Dr. Annette Carruthers - nib - PHI working with general practice

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THE PROBLEM

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Small proportion of customers consume a large percentage of overall benefit

outlays …we call them our “frequent flyers”

Distribution of hospital benefits amongst nib insured customers (incurred CY13)

0%

20%

40%

60%

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100%

120%

$0

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$200

$300

$400

$500

$600

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0% 1% 2% 3% 4% 5% 6% 7% 8% 9% 10% 11% 12%

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Proportion of Total Insured Hospital Customers

1% of our hospital customers account

for more than 50% of hospital benefits

(pre risk equalisation)



THE SOLUTION

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Coordinated care trial (Brisbane North)

Team Care II Coordinated Care Trial

• 3 year controlled trial, randomised by patient

• Participants were over the age of 50 with at least 1 chronic condition, recruited

by their GP for their complexity

• Approximately 3000 patients (2000 intervention, 1000 controls)

• Over 100 general practices, 175 GPs



THE EVIDENCE

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▼ Hospital utilisation for intervention participants ‐ 19% fewer hospital

admissions at 20% lower cost than control participants (after 12 months

of service coordination)

▼ Hospital utilisation for intervention participants ‐ 25% fewer hospital

admissions at 26% lower cost than control participants (after 18 months

of service coordination)

▲ MBS utilisation for intervention participants increased when

compared to control participants

► PBS utilisation similar between both groups

▼ Overall cost impact ‐ 8% lower cost for intervention versus control

participants



THE RISE OF CHRONIC DISEASE

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Chronic health problems account for ~30% of presentations to GP

• Ischaemic heart disease (also known as coronary heart disease)

• Stroke

• Lung cancer

• Colorectal cancer

• Depression

• Type 2 diabetes

• Arthritis

• Osteoporosis

• Asthma

• Chronic obstructive pulmonary disease (COPD)

• Chronic kidney disease

• Oral disease



PREVENTION

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Primary and secondary

• Smoking

• Physical activity

• Alcohol

• Poor diet

• Obesity

• Hypertension

• High blood fats



GP MANAGEMENT PLAN

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• Patient education

• Evidence based

prescribing

• Disease monitoring

• Action plan

• Immunisation

• Risk factors

• Medication reviews

• Falls prevention

• Advance care plan



DIABETES

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• Fastest growing chronic illness

• Approximately 100,000 new diagnoses each year

• Annual cycle of care

o BP, weight, BMI

o HbAlc

o Lipid management

o Diet, smoking and exercise advice

o Eye care

o Foot care

o Screening for kidney disease



GP DEMOGRAPHICS

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• 75,653 registered medical practitioners currently

working (AIHW 2012)

• 34.5% GPs = 26,100

• 40.8% GPs female

• Average age 50

• 35% GPs overseas trained

• 1,200 GP training positions per year

• 24,000 specialists,12,500 in training (AIHW 2011)



SPECIALISATION

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• Unrestrained growth specialist services

• Subspecialisation, narrowing scope of practice

• Increased fragmentation

• Supply induced demand

• Over diagnosis and over treatment

• Not matched to community need

• Cluster in urban areas

• Driven by income differential



ARE ALL GPs THE SAME?

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• VR vs non-VR

• Accreditation (67%: 2010)

• Home visits, after hours cover

• Practice nurses

• Corporatisation (15-20% DOHA 2012)

• Rapid turnover practices

• IT



THE VISION – THE MEDICAL HOME

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• Comprehensive whole person, whole of life care

• Patient registration

• Preventive care

• Chronic disease management

• Patient registers, recall systems

• Multi-disciplinary care

• Discharge planning

• Palliative care



HOW?

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• Divisions of general practice

• Medicare locals

• Primary health care networks

• Coordinated Veteran’s Care Program

• COACH



ENABLERS

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• PCEHR

• Electronic health fund identification

• Product restriction information

• Pathways

• Alliancing

• Consumer engagement and empowerment (eg Whitecoat)



PATHWAYS

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Rapid access to information about specialist services as a

key tool to help them care more effectively for patients



CONSUMER ENGAGEMENT & EMPOWERMENT

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Whitecoat allows users to search (by specialty, by location) and

compare (cost and consumer reviews) ancillary providers



DO

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• Reward quality, not quantity

• Incentivise best practice

• Support discharge planning, advance care planning

• Share information re costs

• Expect accountability

• Provide information for customers

• Support eHealth

• Contribute to research



DON’T

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• Disrupt quality care models

• Further fragment health care

• Introduce single disease programs

• Confuse patients

• Under-estimate complexity

• Reward rapid turnover

• Remove price signals

• Reduce access for disadvantaged

Dr. Annette Carruthers - nib - PHI working with general practice

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Dr. Annette Carruthers - nib - PHI working with general practice