GP payments to identify dementia: would it work here?

By David Donaldson

Friday October 31, 2014

The United Kingdom has introduced a payment of roughly $100 to GPs for every dementia diagnosis they make in an effort to increase diagnosis and early treatment rates. Would a similar incentive work in Australia?

“Early diagnosis makes a whole lot of sense,” according to University of New South Wales associate professor Tom Keating, explaining that it is not just the UK that has problems with lateness in diagnosing dementia.

He thinks providing incentives to facilitate this “would seem like an appropriate thing to do”, but stresses that Australia’s health funding system works differently to the NHS.

Whereas the Australian model is based on fee-for-service, in which Medicare pays GPs per visit, British payments are capitated, meaning patients are enrolled at a clinic and payments are made for the enrolment period based on the patient’s health needs, whether or not that patient seeks care.

In this context, the £55 incentive payment can be used to increase staffing to help care for dementia patients, fitting with the broader system of payments based on assessed care level. Because chronic conditions such as dementia require ongoing treatment, capitation allows for, say, the hiring of a nurse to liaise with the family of a patient.

Capitation helps promote preventive and overall health approaches, argues Keating, rather than being focused on treating illness when an already sick patient presents. Moving away from Australia’s current “episodic” approach would better place the health system to deal with the types of chronic conditions that are becoming increasingly prominent as the population ages and lifestyle-driven problems, like obesity, spread.

Chronic problems like dementia are an area that Australia’s health payments system is not well designed for, says Dr Brian Morton, chair of the Council of General Practice at the Australian Medical Association.

“We need to look at blended payments, where there’s a recognition that treatment of conditions like dementia requires a team approach.”

“We need to look at blended payments, where there’s a recognition that treatment of conditions like dementia requires a team approach,” he told The Mandarin. Incorporating payments for work not requiring face-to-face interactions with a doctor alongside fee-for-service would help improve the treatment of chronic conditions.

Morton cites New Zealand, where there is a blended funding system, as a model for Australia to follow.

He is also sceptical of the idea of targeting individual diseases, arguing that doctors are better off “treating the whole person in their community context”. Nonetheless, Australia has used similar types of incentives in the past to help increase the vaccination rate, where “the money was for a nurse to ring and remind parents to bring their kids in, and it worked very well”.

Morton adds that Medicare already provides funding for examinations of mental state among over-75s, which perform a similar function without being targeted at a single condition.

Keating argues Australia is in fact going backwards on the issue of funding for dementia patients, pointing out the federal government has removed additional subsidies paid to aged care providers for dementia care. He argues “it would seem to be a strange thing to provide incentives to increase the diagnosis rate for dementia while withdrawing other support”.

One of the strengths of the British system, he says, is that capitation payments facilitate planning, something Australia is not so good at. Keating thinks the primary health networks could be used to help increase planning for dementia patients.

Whatever the method, both agree early identification of dementia is important.

“The biggest problem for dementia is denial,” Morton said. “Because a person is demented they don’t realise they are losing it. It starts out as a subtle change, like missing appointments. Subtle changes family or a spouse might notice. Bringing it to a doctor’s attention is very important.

“Most of the medications are more effective in the early stages, and early interventions for safety and health can make a difference.”

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