Australia is evolving its primary care system, from fee for service, towards healthcare homes that will capitate payments according to patient risk tiers. Whilst this is sound policy to ensure continuity and consistency of care, many see healthcare homes as a cost-cutting exercise aiming to cap the growth of Medicare chronic disease-related payments (growing at 25 percent per annum, towards A$1 billion), and having limited benefit if the change in funding is not delivered in conjunction with a change in the service model for patients. If the same monies are repurposed and paid to the same clinicians to care for the same patients, and these clinicians behave in the same way without innovation in the care model, then improvements will be marginal at best.
New service models exist overseas and it may be useful to see what’s possible beyond healthcare homes. Broadly speaking there are innovations in 3 areas: Access, Experience and Quality:
- Models improving access: Some commercial retail chains focus on simple primary care presentations and making it convenient for patients to access care. They are predominantly staffed by nurse practitioners and allied health practitioners, and default to standardised processes and workflows. Success is defined by size of their network and proximity to patient, volume of consultations and market penetration, but runs the risk of being a commoditised service that fragments when patients need help with more complex health issues. Useful for GPs to be aware of when pharmacies and grocery stores ramp up their health services in Australia. We’re already seeing more clinics opening in shopping centres to counter migration of retail consumers to online. Examples include:
- Minute Care: Walk-in clinics covering the most common family-medicine presentations, offering routine tests, standardised care plans and patient education
- Vera: Work-site clinics providing corporate health medicals, episodic acute care and ongoing chronic disease surveillance.
- Models improving experience: Some concierge providers aim to deliver a premium consumer experience, for a premium fee. They generally target a higher end market, with nice retail clinics and furnishings, employ a membership model that commits higher service levels (e.g. appointments starting on time, after hours support, home visits), and employ workload scheduling tools to ensure capacity exceed peak demand to deliver less standardised, higher customer experience interactions. Examples include:
- One Medical: ‘High street’ located clinics service members with 95% on-time appointments and technology-enabled interactions
- MDVIP: Personalised primary care services including preventative care, counselling, wellness programs, focusing on physical, emotional and mental well-being.
- Models improving quality: Some wrap-around providers focus on assuming patient risk, and sharing in potential rewards of improved patient outcomes or reduced health expenditure. These are service models designed for capitated payments or pay for performance funding. They rely on reducing unnecessary health expenditure, such as avoided hospital admissions and strong patient engagement, not just frequent attendance. Examples include:
- ChenMed – GPs co-located specialists managing full health care budgets, focusing on seniors with chronic disease and using a data-driven approach to drive quality
- Oak St Health – GPs and geriatricians taking on capitated payments and employing a patient-engagement approach; clinics have community events, health coaches and free transport
- Iora Health – GPs are supported by non-clinical patient aids, and deliver managed care to employees; any realised savings are shared back with clinicians.
For those interested in countering the trend to commoditise and streamline general practice, it’s worth considering the key differences between successful innovators and our current general practice structure, even under healthcare homes:
- More team-based care – in addition to GPs and nurses, often allied health, nurse practitioners, care coordinators, social workers, health coaches and specialists are involved
- Less patients per GP – the average patient population per GP is reduced to as small as 400 patients, allowing more time and follow-up with those same individuals
- Broader scope of services – home visits, virtual consults, transport, coaching, patient education and after-hours support are often part of the mix
- Embracing technology – proprietary platforms to drive proactive population health, patient portals (where consumers can truly own their own health record) and mobile Apps
- Emphasis on patient engagement – higher customer service levels, more patient empowerment and involvement.
To rescue general practice, I argue we need to demonstrate better outcomes using innovative models of care, in order to justify greater investment into our sector.
Image source: http://www.bristol.ac.uk/primaryhealthcare/whatisphc.html
