15 February 2023

The big dumb thing the Medicare taskforce did

KnowCents Medicare

No one had particularly high hopes for the Strengthening Medicare Taskforce, so no one was particularly disappointed when its 12-page report came out with a lot of high-level ideas, a few big promises, no executional detail, and no more money than had been committed already in the election.

That’s about $750m over three years – or, one fifth of virtually nothing if you seriously wanted to reform Medicare and help GPs.

For what effectively was a pre-election thought bubble with no meaningful money ever behind it, the taskforce has produced a document that at least provides the sector with a reasonably well articulated set of targets, intended levers of change and ideas the government intends to work with over time.

This is important because everyone in the sector needs some certainty around what the government is at least going to try.

If you look at the giant mess we got ourselves into on climate change and energy policy over the past 20 years, you can see what happens if a government doesn’t provide some sort of framework and roadmap for a sector to operate within moving forward.

That the report is a dozen pages and brochure-like says a lot about this being a high-level aspirational document. The key concepts from those pages include:

  • A move towards more blended funding to address outcomes (but not a huge move)
  • Paying doctors more maybe when the government gets itself a mandate to do it (that’s actually not in writing but between the lines), which is presumably in a second term if they get it; a level E consult (real long one) for GPs is one possible tactic here
  • Moving ahead with voluntary patient enrolment (zero detail on how, how much and when)
  • Fix rural health (yep, that’s about it)
  • Improve primary care access, including after hours (again no detail)
  • “Strengthen funding to support more affordable care” (actual report words) which is clearly a good idea if they can really do it over time (see: next election, maybe).
  • Allow pharmacists and nurses in on GP work, including things like prescribing (which as explained in the report feels like a big dumb idea, but it’s not what this article thinks is the big dumb one); hopefully this goal eventually means: get allied professionals to work closely with GPs in integrated care teams to create more efficiency and access in care, so we’ll allow it
  • Pump up PHNs and LHDs for better integration of care in the community, which some GPs might see as a dumb idea because a lot of PHNs don’t support their GP networks very well and sometimes compete with them on stuff like mental health – but if it was actually done well (some PHNs are doing great work), it could be a good idea

Most of these ideas, as high-level, entirely unfunded and lacking in detail as they are, probably could help a lot over time if they come to pass.

The good and some bad

The inside dope on what the government is thinking by putting out this kind of report, and thinking about the health system in general, goes a bit like this:

  • We aren’t going to be killed today for not fixing health because this has taken years to screw up, but we can see we really need to do something soon
  • We’ve alerted everyone that we care and we’re interested in serious reform to Medicare and fixing the GP crisis
  • But there’s a lot of stuff in the queue ahead of health in political terms that we’ve promised we will do first and have committed the budget money to already (e.g. aged and child care) and we want to be a government that keeps promises
  • We haven’t asked anyone for a bigger mandate to fix health or for the money which we know would be needed, and we know is a hell of a lot more than $250m per year, but we intend to when we’re ready
  • We’re happy to start looking at ideas and planning, but the real deal in reform and money is going to need to wait until after the next election, if we make it that far

This strategy is in the paradigm of “it’s not everything I want, but it’s probably more than I expected”.

If our “inside dope” provider is right, it’s a good thing, because we have a government that probably mostly gets it, is assessing its political options, and planning for much bigger and better stuff in health moving forward.

Health is a hugely complex beast to reform, so it’s not such a bad stance to take.

Establish a framework for change, float a few ideas to get input on possible strategies, start some internal planning, and secure the love of the people so they trust you when you say you’re really going to turn this beast upside down and spend a lot of their money doing it, in the run up to the next election.

That’s the good side of the Strengthening Medicare Taskforce report.

And I hope you’ve noticed that I’m being a glass half full commentator here, giving the government the benefit of the doubt, and also trying to be a tad optimistic to boot.

The downright ugly

Here’s one of the last recommendations made in the report:

“Modernise My Health Record to significantly increase the health information available to individuals and their healthcare professionals, including by requiring ‘sharing by default’ for private and public practitioners and services, and make it easier for people and their healthcare teams to use at the point of care.”

This single sentence demonstrates such monumental ignorance of the situation we have with digital health in this country, it calls into question whether the government really does have a handle on what is wrong and the capability, with time, to fix it.

Anyone in the know on our digital health infrastructure, understands that compared to most of the rest of the developed world now, we are a long way behind, so will probably have been pretty shocked to see the My Health Record given top billing again in government plans as the centre piece of our digital health future.

Anyone else might have noticed the word “modernise” and asked themselves, “hang on, we’ve spent more than $2 billion on this thing in the last 10 years, and we now need to ‘modernise’ it?”

Just how much money can you keep pouring down that particular drain?

I thought my days of ranting about how outdated the My Health Record is were over, and  

  • that even the powers that be in relevant government agencies and departments were now aware that we turned a hard left when we should have turned right on our strategy for digital health with this project five years ago
  • that the fundamental architecture of the My Health Record, a centrally maintained and regulated data hub, was old when the very first iteration of it started 10 years ago, and this should have been realised five years ago
  • that almost every other developed country is pursuing distributed data architecture models to solve the problem of data sharing between health providers and patients – and some countries, the US for example, have generationally started changing their healthcare system as a result
  • that the My Health Record isn’t a total writeoff and parts of it can be used to help develop our digital infrastructure the right way, but as a centrepiece of our attempts to share data efficiently, its days are long over
  • that switching to the right strategy to open up health data sharing in a safe, secure and efficient way isn’t actually that hard or expensive: you start, like the US did with the 21st Century Cures Act, and set a time frame for everyone – tech vendors and healthcare providers – to get their act together and install the right technology, giving everyone standards of digital health data sharing that they must adhere to (or else maybe go to jail, like you can now in the US)

But there you go.

