre – owned or leased
Co-located services – pharmacy, dental, physio
Pathology collection service
Allied Health services
? Has ability to offer greater work – lifestyle balance
Models of General Practice
Definition of a Corporatisation of General Practice
 Corporatisation of General Practice is defined by the
government “as when a general practice becomes, or is
acquired by, a for-profit company registered under the
Corporations Act 2001”
 A legal entity created through the process of
incorporation
 The aim is to return a profit to its shareholders
 Contracted doctors are major working assets
Models of General Practice
Corporate Models
 Began to appear mid – late 1990’s
 Initially in NSW and WA
 Remain primarily suburban metropolitan but now offering services in some
larger rural communities
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GPs are contracted
Percentage of medical fees (billings v receipts) retained
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Generally in range of 50 – 70 % of billings
Services provided for doctors
- Premises
- Administration staff
- Nursing staff
- IT services – immediate dial in for problems
- Clinical equipment and services
- Further education
Models of General Practice
Corporate Models
GP contracts: Defined period of time for contract
 Complex issues relating to sale of practice – exclusion clauses
 Individual doctors or whole practices
 Different terms / different hours of engagement and leave
 Upfront or graduated lump sum payments – seek financial advice
regarding ATO interpretation – keen interest from ATO recently
 On completion of contract - rolling or renewal of terms – generally
the longer the contract the greater the percentage retained by GP
Models of General Practice
Management structures
Some corporates impose:
• billing practices –generally universal bulk billing
• appointment systems often encourage walk-in arrangements
• may not be able to consult doctor of choice
• referral patterns / prefer exclusivity of association
• Others allow full clinical sovereignty / independent billing
• May have other affiliated services eg skin clinics - ? Further
fragmentation of GP services
Models of General Practice
Advantages of Corporate Models
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Freedom from administration
Freedom to concentrate on patient care
Economic viability/loss of financial stress
Flexibility – hours worked and holidays
Larger infrastructure – education, doctors benefits ( negotiated discounts on
private health premiums / medical indemnity insurance), professional
development
 Larger practices facilitate multi-disciplinary team approach
Models of General Practice
Disadvantages of Corporate Models
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Lack of autonomy / Bound by contract
Loss of control over staff
Standardisation – more formal structures
May lead to less contact with patients / loss of personal touch
Loss of continuity of care in some models
You may not get to choose your colleagues
Problems with management however some models promote GP panel
meetings with executive staff on regular basis and encourage formal
practice meetings
Models of General Practice
Future Landscape: Looking Forward
What does the future look like for general practice?
Does Item-of-Service care represent a sustainable
system?
Two major trends are likely to dramatically change the
GP landscape in the not-too-distant future
- the increasing burden of chronic disease
- increased use of disruptive technologies
Models of General Practice
Chronic disease in Australia is increasing
 Now responsible for 80% of the burden of disease
 It’s estimated that by 2025, 80% of adult Australians
will be overweight or obese
 ~50% of people over the age of 65 are taking 5 or
more medications
 Up to 70% of adult Australians can be classified as
having a chronic condition
Models of General Practice
 What impact is this burden likely to have?
 Hospital services are under increasing strain and are unable to
deliver the appropriate care to those patients with chronic
disease
 Increasingly, Governments will look to General Practice to
manage the burden of chronic disease
 The future of chronic disease management will be in care coordination
 The GP must be central to this…but it does require the patient
to have a medical “home”
Models of General Practice
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• Funding Options
Radical reform is unlikely soon
Currently fee for service – current model in Australia
 Provides billing for each item of service undertaken
 Allows reasonable access
 ?encourages activity rather than quality / shorter consultations / fragmented care
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Co-payment system – previously tried twice – not popular with community
Capitation – currently in NZ ( concurrent co-payment ) / UK / Canada
 Allocation of annual funding amongst GPs is dependent on patient registrations
 No increase in funding if patients seen more often
 May lead to under servicing / lack of incentive to improve performance &
outcomes
 May be blended to include fee for service for some items (NZ / Canada)
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Outcome-based funding
 Funding is geared to expected activity and meeting measured outcomes
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These changes will fundamentally influence the business models of General Practice
Models of General Practice
Technology - ? Disruptive
Emerging array of technologies that can influence the way in
which we deliver healthcare:
- video consultations
- PCEHR (Personally controlled electronic health
record)
- health-based apps
- blue-tooth devices in the home
- fitbits, jawbones etc
If unable to examine patient ? Increase in litigation
Models of General Practice
In the future, it’s likely that a GPs day will comprise
delivery of healthcare in a variety of ways:
- Face to face consultations
- video consultations - ? particularly rural
- email
- care co-ordination
Models of General Practice
Possible Future Scenario
Corporate General Practice unlikely to ever dominate
Remain vulnerable to changing government policy
Maximum capacity 25-30%?
Novel models of delivery of GP
- GPs in Nursing Homes
- GPs attached to private hospitals
- Private Health Insurers owned and run practices BUPA, MBP etc
- Boutique Corporate models eg Mater Health in QLD, RFDS (Charleville QLD)
- Mobile services –currently After Hours Medical Services
The traditional role of the GP will not disappear
...though it will almost certainly change
Studies emerging from UK suggest health care outcomes are improved when primary
care is in the hands of generalist practitioners –GPs and general physicians
Models of General Practice
• We all must continue to lobby all agencies involved in health management
to ensure the high standard of our specialty training is maintained and
general practice remains at the forefront of primary health care delivery
Models of General Practice
Thank You
Activity: Case Discussions
 In your small groups discuss the case studies.
 Make a list of the considerations and option
each GP would need to make if they were to
choose to join a corporate model.
Activity: Case Discussion - 1
Dr John Fredrick is a 52 year old GP who owns a 5doctor practice in an outer metro location. John has
become jaded with the increasing administrative
burden associated with running a practice and is
considering an offer of purchase from a Corporate.
What factors does John need to consider and what are
John’s other options?
Case Discussion - 2
Dr Alice Wall is a 31 year old GP Registrar in her final year of
training. AW is interested in pursuing a career in General
Practice in a metropolitan environment.
Alice has been approached by a number of practices,
including a Corporate-owned practice.
What factors does Alice need to consider in making her
decision?
Case Discussion - 3
Dr Stan Taggart, Anis Obaid and Brett Richards are partners who
have built up a profitable business over 10 years. They have two
General Practices in an outer metropolitan location, each
employing 7 FTE staff and also have sub-tenant Allied Health
practitioners.
They have approached a Corporate concerning a possible sale.
What factors do they need to consider?