Case 1
Hazel is having
trouble with her arthritis...
This 76-year old woman illustrates
a number of concepts central to population health. The case begins with an
outline of various sources of health data in
Because GPs
work within the community and have clinical contact with its people we are in
an important position to apply population health strategies to our patient
group. This implies a shift in focus from the individual to the population.
This case demonstrates the link between the individual and population
approaches. In practice, this shift of focus is not always easy to make as we
often feel that our obligations are to the individual patient rather than to
the population; this case will demonstrate that these approaches are
complementary.
Learning Objectives
· Understand the Australian health care system (including funding mechanisms and policies)
·
Be aware of the sources of
population health data in
· Understand the role of clinical practice guidelines
· Understand the need for organisational change within practice to integrate population health strategies such as screening, recall and the use of clinical practice guidelines
· Understand the principles of self-management as they apply to chronic diseases in general practice
Hazel’s Clinical Summary
Past Medical
History:
Osteoarthritis
Hypertension
Past
Surgical History:
Nil
Allergies:
Nil known
Meds:
Panadeine forte ii qid prn
Indomethacin 50 mg tds prn
Tritace 5 mg daily
Aspirin 100 mg daily
Ibuprofen 200 mg daily
Social
History:
Nil cigs or ETOH
Lives alone in a ground floor unit
Pensioner
Case Notes:
Hazel is a 76-year old woman whom I saw today
with a flare up of her osteoarthritis.
She takes Ibuprofen daily for pain control but
regularly uses Indomethacin
50mg tds when her pain flares. She put her most
recent exacerbation down to a change in the weather. I have seen several people
this week who have also complained that the weather has worsened their
osteoarthritis pain. I seem to have a lot of patients in my practice with
osteoarthritis. Is this normal? Where can I go to find out how common arthritis
is in my community?
An Overview of
Chronic Diseases:
Chronic
diseases are becoming more of a problem for our health care system. Over the
next 40 years, total expenditure on health care is projected to increase from
just under 10% of GDP to between 16 and 20%. Most of this growth in demand will
come from the burgeoning chronic disease burden, which is increasing in both
absolute as well as relative terms and is estimated to grow from the current
70% of the total national burden of disease to 80% by 2020. The ageing population demographic and increasing prevalence of some risk
factors are the key drivers behind this increase. The attached document
provides a more detailed overview of chronic diseases in
Sources of Health
Data:
Data collections enable us to
understand the ways in which the chronic disease burden is changing. Data
regarding the health of the Australian population are collected in three main
ways:
·
Firstly,
as the population has contact with the health care system, data is collected.
Hospital admission statistics, general practice consultations (which simply record
the doctor and item number), and the registration of births and deaths are
examples of this type of data.
·
Secondly,
specific registries of diseases, risk factors, treatments or at-risk groups
exist to provide data regarding specific health concerns. For example, each
State and Territory has a cancer registry that collects essential information
regarding all pathologically confirmed malignancies within the State. Other
registers you may be familiar with include the Australian Childhood
Immunization Register, the Australian Cervical Smear Register, and rheumatic
heart disease, diabetes and methadone program registers.
·
Finally,
government, research organisations or peak bodies, conduct population surveys
from time to time. Some of these surveys are conducted nationally and on a
regular basis, such as the National Census and the National Health Survey
conducted by the Australian Bureau of Statistics (ABS) http://www.abs.gov.au,
while others might be longitudinal studies such as
Each source of health information has
its advantages and limitations. Hospital morbidity data, for example, is useful
in monitoring diseases because each admission is coded for disease using the
International Classification of Disease (ICD-10). However comparisons of
admission rates over time have to be interpreted with caution as they can be
influenced by other factors such as bed availability or changes in methods of
hospital funding. Statistics derived from contact with the health care system
are also influenced by access to the system. Self-reported measures of
morbidity, such as national health surveys, are subject to the individual’s
knowledge of and response to illness.
