The Whitlam Government introduced the national Community Health Program in 1973. As detailed in a recent article in the Australian Journal of Primary Health, https://connectsci.au/py/article/31/2/PY24194/200417/Community-health-in-Victoria-a-history-of the intention was to support the States in the provision of affordable comprehensive primary health care.
Funds were used differently in different States. The Fraser Government ended the federal funding but some states, including Victoria, continued to support the expanded community health initiatives.
Federal funding was restored by the Hawke Government in 1984 but was granted as a part of the general healthcare funding to states. Only in Victoria has there been a continuation of non-government community health care centres supported by State and Federal funding.
Twenty-two registered independent community health centres (CHCs) now exist in Victoria. Whilst dependent on government funding, they have independent Boards of Management. These were very community based but with the increased complexity of care, amount of funding, and size of amalgamated CHCs, they have moved to skills-based boards with varying degrees of community input. The history of non-GP funding for CHCs is complex and not the focus of this article.
Recurrent funding of the General Practitioner (GP) component of CHCs is dependent almost completely on federally funded Medicare rebates with a small component from special purpose payment and some state government funding for nurses. The Victorian Government also provides the site for a peppercorn rent.
Sector Overview
A recent report from the peak body for Victorian CHCs https://www.communityhealthfirst.org.au/our-impact-2425 gives a picture of what CHCs do.
Nearly 10 percent of Victorians access their services. Nearly 50 percent of those have made use of more than one service. The majority feel the care they receive is better than they would receive from other providers. This care crosses the spectrum of primary care, and a major portion would not be access to GPs.
The Victorian Government funds 50 percent, the Federal Government 36 percent. But these centres exist in areas of greater need, whether rural or inner city, and they are accessed because they are affordable. GPs provide a very important role in these settings, which are renowned for otherwise having unaffordable and/or delayed access to GPs.
Proposed Service Cuts
Hence the public outcry when one of the larger Victorian CHCs, cohealth, announced it would be closing three of its GP clinics in Melbourne because they were financially non-viable.
There are at least three possible explanations for this lack of viability: managerial incompetence, a lack of adequate State funding, and a lack of Federal funding.
It is likely that GP clinics in CHCs that have a large cohort of very high needs patients have been struggling for years to be financially viable.
But issues like making maximum use of space and getting all the different Medicare rebates are indeed what managers have to address. Because this has been an ongoing challenge one would hope that it has been as well addressed as possible.
Financial Viability
Recently I spoke with a CHC GP about his approach to making the practice financially viable.
The GP told me that the managers indicated an hourly Medicare income target required. As he saw his patient, he would be thinking which of many different rebatable actions he could perform to both treat the patient appropriately and maximise the income.
In the hands of an experienced GP that would not necessarily be a problem but for a GP to be seeing patients with money as even a small partial focus, does not sound like it will always deliver optimal care
We doctors would prefer to focus just on the patient’s needs, at least while face to face with one.
The state government provides the buildings and land on which CHCs exist. Buildings occasionally need major repairs. CHCs don’t have money for such. One of the stated problems with one of the cohealth sites is that the building is in a state of significant disrepair. That should be a state responsibility.
GPs in CHCs are either paid a salary or paid directly through the Medicare rebates they earn, with a percentage paid to the practice (a facility fee). This fee varies considerably from as low as 10 percent to 50 percent or more.
As CHCs essentially have rent free site access, they generally have a low fee whereas practices which have bought or are leasing premises have a much higher fee. But most CHCs either bulk bill everyone or charge a very small copayment for a small percentage of patients deemed able to afford to pay.
The federal government provides Medicare income, mainly through rebates for items of care. The value of the rebate ignores the greater needs for patients in areas of low socio-economic status (SES), despite overwhelming evidence of poorer health outcomes for such patients.
Thus, when a GP has to spend extra time working through an interpreter explaining things to a person who might be so lacking in medical knowledge as to think that diabetes is a kind of cancer, having to address major cultural issues, and more mental health issues, the remuneration is the same as for the GP speaking to a highly educated articulate English speaking Brighton billionaire. In addition, a significant copayment will usually be paid to guarantee the financial viability of the Brighton practice.
Beyond short term fixes
Following the federal government’s Strengthening Medicare Taskforce, Minister Mark Butler indicated that there would be a major change in how general practice would be funded. Currently over 90 percent is through Medicare rebates i.e. fee for service.
He indicated that by 2030, that would change so that 40 percent would be paid in various blocks of funding. A subsequent committee recommended such payments be adjusted for disease complexity, rurality, and socioeconomic status.
Nothing has been heard of that suggestion since. If implemented, it would make CHCs more viable.
The Future
The Federal Government has announced a six-month Band-Aid to add to the many welcome Band-Aids (tripling the bulk billing incentive, 12.5% bonus for 100% bulk billing clinics), expensive urgent care clinics.
For cohealth, these have not been sufficient to address the issue of the potential loss of GP services to thousands of needy Melbournians.
Minister Butler quite rightly indicates that a review of how coHealth works is required but his claim that `This is not the sort of problem that’s been faced in other community health centres’, is incorrect.
More funding is needed for patients with greater needs. Other CHCs face similar issues as cohealth with respect specifically to Medicare funding, if they are to continue to provide optimum care for the most disadvantaged.
It is time we heard about long term structural changes to funding which will ensure ongoing care for the most vulnerable and disadvantaged, who are so well served by CHCs throughout Victoria.
Minister Butler, please tell us how and when these structural changes you flagged nearly three years ago will be implemented.