I’m saying it all over again.

And wondering out loud what happened here because that taskforce had plenty of responsible, capable and smart people that know this is our situation in digital health.

One other obvious problem: where’s the money to do this?

Last time we doubled down on this wrong turn five years ago we spent another $800m or so and we are precisely nowhere compared to countries like Denmark, Israel and the US are today.

If it’s a choice between putting another $800m into the MHR and giving GPs a bit more money to play with to create better equity and access in the system, it’s a no-brainer where that $800m should go.

It’s partly a no-brainer because the actual solution to an appropriate digital health infrastructure in this country is very inexpensive, at least in the short term (see below).

Can this problem be fixed quickly, or does no one really care?

If no one really cares – I’m talking to Mark Butler here directly – then you may as well not bother with any of your other grand ideas and commitments for health and Medicare reform.

Without a decent technology base in this country for data sharing, you’re not going to make any dent in care over time, given all the big cost issues you have coming at you in the near term as a result of our shift from an acute-focused care system to a chronic-focused one.

Healthcare reform will never work and never be affordable if you don’t get our digital health infrastructure right, and make it your first priority, given how long it will take to get everyone on the right path using the right technology.

No one will be able to share data or talk to each other properly and easily, and you will have an increasingly expensive mess (which is what we have now techwise across all our healthcare platforms that suck up and attempt to share patient data) which ignores your main goal in reform, which should be better and more efficient patient-centric care.

Why did this happen?

We have a huge problem in this country in healthcare in that the government employs directly or indirectly nearly everyone, so very few people are prepared or in a position to stand up and shout: “stop acting like a bunch of idiots in Yes Minister or Utopia, you can see what is wrong, let’s get on with rebirthing our digital health and data sharing infrastructure and leave the politics, the egos and the large mess of our apparently ‘unmodern’  two-point-something-billion-dollar My Health Record behind us”.

At a more granular level, we obviously do have a big problem still with the Australian Digital Health Agency (ADHA).

After all it’s that agency which has been tasked with the job of facilitating the build-out of our digital health infrastructure and it’s this same agency that conceived, developed, promoted and keeps repromoting the MHR. 

The weird part of this whole dynamic is that if you talk to many people in the ADHA over the years, most of them have been smart and wholly devoted to the idea of building a brilliant digital health infrastructure in Australia. Many I’m guessing have tried to do this on the inside of the agency and ending up leaving in despair. Some particularly talented ones were actually fired by the ADHA.

Even today, I talk to people in that agency and there is commitment, good intention and good ideas.

But nothing changes.

There is something very wrong with the ADHA and how it is being governed for it to waste this much money so obviously over such a long period of time, for it to still be asked to provide input at such a vital initiative as the Medicare Taskforce, and to give it such misleading information.

To put it to Butler, and somehow convince other taskforce members, that the My Health Record is OK it just needs a bit of “modernisation” (whatever that actually means), is a grossly bad piece of advice, possibly in a manner approaching the sort of advice the Department of Human Services was giving the government once on Robodebt.

To be clear, we don’t know for sure it was the agency’s advice, or if some other weird politics are in play.

But given the agency has stuck by this project and continues to spend money on trying to shove its very square profile into an obviously round hole, you have to suspect it is.

The ADHA costs taxpayers more than $250m on an average per year, and much much more when it’s spending on new infrastructure contracts to build things like the MHR – it has spent upwards of $700 million over the years with Accenture alone to build and maintain the MHR.

Notably the ADHA reports to and is funded by all state and territory governments as well as the federal government, so a lot of people have to agree if anything changes in how it works or is governed. You can’t blame the federal government alone, or the Department of Health, for how dysfunctional and wasteful it seems to have become for taxpayers.

What to do?

One thing that can easily be done, even if the ADHA persists in wanting to double down on the MHR and the government lets it do that, is to do what the US did and set in motion a standards regime whereby within three to five years every vendor and healthcare provider needs to upgrade their technology platforms so they are web sharing enabled, cloud based and able to talk to each other and to patients (like so many other platforms in major markets like finance and travel have been for years now).

If as a GP you consider that between Best Practice and Medical Director, nearly 90% of you are going to need to shift your major technology base (not necessarily your supplier as both either have or are working on that new technology) within a few years, that’s not a simple goal and it illustrates while the change is inexpensive to start, over time, it will be very expensive for everyone in the sector.

But that means we need to think very carefully whether we pour hundreds of millions into attempting to kick start the MHR again, as the Medicare Taskforce is implying, or retain most of this money to help the sector make this change themselves.

If the government does this, and handles this project well (not sure who you’d give the project too but logically it would normally be an agency like the ADHA) it would set Australia on a path to being able to deliver distributed data sharing across the system within about five years.

As a GP, in very simple terms, that would mean your patient management system would talk to most of the major EMRs in big hospitals across the whole country, to other major GP patient management systems anywhere in the country, to pathology labs, and most importantly, directly to your patient’s mobile phone when they walk into your practice.

It’s an even more revolutionary change for patients in terms of access to and efficiency of care.

We are a long way behind other countries, but maybe we can find a way to expedite this process and start catching up.

And, if we do continue to persist and obsess with the MHR, well, this other path doesn’t actually interfere with any of that work.

It will just make most of it obsolete within about five years.

One of the problems we have now, and possibly an argument made by the ADHA in persisting with the MHR, is that we don’t have anything to fall back on if the MHR is mothballed.

That problem would be solved if we can get going on standards within about five years and get the sector to “modernise” as it should have years ago, rather than rely on someone rehashing the MHR yet again.

There you go. I’m being optimistic again.