The Australian Institute of Health
and Welfare (AIHW) is a good starting point to look for information about
common health problems in the Australian population. The AIHW was established
under Commonwealth legislation. Its mandate is to monitor and report on
morbidity levels in Australian society. The AIHW produces a biennial
publication ‘
A more
detailed discussion regarding measuring health and disease is included in the
following document:
Issues to Consider:
Use the above data sources to answer the
following questions:
a) How common is arthritis in the Australian
community?
b) Where does osteoarthritis rank in
c) Estimate the number of times you manage
osteoarthritis per 100 patients in your practice.
Case Notes:
Hazel’s knee was hot and swollen when I
examined her. I wondered whether I could offer her anything else apart from
NSAIDs and what I was going to do when these stopped working. What is ‘best
practice’ in the treatment of arthritis? Are there any guidelines I should be
following? If my treatment was in line with current guidelines, I would feel
reassured that Hazel’s treatment was the best it could be.
Evidence-based Medicine:
To manage chronic diseases as
efficiently as possible, we need to be offering treatment that is effective. As
GPs we have both the personal desire and the professional obligation to offer
our patients the best treatment. We want our management to be based on valid
scientific research. Evidence-based medicine is our attempt as clinicians to do
this. Evidence based medicine (EBM) became popularized in medical jargon in the
1990s with the development of information technology and the ‘information
explosion’ that came with it. Professional interest in the effectiveness of
medical care was also growing, driven largely by increasing governmental
pressure for efficiency and cost-savings. The fundamental premise of EBM is
that our clinical practice ought to be based on the best quality, scientific
evidence.
Clinical Practice Guidelines:
We can systematically apply the results of research to
our patient group by the use of evidence based clinical practice guidelines
(CPGs). These are usually developed through a process of searching and
appraising the peer-reviewed medical literature on all possible interventions
and then adapting this knowledge to local circumstances, with resource
constraints in mind. Guidelines are rarely 100% evidence based because for many
of the problems that arise in clinical practice there is not enough evidence
available to make definitive statements about the best thing to do. In these
situations the guideline developers have to rely on a combination of the
evidence and their knowledge and experience to make recommendations. Likewise
GPs need to assess each guideline on its merits and tailor their responses
according to each clinical situation.
Clinical practice guidelines can be
used as tools to improve the health of your practice population if they are
implemented in a systematic way. The National Health and Medical Research
Council and the
Guidelines in Practice:
Not all guidelines are of high
quality. You should perform your own assessment of the quality of guidelines
before applying them to your patients. High quality guidelines will have the
following features:
Once you have assessed a guideline as being of high
quality and suitable for your patients, the guideline needs to be implemented
in your practice. Implementing guidelines in practice is often difficult. There
are barriers which are logistical, patient-related and environment-related and
which might require a change in the processes or function of the practice. It
is often these organizational changes that are the crucial steps in realizing
the benefits of guidelines. This issue will be discussed in the next section.
Issues to Consider:
a)
Using the above resources, locate clinical practice
guidelines for the management of chronic pain in your patients with arthritis.
b)
Applying the criteria for high quality guidelines
outlined above, what are the strengths and weaknesses of these guidelines?
c) What do you consider to be the main barriers to
implementing these clinical practice guidelines in your practice? Name at least
four main barriers. Discuss these with your supervisor. Discuss ways you, your
colleagues, and practice support staff (e.g. practice nurses, Divisions of
General Practice) may address these barriers.
Case Notes:
Hazel came in for a long consultation, to
discuss her arthritis management at length. Her major complaint was a swollen
and painful knee, and stiffness in her hands. I had reviewed clinical practice
guidelines for the management of osteoarthritis, and had some ideas about ways
we could improve Hazel’s management. We discussed and selected alternative
treatment options, consistent with current guidelines. Within 4 weeks Hazel was
back, with significant improvement in her symptoms. This got me thinking - how
many patients with arthritis do I have in my practice? Is there any way I could
improve their management as a group?
