The first question everyone has asked themselves when looking through the Medicare Review Taskforce’s proposed revamp of GP items is the same.
Is it bad practice, poor care or some sort of rort to draw up a care plan having spent less than 40 minutes with the patient?
The suggested minimum time limit on item 721 — one of the care plan items whose funding probably represents the last proper investment in general practice care — is already becoming a hugely controversial proposal, despite the soothing, no-worries commentary offered by the AMA president yesterday.
The task force’s expert primary care committee, whose members will be familiar to anyone following the GP policy debate over the past decade, is also suggesting Medicare payments for enrolling patients.
It wants to scrap the specific item for team care arrangement, with access for allied health funding available through the care plan.
And it is also suggesting a major boost to the rebate for reviewing care plans, quoting stats that suggest doctors aren’t claiming the MBS review item in around half of cases where a care plan has been written.
The care plan items carry symbolic importance for general practice. Yes, they're bureaucratic, riddled like so much of the MBS with vague rules, the object of scorn, the alleged feeding trough for corporates. But they have also kept the business of general practice afloat in dark times.
So as members of the committee themselves admit in private, meddling with item 721 is no trivial thing, especially when the meddling involves slapping a 40-minute minimum threshold.
What will disturb those reading through the committee’s report is the utter absence of either argument or evidence to justify this 40-minute number.
There are rumors that management consultants at McKinsey & Company were contracted to generate “deep insights” for the task force into what was happening by trawling through the data.
But the precise nature of that work, its adequacies or otherwise, remain hidden.
Before reaching the conclusion that sub-40-minute care plans are junk, you hope that someone went through a big enough sample, documenting their contents against the treatment needed, along with an assessment of the treatment provided, and how all this shows a threshold of 40 minutes is necessary and not, say, some other approach to ensure best care.
Given the stakes — the prospect of thousands of doctors and nurses engaged in a meaningless clinical pantomime with patients to pad out the consults — the policy needs an evidence-base.
Well, if that evidence-base exists, it is not quoted in the report.
Then we get to the team care arrangement item.
The proposal to assign 723 to the dustbin is sold with a 'good news' tag because it will reduce the paperwork headache, allowing GPs to provide patients with access to MBS-subsidied allied health through the GP management plan.
The report makes less of a song and dance about its apparent belief that the change is needed because the item is being abused. It quotes figures that 30% of team care arrangements claimed don’t result in a patient claim for an allied health consult within a calendar year (a stat that, to be honest, may simply be the result of the patient’s own decision rather than a cash grab).
Like the time limits on developing GP management plans, the financial implications of scrapping item 723 are significant.
Around 80% of management plans are co-claimed with the item, generating around $260 in rebates. Left with just management plans, the MBS funding for the GP work falls to $144. The committee itself says ditching item 723 will save Medicare $250 million a year — although it would probably argue that increasing rebates for the reviews to the same level of the rebates for developing the care plans will offset the losses.
Again, despite its 150 pages, there is no detailed assessment in the report on whether this protects the viability of general practice as a business, a ship already holed by the storms of the Medicare freeze.
It is a good question to ask why the committee has come up with two proposals that to some will look like giving a loaded gun to government to finally put general practice out of its misery.
The answer lies in the suggested enrolment payments for signing up patients. This is part of the grander ambitions of the committee to deliver the dreams of the Health Care Homes reforms, the policy so badly botched and buggered by this current government.
The actual enrolment idea as documented in the report is uncosted and ill-defined. The size of the fee would vary based on patient complexity.
But it is not clear whether the committee is calling for a one-off payment or a fee paid annually or how much goes to the GP or whether it all ends up with the practice.
But this fee is meant to open the doors on a new world where there is money for proper holistic patient management, money for non-face-to-face consults, for repeat scripts or referrals issued over the phone, where there is cash to do the important after-hours visits for the chronically ill.
What seems to be happening is that the expert committee — following some prodding from Minister for Health Greg Hunt last year — believes the MBS Review Taskforce is a mechanism to develop wider reforms beyond its remit.
Despite its scale and funding ($33 million and counting), the review is about little more than going through the MBS schedule to identify items no longer clinically justified, to rejig the ones clinically outdated, and perhaps suggest a few new items so that the schedule remains broadly in line with modern medical practice.
It has also been about tightening up items to prevent obvious rorts or misuse.
What the review is not about is acting as a vehicle for creating radical new funding models for GP care. One reason is that under its remit, it has not been tasked with giving specific recommendations on the rebates needed to adequately fund the MBS services delivered through the items.
While Yes Minister re-runs ensure we all understand why no government is foolish enough to set up a review commission to recommend dollar figures for healthcare subsidies, it means the task force could never investigate and therefore fix general practice funding woes by doing something vital like coming up with a serious, evidence-based fee for a standard GP consult.
So what capacity does it have to suggest new funding streams for the specialty?
In the context of this draft report, the task force has been unable to offer a dollar figure on this all-important enrolment payment. How much is it meant to be if it is to do the things the committee suggests it should do? A couple of hundred dollars? Or a couple of thousand? The report is just a blank.
As a result, it ends up combining a disturbing mix of hard concrete changes to the specialty’s current economic lifeline — the multimillion-dollar care plan and health assessment items — alongside uncosted, vague aspirations for a revolution in patient-centred general practice funding.
In fact, in its current form, I'd suggest its wording is a menace to general practice. It's format encourages government to pick and mix the recommendations, allowing it to focus on the bits the task force was asked to do (fix outdated MBS items) at the expense of the wider issues (deliver an appropriate funding stream for GP care).
Supporters of the reform ideas outlined in this report will suggest the political ecosystem is safe.
Mr Hunt is wedded to a Health Care Homes concept. He wants to make the policy work. The report’s recommendations, which included repeated calls to invest in the GP care, apparently reflect his perspective.
But Mr Hunt, following his flirtations with his colleague Peter Dutton, is fighting for his political future along with the life of his troubled, chaotic government. His public utterances on what he actually wants for general practice remain vague to the point of being meaningless.
And while his sweet talk is nice, the track record of his party under its numerous leaders shows it has done little but actively harm general practice in the name of a so-called budget crisis.
As for Opposition health spokeswoman Catherine King — Mr Hunt’s likely successor, given the polls — you would hope she understands the significance of what confronts the specialty having been eight years in the job.
But she has also said little publicly about GP funding, probably because she is waiting for the party minders and their election strategists to devise the health policy she will be told to sell. To date, the party has said little, apart from its commitment to Medicare and bulk-billing rates.
Elections are brutal and can obliterate the political context. New governments come in, the old guard and the old assumptions disappear. The ecosystem changes.
This 150-page report reads like a shopping list of recommendations for general practice - apparently signed, sealed and ready to be delivered by the profession.
It needs a rewrite and at the very least published, robust evidence that what it is demanding won't prove toxic in its effects.