Jane Gunn is Chair of Primary Care Research and Head of the Department of General Practice at the University of Melbourne, Australia
Primary care in Australia
What do populations need?
Populations need a fair health care system that reduces the current inequities seen in the health of the population. Australia needs a health care system that focuses on prevention in addition to treatment and care. In particular, we need to improve the health of Aboriginal and Torres Strait Islander people. Populations deserve a strong primary health care system in the community for “first contact” care that builds upon the strengths of existing general practice.
How does the system provide for these needs?
Australia is embarking on a period of health system reform; between 2008 and 2010, the National Health and Hospitals Reform Commission conducted a comprehensive review of the entire health care system. The Commission noted that the current system is under growing pressure and suffering from fragmentation owing to the complex funding arrangements and the way that these are split between national and state levels of government. Many challenges lie ahead for Australia, but the Commission identified the central role of primary health care, and the Government is about to establish the first Primary Health Care Organisations to support better service coordination and population health planning. These Primary Health Care Organisations will be known as “Medicare Locals” and will replace the existing Divisions of General Practice. Currently, primary health care is delivered by general practitioners and general practice nurses in privately owned community-based practices or in state-funded community health centres. The Australian government has launched a recent program to fund comprehensive multidisciplinary primary health care centres and services, known as “Superclinics.”
Who pays for the primary care system?
Payment for primary care services is complex. The primary care system is funded via fee for service and blended payments from the universal compulsory health insurance scheme known as Australian Medicare, which was established in 1984. Australian Medicare is funded out of general revenue via a 1.5% levy on taxable income (exceptions for low-income earners), with an additional 1% levy surcharge imposed on high-income earners (AUD $73 000 for individuals; AUD $146 000 for families) without private health insurance. Many consumers pay a gap between the Medicare rebate and the fee charged by the primary care service. It is not possible for Australians to insure themselves for the gap payment. Medicare usually reimburses 85%–100% of scheduled fees for ambulatory services. This amount is increased if the patient is a concession card holder or receives other benefits; the safety net amount has been met for out-of-hospital services (AUD $383.90 in 2009); or their total out-of-pocket health care expenditure for the financial year exceeds $1500 (eligible for an additional 20% tax rebate).
What are the strengths?
The primary health care system in Australia is strong and widely distributed across the nation. In 2007, there were 99 full-time general practitioners per 100 000 population. People can choose the doctor that they wish to see, and 85% of the Australian Population visits a doctor at least once every year, with most patients able to visit their preferred general practice. General Practitioners are highly trained with a compulsory graduate training program being in place. Primary care in Australia has excellent access to pathology, diagnostic tests and imaging. General Practitioners act as the gatekeepers to specialist care and can refer people to a wide variety of private specialist practitioners or to public hospital specialist services. Primary care provides essential preventative health services such as cervical screening and immunization, and is playing an increasing role in reducing smoking, improving physical activity and nutrition. A systematic approach to health promotion and disease prevention is being implemented in most practices. The three-year participation rate for cervical screening was 73.9% for 2007–2008. Primary care has made a substantial contribution to the achievement of the excellent childhood immunization rates of about 90%. Primary care is highly computerized, with most practices using electronic medical records.
What are the weaknesses?
The payment system is complex, and the split of funding arrangements between the national and state governments results in poor integration between primary care (nationally funded) and hospital care (state funded). There is a substantial gap between the health status of Aboriginal and Torres Strait Islander People and the wider Australian population. The links between general practice and allied health care providers are not strong, with few being colocated. Although most practices use electronic medical records, many obstacles are yet to be overcome before the data stored within these systems can be put to best use, even within the practice in which they are being used.
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