Population Approaches in Primary
Care:
Over the past few years there has
been an increasing emphasis both in government policy and within clinical
practice to use a ‘population approach’ instead of only a ‘problem-based
approach’ in the prevention and treatment of illness. What is the population
approach? What evidence is there that it works? What does this mean to the
general practitioner?
Clinical practice is largely
problem-based. That is, a patient comes along with a problem and we go through
the process of history taking, examination, investigation, diagnosis and treatment
in response to this problem. We are responsive to the immediate concerns of the
patient. The patient gets better (or has his or her immediate needs satisfied)
and we have done our job. This process has been reinforced by our system of
remuneration that pays us per episode of care or visit.
An alternative to the above is a
population approach. Population health approaches are effective
and cost effective as risk factors for chronic diseases are widespread across
the population and cumulative over an individual’s lifespan. The attached document provides a
description of the population approach to chronic disease management in
What might a population approach for
arthritis look like in practice? Approaches I might take include the following:
·
First,
I would find the patients with arthritis in my practice using my practice
records.
·
Then,
I would extract from the data held in my records, information about my patients
with arthritis – for example, their age and sex profile, their co-morbidities
and their medications and other forms of treatment such as physical therapies
they use.
·
I
might then make an assessment of their needs and health status by some form of
organized inquiry, such as a practice survey.
·
I
could then look up best-practice treatments in evidence-based guidelines, and
assess whether these could be established and perhaps modified for the specific
purposes of my practice population.
·
I
could then apply the best-practice treatments in a systematic way to my
practice population, mindful that each may have to be adapted to suit the needs
and desires of each patient.
·
I
would need to ensure that the changes I made were sustained by periodically
reviewing the guidelines; to make sure I was still offering ‘best practice
treatment’ and periodically reviewing my patients with arthritis. A recall and
reminder system might be one way I would do this. Alternatively, encouraging my
patients to make a regular appointment, specifically for the purposes of
managing their arthritis, might be a way I could do this.
If I wanted to know whether there
were specific barriers to physical activity in the lives of my patients with
arthritis, I could conduct a needs assessment. Without such an assessment, the
main sources information I would have on which to assess this would be those
kept by government agencies, such as mentioned above. Even if we could get this
information, these routinely collected statistics are often more likely to
reflect the agency’s activities rather than the situation of each patient. The
beauty of the needs analysis is that it informs me about real patient needs
rather than leaving it to providers to guess or assume what is best for the
patient. Further methods conducting needs assessment in general practice are
available in the RACGP Green Book “Putting Prevention into Practice”.
A full needs assessment is a large and complex task and
would be difficult to do in a practice, even if there were adequate resources.
It relies on the collection of data not just from patients but also from the
community and other health service providers. However, there are other ways to
assess need that are less onerous – for example, asking consecutive patient
with arthritis specifically about a particular need, or conducting a practice
audit and surveying my patients with arthritis might be options I would
consider. The needs my patients identify might be individual needs, for
example, a need for more specific advice about the types of activities they
should be doing, or needs for my patients with arthritis as a whole, for
example a need for warm water exercise classes to be offered free or at low
cost at the local pool. If this were the case, networking with other GPs, GP
organizations and organizations such as Arthritis
There are lots of reasons not to
practice population health strategies. To us as GPs it might seem to be an
inefficient use of our time, not least because there is no remuneration. We are
too busy responding to the explicit and immediate needs of our patients to go
looking for new reasons to intervene or new strategies to try. There is neither
an immediate health gain nor an immediate patient need to satisfy, so there is
minimal reward for the patient or the GP. Besides, our obligations ought to be
to our patients rather than to the nebulous concept of population.
However, if we think that we have a
professional responsibility to maximize the health and well being of our
patients rather than just to fulfill their immediate needs, we ought to think
about our practice population as a whole. We can be confident that the benefits
of using this approach are likely to appear down the track. By ensuring that
all our patients are systematically offered management that is both evidence
based and up-to-date, we are, at least, providing the best we can offer and
maximizing their chances of remaining healthy. At best we might make a
measurable and noticeable difference!
