Dr Graeme Doherty - General Practice Registrars Australia · PDF fileModels of General...

Models of General Practice

Dr Graeme DohertyMBBS (Syd), BSc(UQ), FRACGP, DRANZCOG

State Medical DirectorQueensland

Independent Practitioners Network


My GP career…….- Born, raised and educated on Gold Coast - Graduated Sydney University 1981- Joined Family Medicine Program 1982- Commenced General Practice in Charleville (South Western Queensland) 1983- Established own practice on Gold Coast 1986 ( then semi-rural ) & still practising as a GP- Merged with another similar sized practice in Ashmore for economies of scale 1993- Awarded FRACGP & DRANZCOG 1991- Current position of State Medical Director (QLD) Independent Practitioners Network- Have worked in a variety of general practice models- VMO at 2 local private hospitals and Hopewell Hospice- Quality Assurance Examiner for RACGP Fellowship Examination- External Clinical Teacher for General Practice Training Queensland- Former Regional co-ordinator /nodal educator RACGP Training Program Gold Coast /Logan

region 1993– 2001 - Former academic appointment Bond University Medical Program 2005 – 2011- Held various positions on local professional bodies – GCDCP / GCLMA

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Current Australian GP landscapeDOHA workforce statistics 2014 -15

• Almost 33 000 practising GPs

• Making up 22 000 FTE• Approximately 40 % female

• Approximately 50% aged 45 - 65

• 110 FTE GPs per 100, 000 people

• 5.8 visits per head of population


Practice Demographics

• Approximately 7500 practices nationally

• 2400 Solo GP practices

• 3050 practices with 2 – 5 FTE

• 2050 practices with > 6 FTE


Number of solo GPs has halved in the last decade ~ 50% GPs currently work in practices with > 5 FTE doctors ~ 18% of GPs work for corporate companies Average size of practice is 5.2 FTEs Fewer home & after hours visits by traditional general practices – after

hours co-operatives /public and private hospital ED ? Increasing trend by residential aged care facilities to seek services of

one practice to provide care to all residents in urban communities Variety of billing methods –universal bulk billing / mixed billings /

totally private billing (often discounted for pensioners & HCC holders)


Solo GP Works alone in owned or leased premises If owned – local government regulations / town planning /

parking availability etc / maintenance Usually without Practice Nurse / Manager Minimal staff overheads ? Sources locum or closes for leave / illness Locum – continuity of patient care but expensive Closure – no continuity of patient care Responsible for entire practice management On retirement is practice saleable / goodwill?


Small Group Practice Less than 5 FTEs Usually with a Practice Nurse and / or manager Usually GP- owned Partnership (all equal) vs Associateship

(differences –fixed and variable costs) / Employee –agreed wage (benefits) / contractor usually incorporated with ABN –usually % of billings (no benefits no leave entitlements and responsible for own superannuation and ATO)

Purpose-built or leased premises – same constraints as solo GP Allows continuity of care Often able to provide extended hours Small staff with or without Pathology collection service Still has responsibility for practice management


Medium Group Practice More than 5 FTEs Practice Nurse / Manager support Ownership – single GP principal , Partnership, Associateship who

solely or collectively provide management / Corporate / co-located within pharmacy

Premises owned (local government regulations) or leased Employees without financial interest – agreed salary / incorporated

contractor Pathology collection service Allied Health services


Large Group Practice 10 GPs plus Practice Nurse Practice Manager support Ownership – GP, partnership, associateship, corporate, +/-pharmacy Purpose built Centre – owned or leased Co-located services – pharmacy, dental, physio Pathology collection service Allied Health services ? Has ability to offer greater work – lifestyle balance


Definition of a Corporatisation of General Practice

Corporatisation of General Practice is defined by the government “as when a general practice becomes, or is acquired by, a for-profit company registered under the Corporations Act 2001”

A legal entity created through the process of incorporation

The aim is to return a profit to its shareholders

Contracted doctors are major working assets


Corporate Models Began to appear mid – late 1990’s Initially in NSW and WA Remain primarily suburban metropolitan but now offering services in some

larger rural communities GPs are contracted Percentage of medical fees (billings v receipts) retained

Generally in range of 50 – 70 % of billings

Services provided for doctors- Premises- Administration staff- Nursing staff- IT services – immediate dial in for problems - Clinical equipment and services- Further education


Corporate Models

GP contracts:- Defined period of time for contract Complex issues relating to sale of practice – exclusion clauses Individual doctors or whole practices Different terms / different hours of engagement and leave Upfront or graduated lump sum payments – seek financial advice

regarding ATO interpretation – keen interest from ATO recently On completion of contract - rolling or renewal of terms – generally

the longer the contract the greater the percentage retained by GP


Management structures Some corporates impose:

• billing practices –generally universal bulk billing

• appointment systems often encourage walk-in arrangements

• may not be able to consult doctor of choice

• referral patterns / prefer exclusivity of association

• Others allow full clinical sovereignty / independent billing

• May have other affiliated services eg skin clinics - ? Further fragmentation of GP services


Advantages of Corporate Models

Freedom from administration Freedom to concentrate on patient care Economic viability/loss of financial stress Flexibility – hours worked and holidays Larger infrastructure – education, doctors benefits ( negotiated discounts on

private health premiums / medical indemnity insurance), professional development

Larger practices facilitate multi-disciplinary team approach


Disadvantages of Corporate Models

Lack of autonomy / Bound by contract Loss of control over staff Standardisation – more formal structures May lead to less contact with patients / loss of personal touch Loss of continuity of care in some models You may not get to choose your colleagues Problems with management however some models promote GP panel

meetings with executive staff on regular basis and encourage formal practice meetings


Future Landscape: Looking Forward

What does the future look like for general practice?

Does Item-of-Service care represent a sustainable system?

Two major trends are likely to dramatically change the GP landscape in the not-too-distant future

- the increasing burden of chronic disease

- increased use of disruptive technologies


Chronic disease in Australia is increasing

Now responsible for 80% of the burden of disease

It’s estimated that by 2025, 80% of adult Australians will be overweight or obese

~50% of people over the age of 65 are taking 5 or more medications

Up to 70% of adult Australians can be classified as having a chronic condition


What impact is this burden likely to have?

Hospital services are under increasing strain and are unable to deliver the appropriate care to those patients with chronic disease

Increasingly, Governments will look to General Practice to manage the burden of chronic disease

The future of chronic disease management will be in care co-ordination

The GP must be central to this…but it does require the patient to have a medical “home”

Models of General Practice• Funding Options

Radical reform is unlikely soon Currently fee for service – current model in Australia

Provides billing for each item of service undertaken Allows reasonable access ?encourages activity rather than quality / shorter consultations / fragmented care

Co-payment system – previously tried twice – not popular with community Capitation – currently in NZ ( concurrent co-payment ) / UK / Canada

Allocation of annual funding amongst GPs is dependent on patient registrations No increase in funding if patients seen more often May lead to under servicing / lack of incentive to improve performance &

outcomes May be blended to include fee for service for some items (NZ / Canada)

Outcome-based funding Funding is geared to expected activity and meeting measured outcomes

These changes will fundamentally influence the business models of General Practice


Technology - ? DisruptiveEmerging array of technologies that can influence the way in which we deliver healthcare:

- video consultations

- PCEHR (Personally controlled electronic health record)

- health-based apps

- blue-tooth devices in the home

- fitbits, jawbones etcIf unable to examine patient ? Increase in litigation


In the future, it’s likely that a GPs day will comprise delivery of healthcare in a variety of ways:

- Face to face consultations- video consultations - ? particularly rural- email - care co-ordination


Possible Future Scenario

Corporate General Practice unlikely to ever dominateRemain vulnerable to changing government policy Maximum capacity 25-30%?Novel models of delivery of GP

- GPs in Nursing Homes- GPs attached to private hospitals - Private Health Insurers owned and run practices BUPA, MBP etc- Boutique Corporate models eg Mater Health in QLD, RFDS (Charleville QLD)- Mobile services –currently After Hours Medical Services

The traditional role of the GP will not disappear...though it will almost certainly change

Studies emerging from UK suggest health care outcomes are improved when primary care is in the hands of generalist practitioners –GPs and general physicians


• We all must continue to lobby all agencies involved in health management to ensure the high standard of our specialty training is maintained and general practice remains at the forefront of primary health care delivery


Thank You

Activity: Case Discussions

In your small groups discuss the case studies.

Make a list of the considerations and option each GP would need to make if they were to choose to join a corporate model.

Activity: Case Discussion - 1

Dr John Fredrick is a 52 year old GP who owns a 5-doctor practice in an outer metro location. John has become jaded with the increasing administrative burden associated with running a practice and is considering an offer of purchase from a Corporate.

What factors does John need to consider and what are John’s other options?

Case Discussion - 2

Dr Alice Wall is a 31 year old GP Registrar in her final year of training. AW is interested in pursuing a career in General Practice in a metropolitan environment.

Alice has been approached by a number of practices, including a Corporate-owned practice.

What factors does Alice need to consider in making her decision?

Case Discussion - 3

Dr Stan Taggart, Anis Obaid and Brett Richards are partners who have built up a profitable business over 10 years. They have two General Practices in an outer metropolitan location, each employing 7 FTE staff and also have sub-tenant Allied Health practitioners.

They have approached a Corporate concerning a possible sale.

What factors do they need to consider?

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