Modernising the MBS
The MBS has remained largely unchanged since its inception in 1984 and as a result does not adequately support modern general practice. The MBS was designed before the management of chronic diseases was commonplace, and before the technology existed to facilitate the delivery of healthcare safely without face-to-face consultations.
A fee-for-service model is, and should remain, the foundation platform for general practice funding and the primary means of support for patients accessing Australian general practice services. This model ensures that care can be provided to patients regardless of practice size, structure, infrastructure, geographic location or any other limiting factors.
Patients must have access to affordable general practice services. This is especially important for patients with limited resources. Patient rebates for general practice services provided through the MBS need to be reviewed as they have failed to keep pace with the increasing time and complexity of general practice care, and do not reflect the cost of providing safe and high-quality care.
Furthermore, the MBS overvalues procedural medicine compared with consultation medicine, and also values rapid throughput more highly than longer time spent with patients. All of these perverse incentives within the MBS make the provision of high-quality, patient-centred general practice less and less viable.
Although the MBS Review Taskforce has reviewed the appropriateness of individual MBS item numbers, it has not been successful in correcting the long-known fundamental imbalances within the MBS.
As well as increasing patient rebates for MBS services, Medicare regulation requires reform. Under the current Medicare system, when doctors need to charge a fee to cover additional expenses related to a service (eg dressings, disposable equipment), patients are required to pay the whole fee rather than the patient rebate. The patient then has to wait for reimbursement from the government. This administrative burden is unnecessary and results in larger out-of-pocket expenses for patients on the one hand, and increasing costs for practices on the other.
Appropriate recognition of GPs as medical specialists
The MBS fails to recognise GPs as specialists. General practice has evolved as a speciality since the inception of the MBS. However, the MBS still significantly undervalues GP services compared with services provided by other medical specialists, and this disparity requires urgent correction.
Supporting payments through appropriate indexation
The ‘Medicare freeze’ and subsequent inadequate indexation has led to the loss of more than $1 billion of general practice Medicare funding. This funding has never been reinvested back into general practice, and as a result general practice is losing tens of millions of additional funding dollars annually.
Even as the Medicare freeze has slowly been lifted, rebates continue to decline in value as a result of inappropriate indexation.
Medicare is not indexed against the consumer price index (CPI); it is instead indexed against the wage cost index 5, which is considerably lower than both the CPI and health inflation.
All general practice payments, including patient rebates and additional support payments, must be appropriately indexed. Suitable indexation of current patient rebates and new support payments will help build genuine sustainability for general practice service delivery.
Teaching: Ensuring the sustainability of the general practice workforce
Recent medical workforce data indicate that for every GP graduate trained in Australia, there are nearly 10 non-GP specialist graduates.1 With increasing workloads and decreased financial viability, many practices are unable to accommodate teaching and training without a financial loss. Without positive exposure and experience in primary care, health professionals (doctors, nurses, allied health professionals) are more likely to pursue a hospital-based career than one in primary care.
Enhanced funding for GPs and practices to undertake teaching is needed to better support the education of students, registrars and junior doctors working towards a career in general practice. This not only includes those working towards a career as a GP, but also students of nursing, pharmacy and allied health.
Due to the interactions between general practice and other parts or the healthcare system, other health and medical practitioners would benefit greatly from experience in and understanding of general practice.
General practices should also be supported to provide placements for medical students or registrars working towards a career in another medical speciality.
Funding must support coordination, infrastructure and administrative duties related to placing students within general practice. For individual GPs who provide teaching and supervision, payments will support them to provide these activities and compensate for any potential loss of income from their regular practice.
Quality improvement: Supporting practices to provide evidence-based, safe and high-quality care
Funding for both GPs and practices through a quality improvement payment would increase the capacity of practices to undertake data analysis and to monitor and improve the quality and safety of patient care.
GPs have an important role in monitoring their patients over time. The information gathered through multiple interactions is used to guide ongoing care. The use of this data is currently restricted to individual practices in most cases, but could have a role in guiding development of health systems and appropriate allocation of resources. The capacity to re-use existing general practice data will depend on the support practices are given to improve and review the quality of their data.
The Practice Incentives Program Quality Improvement (PIP QI) provides payments for practices to share data, but additional payments are needed to support GPs in collating and analysing high-quality data. This payment should recognise the clinical leadership role GPs assume in leading quality and safety improvements and research activities. It should also recognise the role of practices in undertaking and supporting quality improvement activities.
There is a role for government to help practices maintain a high standard of safe care by supporting them to gain accreditation against the RACGP’s Standards for general practices, 5th edition.2