Issues to Consider:
a)
What do
you consider to be the main barriers to implementing a population approach to
chronic disease in your practice? What are the four main barriers? Discuss
these with your supervisor. Discuss ways you, your colleagues, and practice support
staff (e.g. practice nurses, Divisions of General Practice) may address these
barriers.
b)
Use the
Practice Prevention Inventory (Appendix 1 of the RACGP Green Book) to assess
putting prevention into practice in your own practice.
c)
Time is a
commonly cited barrier because we are often too busy doing the day-to-day work
to be able to sit back and take a whole-of-practice view. How could you
incorporate some of these population strategies into your practice in a
time-efficient way? Can you think of a role for practice support staff (e.g.
practice nurses, Divisions of General Practice) in helping you with population
approaches to your patients?
Case Notes:
Hazel has seen a leaflet for a chronic disease
self-management program being offered by Arthritis
Chronic Disease Self-Management:
Self-management is about
training and supporting patients to better manage their chronic condition(s).
The underlying philosophy
is that patients will improve their management of their own chronic disease if
their knowledge, skills, confidence and ability to communicate about their
disease are improved.
Chronic diseases are
common and are on the rise. The worse they are managed, they more they cost the
government. Ways to improve self-management are therefore being evaluated to
improve outcomes for those with chronic diseases and to curb rising costs of
care.
The 1999 / 2000
Department of Health and Ageing (
The evidence was reviewed
to look for different self-management models. Then a series of demonstration
projects were set up to test them out and see how the different models
worked. Now the boffins are looking at ways
to translate these ‘learnings’ into a model of delivery of self-management in
the real world, including via general practice.
There are lots of chronic
disease self-management programs around. The most famous and probably the
earliest was the Stanford Model, discussed below. Since then, others have
popped up.
The common factors that
are associated with chronic conditions include:
The Sharing Health Care
process identified factors to address to help people to manage their chronic diseases
better:
Approaches to
self-management included:
Approaches have to be
patient-centred. In the jargon of self-management, patient-centred means:
Approaches also have to
be sensitive to the patient’s ‘stage of change’. Practitioners are encouraged
to assess where the patient is ‘at’ in relation to their stage of change, and
to motivate patients to change using the A-H model:
A – give advice,
B – remove barriers, C – provide choice, D – decrease desirability, E –
practice empathy, F – provide feedback, G – clarify goals, H – active helping.
Practitioners encourage
patients to set goals. Goals should be SMART:
The whole chronic disease
self-management bandwagon has its formal origins in the Stanford model,
although informally the idea has been around longer. This is much talked about
in the self-management literature. A researcher by the name of Kate Lorig, who
works for
Strictly speaking, the
real Stanford Chronic Disease Self-Management Program is a series of workshops
two and a half hours long, given once a week for six weeks, in community
settings such as senior centers, churches, libraries and hospitals. People with
different chronic health problems attend together. Workshops are facilitated by
two trained leaders, one or both of whom are non-health professionals with
chronic diseases themselves.
Subjects covered include:
1) techniques to deal with problems such as frustration, fatigue, pain and
isolation, 2) appropriate exercise for maintaining and improving strength,
flexibility, and endurance, 3) appropriate use of medications, 4) communicating
effectively with family, friends, and health professionals, 5) nutrition, and,
6) how to evaluate new treatments.
Each participant in the
workshop receives a copy of the companion book, Living a Healthy Life With
Chronic Conditions, 2nd Edition, and an audio relaxation tape, Time
for Healing.
It is the process by
which the program is taught that is supposed to make it effective. Classes are
‘highly participative’, where ‘mutual support and success’ build the
participants’ confidence in their ability to manage their health and maintain
‘active and fulfilling’ lives.
The evidence suggests
that undertaking this type of ‘training’ will result in a delay in disease
progression, reduced unplanned hospital admissions, and improved symptom
control.
