rural classification and health workforce incentives
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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
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