There are concerns that a voluntary patient enrolment program in Australia could lead to a capitation funding system similar to the one used in the United Kingdom.
At last week’s Budget, along with $3.5 billion earmarked for general practice, the government announced the MyMedicare program, which introduces a voluntary patient enrolment (VPE) option for patients.
Although general practice still operates largely on a fee-for-service model, there are those who are concerned that VPE is too close to the funding system of capitation.
Australian primary health care operates on a majority fee-for-service model, in which patients choose a GP for an appointment and Medicare pays the patient a subsidy. Capitation – the system under which the United Kingdom’s National Health Service (NHS) operates – sees patients register with one GP and the government pays a capped amount for a year’s worth of visits to the clinic. To remain eligible for payment, the clinic must meet a set of key performance indicators (KPIs).
GPs from the UK say that the NHS is buckling under a system of capitation.
There is concern that VPE is too similar to capitation and will be bad for Australian GPs. Elnur/Shutterstock.
Dr Chris Irwin is a GP who ran for the office of Royal Australian College of General Practitioners (RACGP) President last year on a platform opposing capitation. He is concerned VPE will ultimately be bad for GPs and the doctor–patient relationship.
“The buzzword for capitation is [VPE],” Dr Irwin told InSight+. “With VPE you get funded, with a lot of strings attached, directly from the government. So, the government is now your client as opposed to the patient.”
“VPE is part of a blended model, where theoretically we keep our fee-for-service … and we also get an extra payment on the side [for patient enrolment]. My primary argument is that this blended payment model is the thin end of the wedge, and that VPE will become anything but voluntary, because eventually you need that money to survive as a medical practitioner,” Dr Irwin said.
Dr Irwin believes fee-for-service will ultimately be less affordable than it is currently for low income Australians, and that the KPIs will become the focus of primary health care.
“You start off with easy KPIs. Everyone’s happy with extra money floating around. People get hooked onto the system and then every year they tighten the KPIs, making it harder to achieve those hurdles to reach the payment thresholds,” Dr Irwin said.
Are voluntary patient enrolment and capitation the same?
The Australian Medical Association (AMA) supports the MyMedicare announcement, citing its Modernise Medicare campaign. AMA President Professor Steve Robson said that the AMA opposes capitation but supports VPE.
“The AMA supports [VPE], but only as a mechanism to help ensure a stronger linkage between a patient and their usual GP, and establish a basis for extra funding,” Professor Robson told InSight+. “Experiments like Health Care Homes have shown that capitation does not work in the Australian context.”
“Many of the challenges facing GPs in the UK are also felt here, [such as] the increasing health needs of an ageing population with more multimorbidity. Regardless of the funding model, the challenges facing primary care over the next decade are real,” Professor Robson said.
“Capitation is not the answer, but VPE is not capitation.”
The United Kingdom and the NHS
InSight+ spoke with one GP and clinic business manager formerly working in the UK, whose spouse is also a GP. The couple emigrated from the UK to Australia to avoid capitation. (The GP did not want to be named in this article.)
“The workload kept on increasing year by year, and, often, the expectations of what GPs had to do also kept on increasing, but the remuneration was the same. To perform more, we had to employ more staff, and the expenses kept on increasing. The eight- to ten-hour day ended up being a 12-hour day. It was just not feasible,” the GP told InSight+.
“You’re just really ticking boxes and doing paperwork when you should be spending time with patients.”
InSight+ reached out to the RACGP and did not receive comment in time for publication.