Many people have more
than one chronic condition. The program is especially helpful for these people,
as it gives them the skills to coordinate all the things needed to manage their
health, as well as to help them keep active in their lives.
The Good Life Club
project was a 3 year demonstration project funded by the Commonwealth
Department of Health and Ageing (DOHA). The project utilised a number of
interventions to support people with diabetes to improve self management of
their condition and more effectively utilise existing local health services.
These included:
Australian Health
Policy:
To make more
sense of government decision-making in relation to primary care, we need to
have understanding of the policy process – how health policies have evolved,
and how policy decisions are made. The following section is a brief overview of
healthcare policy and financing in
Australian governmental health policy
has historically been concerned with the provision of health services rather
than the improvement of health per se. The early eighties marked a
change in this approach when there was a national response to the World Health
Organisation’s ‘Health for all by the year 2000’ initiative, outlined in the
WHO Declaration of
This declaration is compulsory
reading for those interested in a public policy approach to primary care
because it has influenced international and national policy regarding health
care provision ever since. To some extent its philosophy underpins the
Australian trend towards population-based primary care provision that we are
witnessing today.
In 1985, the Australian Health
Ministers Advisory Council (AHMAC) established the Health Targets and
Implementation (Health for all) Committee. The committee made a series of
recommendations. Their aim was to reduce inequalities in health status by
meeting a series of health goals and targets. The recommendations of the
committee were implemented but did not deliver the predicted health gains. In 1993 a further report entitled ‘Goals and Targets for
Apart from the NHPAs there is at present no all-encompassing national health policy guiding government strategy in primary care at the federal level. Initiatives in general practice and primary care, such as the establishment of GP Divisions and Enhanced Primary Care, continue to be delivered in a piecemeal fashion rather than as part of a coordinated policy approach to improving the delivery of primary health care.
Healthcare Funding
Mechanisms:
The aim of the national health care
funding system is to give universal access to health care while allowing choice
for individuals through a substantial private sector involvement in delivery
and financing.
The major part of the national health
care system is Medicare. It is financed largely from general taxation revenue,
which includes a Medicare levy based on a person’s taxable income. Commonwealth
funding for Medicare is mainly provided as:
State and Territory governments
supplement Medicare funding with their own revenues, mainly for funding public
hospitals.
Members of the armed forces and war
veterans are covered by additional special arrangements through the Department
of Veterans Affairs, while remaining eligible for mainstream Medicare coverage.
Other forms of financing cover some injuries and illnesses - for example,
compulsory workers’ compensation insurance covers work-related injuries and
illnesses, and injuries from motor vehicle accidents may be covered by
compulsory third person motor vehicle insurance.
Residential aged care is financed by
the Commonwealth Government by means of subsidies paid to service providers,
based on the level and type of care needed by the individual. Residents may pay
daily care fees and accommodation payments related to the level of care, with
special provisions for residents who have difficulty paying these charges. The
Commonwealth decides the allocation of new residential care places by an annual
regional population based planning process, inviting providers to bid to
provide the new places.
Community care services for the frail
aged and the Commonwealth, State and Territory Governments jointly fund people
with disabilities. For community care, clients pay different fees for services
depending on the type of service and the client’s capacity to pay. The
Commonwealth funds intensive Community Care Packages of coordinated care to
enable older people to continue living at home, who might otherwise require
low-level residential services.
New Medicare Items for the Management
of Chronic Disease
Click link below to view Slideshow of
Chronic Disease Management
K:\gpttweb\Population
Health\Chronic Diseases\Hazel H\Hazel H.htm
Medicare covers people residing in
All people eligible for Medicare are
entitled to a choice of:
• Free accommodation, and medical,
nursing and other care as public patients in
State/Territory-owned hospitals,
designated non-government religious and charitable hospitals, or in private
hospitals which have made arrangements with governments to care for public
patients; or
• Partially subsidized treatment as
private patients in public or private hospitals, with some assistance from
governments.
