Decline with a capital D: long-term changes in general practice consultation patterns across Australia

The objective of Australia’s Medicare program is to provide “affordable, accessible and high-quality health care”.1 Over time, maintaining this objective has required reform of the Medicare Benefits Schedule (MBS) to ensure its “fitness for purpose”. The website of the Australian Government Department of Health and Ageing (DoHA) lists no fewer than 27 “key MBS primary care initiatives” over the past 10 years that increased “the range of options available to GPs [general practitioners] for the provision of quality comprehensive primary care to Australians”.2 Reforms have included broad approaches to increasing affordability and accessibility (eg, the Strengthening Medicare package in 2004) and special MBS item-based initiatives (eg, health assessments and care plans).

In May this year, further MBS reforms were introduced, again intended to ensure Medicare’s fitness for purpose, and to address concerns that the MBS “is overly complex, encourages ‘six-minute medicine’ and fails to encourage preventative care, particularly for those with chronic illnesses”.3

In addition to updating previous key initiatives, the May 2010 reforms also amend Levels B, C and D consultation item descriptors, which have been unaltered since November 1993.4 The amendments are designed to encourage the use of Level C and D (long) consultation items. However, these reforms are being deployed in an environment of increasing demand and strained resources. Long consultations, the proposed cornerstone of Medicare’s future preventive care agenda, have been the focus of auditing by Medicare and the Professional Services Review.5 The audit approach is controversial among GPs,6,7 and “audit anxiety” has been posited as driving down the use of long consultations by as many as one million consultations.8 In response, the federal government attributed the decline to substitution of long consultations with special Medicare items, such as those for chronic disease management, claiming that the decline was offset by “a 30.9% rise in enhanced primary care (EPC) items”.8 The extent of the offset was disputed, with the Australian Medical Association maintaining that these statistics showed that the preventive care agenda was being undermined, not enhanced.8

Thus far, debates about changing consultation patterns have been based on comparisons of crude service volumes, whereas a longer-term, rate-adjusted approach would provide greater insight. Similarly, the federal government’s concept of consultation offsetting is limited: in addition to items for chronic disease care planning, other potential MBS items creating consultation offsets include health assessments, service incentive payments and mental health care.

Our aim was to determine how consultation patterns have changed over the long term by analysing the use of the four standard general practice consultation items —Levels A, B, C and D — alone and in combination with special MBS items. The broadest range of special items was used to establish whether the so-called consultation offset is sufficient to account for the decline in long consultations. Major supply-side factors that may affect consultation patterns over time, namely bulk-billing and the population-to-GP full-time workload equivalence (FWE) ratio, were also considered.

The historical trend towards increased use of long consultations reflects broader changes in general practice; for example, greater involvement of GPs in complex community-based interventions, a higher prevalence of chronic diseases, and an increased number of presenting problems per GP encounter.13 However, recent years have seen a sharp reversal of this trend in consultation length, coinciding with the federal government’s increasing reliance on MBS special items to guide GPs’ behaviour.

Our results suggest that the federal government cannot rightfully claim, as it has done, that the decline in use of long consultations is offset by use of MBS special items. This argument did have merit up until 2007, but this is no longer the case. Similarly, “workforce supply issues” — those typically remedied by announcements of new medical school places — appear to have had little influence, given the consistency of population-to-GP FWE ratios (albeit with some change in the consultation billings that contribute to that FWE). While bulk-billing levels have now stabilised, the period of change in consultation patterns coincided with a period in which bulk-billing levels were recovering. The relationship, if any, between the restoration of bulk-billing and the shift from 85% to 100% rebates under the Strengthening Medicare program requires further investigation.

The federal government intends the May 2010 MBS reforms to encourage preventive care through the use of long consultations. These reforms are likely to influence consultation patterns, but perhaps not sufficiently to overcome other factors, and the classic friction between professional and bureaucratic interests will remain.14 Further research will be necessary to establish what effect these recent reforms will have on consultation utilisation.

In some instances, the May 2010 MBS reforms reduce the complexity of the special items (particularly the health assessments), but the fundamental problem of reliance on MBS special items remains. These items have created a greater administrative burden, both vertically (through the requirements of individual items) and horizontally (by interactions and incompatibilities between items), as illustrated by the plethora of MBS items applicable to the care of one patient with diabetes.15 Further research is needed to understand the impact of these issues on clinical practice and patient outcomes. Ultimately, administrative burden is linked to Medicare’s fundamental design16 and the continuing suitability of a payment system for episodic care in an era of preventive and chronic disease care.

The assumption that special items are substituting for long consultations is analytically (and politically) expedient, but has significant limitations. It assumes, for example, that a health assessment is directly interchangeable with a Level C consultation, when, in reality, MBS requirements for health assessments are tightly defined, while Level C consultations involve a range of different activities. However, the special items do have considerable overlap with long consultations; for example, 63% of problems managed in Level C consultations are chronic problems, compared with 45% in (shorter) Level B consultations.17

Another limitation of our study is that the data relate to individual services, rather than individuals and their services. Better understanding of changes in practice patterns would be obtained from a longitudinal analysis of individual patients and their service utilisation, which would map the MBS administrative burden per patient. As an example, such research could quantify double care planning under the chronic disease and mental health care programs.15 Individual patients’ use of allied health services and long consultations should also be examined to determine whether care by allied health professionals creates another consultation offset. A final limitation is that the Medicare data do not include consultations under the Department of Veterans’ Affairs National Treatment Account;9 however, these consultations are restricted to a small proportion of patients.13

While the utilisation patterns of individual consultation items varied over time, the overall utilisation rate was notable for its stability (Box 1). In large part, this reflects the high rate of Level B consultations, which account for most general practice consultations (Box 2). However, long and special consultations, even in 2009, accounted for about 15% of all GP services (30% by cost).

Finally, the increase in Level A consultations should be considered carefully, especially since Level A consultations were unaltered in the May 2010 reforms. Their recent rise in utilisation may be related to an increase in patient encounters for vaccinations, prescriptions, medical certificates or test results,13 or to other factors, such as greater use of practice nurses, and, in 2009, the swine flu epidemic. However, BEACH (Bettering the Evaluation and Care of Health) data show that, while these individual reasons for encounter have increased, the number of single-problem encounters has generally decreased.13 This directly contradicts our observed rise in Level A consultations: in strict MBS terms, a Level A consultation involves “an obvious problem characterised by the straightforward nature of the task that requires a short patient history and, if required, limited examination and management”.4 Given that the rise in Level A consultations occurred in tandem with a decline in long consultations, further investigation of a possible relationship with administrative burden is warranted. Research is also needed on how changing consultation patterns affect patients and patient–GP relationships, particularly as patients with chronic disease perceive a “rushed GP” to be a “poor GP”.18

More Level A consultations may also provide an opportunity to consider a broader redesign of Medicare. Collectively, GPs appear to have identified — either voluntarily or under administrative duress — an increasing portion of practice with “obvious” and “straightforward” patient encounters. This may support targeted delegation of such consultations to nurse practitioners or physician assistants, which may alleviate the administrative burden on GPs and assist Medicare to realign with its objectives. The recent federal budget announcement of more funding for practice nurses19 increases the need to fully understand their role and impact on general practice.

1 Standardised utilisation rates for standard consultations, 1994–2009 (relative to 1994 rates)

3 Utilisation rates for standard consultations and special items, 1994–2009 (relative to 1994 rates)

4 Bulk-billing level (%) for unreferred and extended primary care attendances and population-to-GP full-time workload equivalence (FWE) ratio, 1994–95 to 2008–09