17 November 2022
Funding models no longer serving Australia’s healthcare needs
As new models of multidisciplinary virtual and blended care emerge globally, Australia seems to be anchored to a bricks and mortar parental style of healthcare. Outdated funding models continue to create barriers to digital transformation.
But, innovative clinicians are emerging from the woodwork with an eye to develop new models virtual care to improve access and outcomes for patients.
Two examples of these areas of innovation are rural diabetes and aged care. The case studies below demonstrate that the technology and expertise is out there – if funding will allow.
Laura Zimmerman has lived in Goondiwindi in Western QLD since 2012, and used the experience gained as a clinical nurse Specialist, diabetes educator and cardiac rehabilitation coordinator to develop an integrated care pathway for diabetes management.
Type 2 diabetes (T2D) is the fastest-growing chronic disease in Australia.
The burden of T2D is growing particularly rapidly in rural and remote communities. Indigenous Australians were 2 – 3 times more likely than non-Indigenous Australians to have diabetes or pre-diabetes in 2020. Diabetes death rates were 5 times as high among Indigenous Australians as non-Indigenous Australians in 2020. Diabetes death rates were 1.8 times as high in remote areas as in major cities in 2020.
Ms Zimmerman created Macintyre Health to help address the access issues of rural and Indigenous Australians with diabetes, bridging the geographic gap with technology.
“A lot of people believe, often without saying it, that if you are an Aboriginal or Torres Strait Islander or if you live rurally, then realistically you ‘get what you get’ because you live so far away. And that’s just been the status quo,” Ms Zimmerman told Wild Health.
“It has just come to a point where we can no longer accept that, and we have to use telehealth, we have to use technology, we have to think laterally to make that change and to move the needle,” she said.
Macintyre Health offers a one-stop shop for diabetes management, offering services such as insulin pumps, dietitian and nutrition services, glucose-monitoring, education, and telehealth services. It currently has a presence across Queensland and New South Wales.
According to Ms Zimmerman, improved outcomes for her patients included lower HBAIC’s, lower hospital admissions, shorter lengths of stays in hospital due the availability of localised outpatient services within the patient’s rural community, improved quality of life with a quicker return to work or school and a decrease in the cost of travel to access health care services.
The challenge was finding a funding model to support sustainable integrated virtual care, allowing her to deliver this multidisciplinary model.
“The funding didn’t exist; I had to apply for it, and to design the model and prove the value of that and show how we were providing better value at a lower cost to improve outcomes,” Ms Zimmerman said.
Ms Zimmerman was able to secure funding through the Darling Downs & West Moreton PHN in the form of block funding, and used the data she collected on outcomes to show the return on the investment to the health system.
But, to build on the success of programs like this, sustainable long-term funding is needed. This is always a challenge with commissioning cycles that see new priorities and changes to funding without assessing the outcomes being achieved.
But in order to do this, Ms Zimmerman said that the ‘hearts and minds’ of government need to be changed.
“Everyone (in rural areas) wants to tell you that ‘I’m here, I’m real, and I matter’. But they all just get pushed aside and told that you just need to have a stiff upper lip, this is where you choose to live.
“They just want people to know that that their lives matter just as much as someone who lives in Brisbane or in Sydney.”
Moving to outcomes-based funding models where providers can show they are delivering quality care in exchange for continued funding could be a move in the right direction.
Another notable example of a clinically designed integrated model of care was given by Paresh Dawda at Wild Health in Melbourne last month.
Dr Paresh Dawda runs Next Practice, a service that centres integrated practice and team-based approaches. Dr Dawda spoke about the model they have established in the context of aged care at the summit, and about the barriers preventing a truly integrated system.
The problem in aged care, he said, is that an increasing amount of people require care at home – and the most common condition is multimorbidity. And there is no one way of managing this as it necessitates a preference-based approach.
“What I hear the majority of the time from patients is that the issues for them are things like not wanting to go to hospital, wanting to be looked after in the in the place they’re in, and concerns about palliative care; both living well, but also end of life…a majority of them want their preferred place of death to be their home. Yet, we’re not really achieving that as a as a country,” Dr Dawda said.
Dr Dawda said that aged care providers are not “joined up” and do not communicate, leading to fragmented care and unnecessary complications.
“So, the knock on effect of the current state is we get poor coordination, which causes a lot of waste in the system.
“We get repeat testing, we get people being transferred to hospital when they don’t need to…so if you look at the value based equation, we’re not really delivering the outcomes, and we’re doing a poor job at high cost. There’s a lot of waste,” he said.
The other big issue leading on from this is funding. Dr Dawda made the point that as a GP, when he cares for an older patient with dementia or in palliative care, a lot of time is spent communicating with the nursing staff in the facility or with carers over the phone.
But none of that time is rebatable.
“So actually, our payment mechanism is not fit for purpose,” he said.
This is what initiated the idea of an integrated practice unit, which aims to bring the right skills mix to deliver the correct care to the patient. At Next Practice, this mix includes GPs, nurse practitioners, psychologists, pharmacists and social workers.
“So we have been evolving our skills mix to meet the needs of an older population, whether they are in residential aged care or in the community. And we are doing that under the current model with all the challenges it has.
“But, we’re ‘walking with it’ is the way I describe it. So, what would enable us to fly rather than walk?”
Dr Dawda said the barriers to flying are the funding mechanisms, lack of interoperability and interconnectivity, and regulatory barriers.
He advocated for a blended funding model, with a higher proportion of capitation and bundled payment rather than just fee for service.
“We just need to start somewhere and work it out, rapidly iterate.
“In the fullness of time, I’d like to think that we can get to a population health-based approach, where we have a decentralised model of funding, which says, ‘here’s a population that needs to be looked after, and here’s is system that’s going to look after them’ and actually, just devolve that funding to the to the system,” he said.
This could be a co-commission type of approach.
“But that will, I think, really enabled that integrated practice unit. And that integrated practice unit not will not only be horizontally integrated at the same level, but also vertically integrated.”
These were just two of many innovative clinically led and technology enabled models of care that were discussed at Wild Health in Melbourne.
Wild Health is stepping it up a notch in Canberra on 4 May 2023 at the Wild Health Reform Summit. We will again be partnering with the AHHA and Jay Rebbeck, and bringing together leaders from our health and social care system, including Dr Paresh Dawda and Laura Zimmerman, to discuss a vision for a collaborative, innovative, and flexible health system that is patient centred and outcomes focused.
If you would like to register you interest to hear more about the upcoming summit, please email Michelle O’Brien at firstname.lastname@example.org.
Wild Health Melbourne 2022 post event content is available for purchase here – $195 (inc gst).