Costs incurred by patients receiving
private doctors’ services and some optometry services and dental surgery,
whether in or out of hospital, are generally reimbursed either fully or in part
by means of Medicare benefits.
Medicare benefits cover services by
doctors, refraction testing by optometrists, and, in some circumstances,
certain specialized dental surgery services. Medicare benefits are payable for
services by nearly all doctors currently registered in an Australian state or
territory. Newly registered doctors are generally required to enter further training
before their services can attract Medicare benefits, unless they have already
qualified as general (primary) practitioners or as formally recognized
specialist doctors.
Medicare benefits are not payable for
medical services rendered outside of
Although Schedule fees are used to
calculate Medicare benefits entitlements, doctors can charge whatever fee they
wish, provided the service is not ‘bulk-billed’. The rate of benefit for
out-of-hospital medical services, such as visits to a doctor in his/her rooms,
is at least 85 per cent of the Medicare Benefits Schedule fee. For the more
costly services, the benefit is raised to ensure that the difference between
the benefit and the Schedule fee (the ‘gap’) is limited.
For some kinds of medical services,
Medicare requires that a doctor who has been formally recognized as a
specialist provide the service, and that another doctor has referred the
patient to the specialist. If these requirements are not met, either no benefit
is payable or the benefit is lower.
For most pathology and diagnostic
imaging services, Medicare benefits are paid only when another doctor has
referred the patient to the doctor providing the pathology or imaging service.
These requirements are in place in order to constrain costs by removing
financial incentives to obtain unnecessary specialist services. As a
consequence, most access to specialist medical services is on referral from
general practitioners.
Patients may claim Medicare benefits
in the following ways:
Claims may be made either by post or
over the counter at Medicare offices or agencies. Alternatively, doctors can
send accounts directly to Medicare, accepting the Medicare rebate as full
payment for the service. This arrangement is known as direct billing or ‘bulk
billing’. Since the doctor, or any other person, may not make any additional
charge relating to a bulk-billed service, there is no out of pocket cost to the
patient. Unless a service is bulk billed, Commonwealth law does not restrict
the level of the fee charged.
The Pharmaceutical Benefits Scheme
(PBS) aims to provide all Medicare-eligible persons with access to effective
and necessary prescription medications at a reasonable cost to the patients and
to the government.
Pharmaceutical benefits are paid as
cash transfers direct to around 4800 approved community pharmacies that
dispense PBS medications on a claims reimbursement basis. The PBS also provides
other forms of assistance to improve affordable access to medicines, for example
specific funding for public hospitals for certain high cost drugs, such as
immunosuppressants used in transplantation.
It is estimated that around 75 per
cent of all prescriptions dispensed in
subsidized under the PBS. The other
major source of subsidized medicines is public hospitals, where medicines are
provided free to in-patients. The Commonwealth pays around 83% of total PBS
costs. The remainder is funded by patient co-payments.
Under the PBS all eligible persons
fall into one of two categories, which determines the amount the patient
contributes and the amount of subsidy paid:
• Concessional category - People who
receive certain pensions, benefits or cards administered by the Departments of
Family and Children’s Services (FACS) or Veterans’ Affairs (DVA), or who meet
certain criteria for being declared to be disadvantaged; or
• General category - General patients
pay the cost of dispensed medicines up to a maximum amount per item.
Where the dispensed price of a drug
is above that maximum, the general patient pays that amount and the PBS pays
the balance up to the listed price. If the prescription involves a more costly
but equivalent brand, the subsidy may be limited to the lower cost brand (the
minimum pricing policy).
Concessional patients pay a smaller
amount per item than general patients do, and the
PBS pays the balance up to the listed
price. This is also subject to the minimum pricing policy. Pharmacists must
check patients’ entitlement cards before providing medicines at the concessional
rates. Concessional patient prescriptions comprise 80% of the total Government
Expenditure on the PBS.
