Rural Classification and Health Workforce Incentives

Presentation to General Practice Issues Group

19 June 2009

Sharon Kosmina, RWAV

Christine McDonald, GPV

Jane Sheats, VHA

Presentation Overview New Classification system and related 2009 budget initiatives Impact on:

GP Training Recruitment Retention Practice Funding Support Agencies Health Services

Classifications and 2009 Budget New Remoteness Areas classification from 1July 2009 Changes to GP Training General Practice Rural Incentives Program from 1 July 2010 Scaling of Rural Health Workforce Program from 1 July 2010 Rural Primary Health Services

ASGC-Remoteness Areas Classification In 2008, Minister Roxon said that RRMA to be reformed so that

“incentives and rural health policies respond to current population figures and real need”

Geographical classification only Fewer categories and weighted to remoteness on national

basis Information on AGSC + Area Locater + Fact Sheets:

http://www.doctorconnect.gov.au/internet/otd/Publishing.nsf/Content/RA-intro

Victorian areas by RRMA

Victorian areas by ASGC RA

RRMA v RA: Indicative Vic GP Numbers

More than 50% of rural GPs were RRMA 5

More than 80% rural GPs are now Inner

Regional 210 256 309

650

0 8

989

5 0

4200 4470

227

0

500

1000

1500

2000

2500

3000

3500

4000

4500

1 2 3 4 5 6 7RRMA RA

Data sources: Metro: PHCRIS, Division report 2006-07. Rural: RWAV Annual MDS survey, RRMA 3-7, November 2008

Impact of Changes in Classification Commonwealth claims no losers

– 2400 GPs across Australia eligible for incentive payments (many in Inner Regional areas)

– GPs who otherwise lose will retain incentives-unclear for how long.

Definition of rurality– Little change in Victoria

– Metro still Melbourne and Geelong; Rural- the rest

– Some RRMA 1 locations become RA 2 locations

Program eligibility criteria and funding formula– Unclear- yet to flow through many programs

Victoria is Metropolitan and regional, with little remote Will not access larger remote incentives

GP Training Supply of GP Registrars set

to increase 2009 2010 2011 2012 2013

594 675 700 812 812

GP Training to change to RA classification New Rural GP Registrar incentives now same as GPs More PGPPP places, but not likely in Victoria GPET to also manage PGPPP from Jan 2010 and new

incentives for registrars Sliding scale introduced for HECs payments and changes

to scholarship programs in favour of remoteness

General Practice Rural Incentive Program

RAAfter 0.5 yr 1 yr 2 yrs 3 yrs 5+ yrs

RA 1

RA 2 $2,500 $4,500 $7,500 $12,000

RA 3 $4,000 $6,000 $8,000 $13,000 $18,000

RA 4 $5,500 $8,000 $13,000 $18,000 $27,000

RA 5 $8,000 $13,000 $18,000 $27,000 $47,000

Replaces Rural Registrar Incentives Program and Rural Retention grants

Comparison GP Registrar Incentives

Current-RRIP New Implications

RRMA 3-7 placements. Rural and General pathways

Placements to be based on RA from 1 July 2009

GPET mapping placements from RRMA to RA.

Incentives on sliding scale over 3 years based on GPARIA categories

GPRIP using RA categories

More registrars to be eligible.

Significantly less $$ but paid over longer period

Rural pathway same as general pathway

RRIP After 3 yrs:

Cat A: $ 60,000 Cat B: $ 105,000 Cat C: $ 150,000

GPRIP After 3 Yrs:RA 2: $14,500RA 3: $31,000RA 4: $44,500

Implications

More GP Registrars Significantly reduced rural incentives, but paid over longer time

to more registrars No incentive for registrars to train in more remote locations

within categories eg Ararat and Ballarat receive the same

amount GPET to now be responsible for PGPPP, GP Training and

Registrar incentives- better alignment of programs

WILL RURAL TRAINING LOSE OUT WITH THESE CHANGES?

Recruitment Classification changes Impact on many recruitment programs-

yet to know full extent Strategies centre on financial and length of service incentives More city GPs and registrars encouraged to train and work in

the country Little incentive for non-resident IMGs

New Relocation Incentives

To

From RA 2 RA 3 RA 4 RA5

Major Cities $15,000 $30,000 $60,000 $120,000

Inner Regional $15,000 $30,000 $60,000

Outer Regional $15,000 $30,000

Remote $15,000

New Relocation Incentives Sliding scale rewards city doctors moving to more remote locations Rural locations gain incentives and outer metro lose incentives No relocation $ for IMGs coming from overseas

Current

Outer Metro

Inner to Outer Metro Existing Practice- $30,000New Practice- $40,000

Rural

None

IMG Moratoriums - Current

RRMA RLRPAustralia

Five Year Scheme VictoriaRRMA 4-7 with DWS

Five Year Scheme Other StatesRRMA 4-7 with DWS

3 10 years

4 10 years 5 Years 5 years

5 10 years 5 Years 4-5 years

6 10 Years na 3-4 years

7 10 years 5 years 2-3 years

New

RA

1 -

2 9 years

3 7 years

4 6 years

5 5 years

IMG Service Obligations

Rural Recruitment programsProgram Current New Implications

Five Year Scheme

RRMA 4-7 with DWS

To cease?

To be replaced by new service obligations

Service obligations increased to 6-9 years depending on RA classification – incentive is reduced

RLRP RRMA 4-7 and RRMA 3 with DWS

Remain RRMA or change to RA? To be RA 2-5?With or without DWS?

Moratoriums will reduce for Vic RLRP doctors.

