If patient co-payments were removed from general practices

It is only a matter of time before a government, whether Labour or National-led, accepts that patient co-payments for general practice visits are a major barrier for access to primary care.

Steps in this direction began in the late 1990s under a barely remembered associate health minister, Neil Kirton, with free care for those under the age of six. Kirton was a New Zealand First MP which had formed a coalition with the larger National Party.

Although this coalition was short-lived, Kirton’s success proved to be politically ground-breaking and sustainable. In July 2015 the then National-led government increased eligibility for those under 14 years. Labour’s policy has been to further increase eligibility but has yet to advance this since the 2017 election.

Co-payments are a long-standing and contentious issue. The ‘Growing Up in New Zealand’ longitudinal study, by the University of Auckland, of children born in Auckland, Counties Manukau and Waikato regions between 2009 and 2010, has highlighted barriers to access to primary care, one of which is cost.

How general practice is funded

General practices are funded by two main means – government capitation-based payments and patient co-payments. The former are based on the numbers of the enrolled Primary Health Organisations (PHO) population (there is generally one PHO in each district health board).

This means PHOs and their general practices are paid according to the number of people enrolled, not the number of times a patient receives care from a practice. Capitation is a good funding mechanism in principle.

Patient co-payments, the second main avenue for general practice income, are partially offset by government for holders of the Community Services Card for those on low incomes, living in public housing, or receiving the accommodation supplement.

If co-payments were removed, then capitation levels would need to be increased consequentially. This would require a different process to set the new levels and then annually adjust them. But there is a complication.

Whereas publicly owned hospitals provide hospital care, primary care is predominately provided by privately owned general practices. The large majority of these practices are owned by GPs but a slowly growing small minority are corporate owned. The number of GP owners is slowly declining but often other GP partners buy up the equity.

Short of an arbitrary nationalisation of these practices, privately owned general practices are sufficiently embedded to be a dominant feature of primary care for the foreseeable future. This has to be factored in when considering the full removal of co-payments.

The current process

Currently a forum called the PHO Services Agreement Amendment Protocol (PSAAP) has the mandate to agree changes to the PHO Services Agreement. PSAAP has representatives from the Ministry of Health, DHBs, PHOs and the General Practice Leaders Forum.  The Forum’s membership includes the New Zealand Medical Association, Royal New Zealand College of General Practitioners, and General Practice New Zealand (which comprises general practice networks).

Privately owned general practice businesses set their own patient fees, but within a certain threshold agreed to by DHBs and PHOs (in reality, the Ministry on behalf of the Government of the day).

There are strong criticisms of the PSAAP process, primarily because it isn’t a level playing field, with government, through the Ministry, calling the shots. This process would not be fit for purpose if co-payments were removed and, arguably, isn’t fit for purpose now.

Alternative scenarios

In contrast, collective bargaining provides employees – through their unions – with more of a level playing field because of the existence of the right to strike and, to a lesser extent, the availability of a form of non-binding arbitration.

The United Kingdom doesn’t have patient co-payments. Recognising this, it has a statutory system through the determinative National Health Service Pay Review Body. This is sufficiently broad to include privately owned general practices as well as employees. So far, so good. Even better, supposedly the review body is independent.

But there is a problem. This body’s independence is the kind of independence you have when you aren’t having independence. In other words, the government is in charge, including determining the criteria required for each round. The principle of a determinative process is all that we can usefully take out of the Pay Review Body process.

Recognising that general practices are predominantly private businesses, employment law can provide some useful insights. The Employment Relations Act 2000 provides for an adjudicative process, known as facilitation, in collective bargaining between employers and unions.

Facilitation is a process that either employer(s) or union can request from the Employment Relations Authority following an impasse in collective bargaining. It is non-binding arbitration. But it has the extra influence of the Authority being able to publicly release its decision in order to put pressure on the parties to accept.

Another possibility is adapting the resolution process proposed by the Government in its pending fair pay agreements legislation, intended to provide minimum industry or sector employment conditions, including remuneration. In the event of unresolved negotiations between employer and union parties, the Employment Relations Authority could determine these conditions for the affected industry or sector.

The Police Act 2008 provides “final offer” arbitration for the resolution of collective bargaining between the police commissioner and the Police Association when a negotiated settlement can’t be reached. This system is unique to the police because it is unlawful for them to strike. It’s downside is that it is ‘winner takes all’ which is not well suited for satisfactorily resolving complexity.

Through a health lens but fairly

Removing patient co-payments can be justified when considered through the lens of a universal public health system. The structure of privately owned general practices as the means of delivering most primary care should not be used as an argument in opposition. General practice has to fit in with the health system, rather than the other way around.

General practices will continue to be the dominant provider of primary care for the foreseeable future. Consequently, there needs to be a system of negotiation (not just consultation) on capitation levels and related matters that is a genuine playing field and includes, when necessary, a form of mutually agreed, independent, binding adjudication.

[This is a slightly amended version of my column published in New Zealand Doctor on 26 August]

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