A safety net arrangement applies when
the total amount of co-payments paid by a patient (or immediate family) in a
calendar year reaches a certain threshold. From that time until the end of the
calendar year, the co-payment reduces to a smaller amount, with the benefit
paid to the pharmacist increasing. In the case of concessional patients the
safety net threshold is lower; and when it is reached no co-payment is required
for the rest of the calendar year.
Under Medicare, the Commonwealth
government provides a range of grants to government and non-government bodies
in order to achieve specific health care objectives. These include:
·
The
provision of services to special needs groups such as people in rural and
remote areas, Aboriginal and Torres Strait Islander peoples, and people with
mental illness;
·
Funding
of medical services that involve the use of expensive equipment, for example
the capital component of radiotherapy services performed on specific approved
equipment; and
·
Improving
general medical practitioner and associated services.
When Medicare began in 1984, the
Medicare levy was introduced as a supplement to other taxation revenue to
enable the Commonwealth Government to meet the additional costs of providing
the same level of care for the whole population, over the previous system.
Medicare levy revenue provides the equivalent of only around 27 per cent of
Commonwealth funding for Medicare. The rest of Medicare is funded by a range of
taxes such as income tax, taxes on sales of goods and services, and non-tax
revenue which together form consolidated revenue. Parliament appropriates funds
for most government programs from consolidated revenue.
The Medicare levy is paid by
individuals at a basic rate of 1.5 per cent of taxable income above certain
income thresholds. Taxpayers on high incomes who do not have private health
insurance pay an additional 1 per cent of taxable income as part of the levy.
Private health insurance is an
important component of funding of heath care in
The Commonwealth regulates insurance
offered by registered health insurance organizations to ensure that the
principle of community rating is maintained.
Community rating means that health funds
must charge everyone the same premium regardless of the health status or claims
history. This ensures that private health insurance is open to a wide range of
people in the community and that the aged and chronically ill are not priced
out of private health insurance.
In order to support community rating
there is a system of ‘reinsurance’ in place that redistributes the costs of
claims for the elderly and those in hospital for an extended period across all
private health insurance funds. This ensures that health funds with a high
proportion of these higher cost members are not disadvantaged.
There are over forty private health
insurance funds registered by the Commonwealth.
Most of these are open to everyone,
but some only offer cover to restricted groups such as employees of a
particular firm. In order to ensure that there is a balance between the public
and private health sectors in
Issues
to Consider:
a) The RACGP has formally acknowledged that GPs play a pivotal role in identifying and addressing inequalities in health care. Health inequalities are unjust, unfair and avoidable differences in health status or health care based on social position or economic circumstances. How might Hazel’s management differ if she had private health insurance or a DVA Gold Card? Is this a health inequality?
This case illustrates many concepts central to population health. As
a GP you are in an important
position to apply population health strategies to your patient groups. This
implies a shift in focus from the individual to the population. This case
demonstrates the link between the individual and population approaches. In
practice, this shift of focus is not always easy to make as we often feel that
our obligations are to the individual patient rather than to the population.
As a result of completing this case you should
have a better understanding of the Australian health
care system (including funding mechanisms and policies), be more aware of the
sources of population health data in Australia, understand the concepts
underpinning good clinical practice guidelines, and be conscious of the need
for practice systems that allow you to integrate population health strategies
such as screening, recall and the use of clinical practice guidelines into
healthcare delivery.
References and Further
Economics of hospital care. In G. Mooney
& R. Scotton (eds), Economics and
Australian Health Policy.
Swerissen, H., & Duckett, S. (2002).
“Health Policy and Financing”, in H. Gardner & S. Barraclough (eds) Health
Policy in
Arthritis and other musculo-skeletal disorders.
In: Australian Institute of Health and
Welfare.
Wright J, Williams R, Wilkinson JR. Development
and importance of health needs
assessment BMJ 1998;316:1310-3.
Wilkinson JR, Murray SA. Assessment in primary
care BMJ 1998;316:1524-8.
Department of Health and Ageing. The Australian Health System – An Outline. September 2000.