International RecruitmentProgram

RRMA 3-7 with DWS.

RHWA contract to 30 June 2009

Program will continue Remain RRMA or change to RA? To be RA 2-5?

If not RA 2-5, number of eligible locations will reduce significantly

Implications for Vic LocationsMelbourne

and Geelong

No incentives or moratorium benefits

Outer metro lose incentives

Will lose doctors to RA 2-5 areas if incentives work however Outer Metro relocation incentives, which were at higher $$, had limited effect

Regional

Cities and

RA 2

locations

New relocation incentives at RA 2 levels and possible one year moratorium reduction under RLRP

Regional locations potentially more attractive than smaller surrounding small towns?

Eligibility for MBS rural incentives?

RA 3, 4, 5 New relocation incentives rewarding remoteness

Reduced moratoriums on sliding scale

Might have higher incentives, but will doctors be recruited there?

Victoria overall Change of RRMA to RA classification need to be RA2-7 or

Victorian locations will lose substantial access to recruitment Depends on effectiveness of incentives and the responsiveness of

urban doctors to relocate More difficult to recruit non resident IMGs to rural Victoria, which is

dependent on IMGs; Will heavily rely on marketing Victoria and HWA initiatives; very

little other incentives for IMGs or recruitment

WILL THESE CHANGES GET GPs TO AREAS WHERE THEY ARE NEEDED IN VICTORIA?

Retention GPRIP payments to apply from 1 July 2010 Retention centres on incentives All areas from RA2 to RA5 are eligible for retention packages

on a sliding scale All qualified doctors in the eligible regions qualify provided they

meet minimum Medicare requirements. Many new areas in Victoria qualify

Revised Retention grants

Potentially Eligible GPs

GPAria category

Inner Regional

Major City

Outer Regional Remote

Grand Total

Ineligible 714 2 40 756

A 209 19 228

B 66 135 201

C 33 3 36

D 2 2

Grand Total 989 2 227 5 1223

RWAV RRMA 3-7 GPs, Nov 2008

Comparison After 5 Years

GPARIA RRP payments after 5 years

RA GPRIP Payments after 5 years

Cat A 0 RA 2 $34,000

Cat B 10,000 RA3 $62,000

Cat C $45,000 RA4 $89,500

Cat D $80,000 RA5 $140,000

Cat E 125,000

Retention- Implications

Substantial increase in number of eligible GPs in Victoria

Significant increases in retention payments

No comprehensive focus on factors other than incentives to retain GPs

Practice MBS incentivesCurrent New Implications

Rural loading for PIPPractices in RRMAs 3–7

15-50% depending

No change If RRMA 1 or 2 RA2 = no benefit

Uncertainty about longer term

Practice Nurse Subsidy$7 per SWPE p.a. to practices & AMSs in RRMAs 3–7. Capped at $35,000 p.a.

No change As above

Item 10991$8 per consultation to bulk bill concession card holders & under 16

No change

As aboveSeen as a critical item for many GPs given high level of concessional payments

in rural areas.

Support Agencies: Divisions Program Current New Implications

Divisions funding

$0 per person:

RRMA 1

$2.47 per person:

RRMA 7

Population weighted by area

RA2 – 0.5

RA3 – 1.0

RA4 – 1.5

Likely loss of rural component for RRMA 5 RA2

Workforce Support for Rural GPs

Subsidy of 29,200 - $54,700 depending on rural load

No change for 2009-2010

Will be reviewed for value for money + for efficiency.Expect change for 2010-2011

MAHS $3, 770,783 total funds for Victoria 2007-2008

Rural Primary Health Services Program

Division funds end December 2009

Support agencies: RWAVRWAV RRMA 3-7

Current contract concludes June 2010. Can include new RA locations but more remote priority

New contract to be negotiated during 2009-10

Demands of new RA2 for recruitment & retention support

Demands of former RRMAs 4 & 5 to support new models

Impact on Health Services Small rural HS linked to GPs Burden on A&E departments Loss of health services weakens community viability

Accident & Emergency Lack of access to GPs Regional & subregional HS are funded Local health services not funded to provide A&E

GPs on-call 24/7 Workload increased over summer months REP Payment to VMOs inadequate Nursing staff EBAs Regional hospitals struggle

Health Service Concerns

Increased load on remaining clinicians

Lose of variety in clinical workload

Lose skills of clinicians and staffLose specialist/proceduralist

services

Lose ability to train

junior doctors or OTDs

Lose rural GP

Changes to programs

Rural Primary Health Services Regional Health Services More Allied Health Services Multi Purpose Centres Building Healthy Communities in Remote Australia

New program starts 1 Jan 2010 Uncertainty creates recruitment and retention problems

Summary System in transition, with the end point not yet known eg recruitment programs,

MBS items, WSRGP, ROMPS

Winners:– GPs who stay in rural areas– RRMA 1 locations who become RA 2– Regional cities access to some programs

Losers:– Outer metro areas – Rural incentives for GP Registrars – Former RRMA 5 locations with no competitive advantage to Regional cities– RRMA 2 (Geelong) not helped– IMGs, especially non resident IMGs

What about population and need in classifications? Are we targeting the wrong locations?

Heavily reliant on incentives that currently have little evidence basis for success

ConclusionHaving health workers in remote or rural areas (or any

area) relies on two interlinked factors:

(a) Factors that influence the decision or choice of health workers to come to, stay in or leave those areas, and

(b) The extent to which health system policies and interventions respond to these factors.

WHO Background Paper to Expert Meeting Geneva, 2009