National Health Reform

Primary Health Care Reform in Australia - Report to Support Australia’s First National Primary Health Care Strategy

Element 10: Fiscally sustainable, efficient and cost effective

Objective: All Australians have a primary health care system which is efficient, including making the best use of the available workforce, and is cost-effective, fiscally sustainable for governments and affordable for individuals and families.

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Where are we now?

Current funding arrangements for primary health care service delivery in Australia include:

• Commonwealth benefit payments (MBS/PBS, Department of Veterans’ Affairs);
• publicly-funded services either delivered by states and territories such as hospital outpatient, community and public health services or delivered through non-government organisations (NGOs) such as the Royal Flying Doctor Service, More Allied Health Services Program and Access to Allied Psychological Services Program;
• private health insurance (ancillary tables plus limited services through broadened hospital tables); and
• private patient contribution including some services delivered through NGOs.

Possible reform of financing arrangements for primary health care in Australia is a recurrent theme in submissions and in broader discussion of primary health care reform.

While not the sole issue, the limitations and strengths of the MBS as a financing mechanism for primary health care have been raised in the context of other Elements, in particular under Elements 1, 3 and 4.

While many of the submissions to the Draft Strategy reinforce this view, it is not universal with a small number of submissions suggesting radical changes to financing arrangements and a move away from MBS arrangements.

More generally, in the primary health care context the need for changes to current financing arrangements is acknowledged. However, there is a range of views on the optimal structure of, and priorities for, changes to financing for primary health care service delivery in Australia.

While simplified, the dimensions of debate over public funding, particularly Commonwealth funding for primary health care, identified through the Discussion Paper, and confirmed through stakeholder feedback, could be summarised as covering:

• how do we allocate funding across the health system?
• how do we allocate funding geographically and across population groups?
• which health professionals do we fund?
• how do we pay our health professionals?

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How do we allocate funding across the health system?

Discussion in this area is around the distribution of funding between primary health care and other health care sectors, particularly hospitals and between different activities within primary health care. Internationally, there is renewed interest in investment in primary health care. Primary health care can provide better long term value than alternative investments in health care; through continuity of care it can result in reduced use of expensive pathology, emergency services and hospitalisations.³⁷¹

A 2004 article from WHO stated that ‘Despite the evidence for primary care, resource allocation in most countries still favours hospitals and specialist care. This is partly due to perceptions about what PHC [primary health care] is, what it has to offer, and its development as a control function to reduce costs or access to secondary care, rather than its positive contribution to health gain. This explains the paradox of the attractiveness of primary care on empirical grounds and its lack of appeal to national policy-makers and healthcare professionals, who see it as a low-grade activity with little effect on mortality and serious morbidity and a predominant role in triage of access to hospitals.’³⁷²

In submissions, there was a particular emphasis on the role of primary health care in prevention; the difficulty primary health care faces in fulfilling this role within current funding mechanisms; and the benefits of prevention and early intervention activity. (see Element 3).

A key challenge in primary health care is how to make the health care system adjust to focus on the most effective and cost-efficient approaches to caring for an individual patient or a population:

• in the face of pressures from each sector of the system (particularly hospitals, which are large resource consumers);
• the propensity of individual providers to focus on their own specialty, rather than patient outcomes across the system;
• financing rules that narrow rather than broaden the range of treatment possibilities; and
• emerging technologies and new information that can change accepted clinical practice.

An example of the treatment of back pain is outlined in Box 5, below.

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How do we allocate funding geographically and across population groups?

As discussed under Element 1, the current primary health care system struggles to provide equitable access to appropriate services for a number of population groups and areas of the country which can often contribute to a lower level of health status for these individuals. Examples of the types of populations that fit into this category include Indigenous Australians, refugees, Australians from non-English speaking backgrounds, and people living in remote and regional Australia. Underpinning this is the fundamental impact which workforce distribution has on the availability of services. While a small number of submissions suggested somewhat radical approaches to addressing workforce distribution such as geographic provider numbers or radical realignment of pooled funding, most commentary sought optimal ways to organise funding to supplement basic Medicare arrangements.

Several themes emerged from submissions:

• the need to reduce the current fragmented service delivery and funding arrangements to produce a more coherent nationally consistent primary health care system and address inequities in access;
• the need to increase local flexibility to identify and better address the needs of
  under-serviced/disadvantaged populations;
• the scope to consolidate and rationalise existing funding streams to reduce administrative impost and support greater local flexibility to meet the needs of at-risk and under-serviced populations (see Element 1); and
• the possible role of enhanced Regional Primary Health Care Organisations as
  fund-holders and purchasers of supplementary services at the regional level (see Element 7).

Which health professionals do we fund?

The potential for other non-medical health professionals to take an expanded role in the delivery of primary health care services is a key issue in financing deliberations.

The current primary health care system is relatively fragmented when it comes to providing access to multi-disciplinary care for patients. Some public funding is provided through Medicare for individuals with chronic and complex conditions to access a limited range of services. States/territories also fund a range of services. The amount and effectiveness of team-based care seems largely determined by a GP’s motivation and capacity to develop and maintain team-based care arrangements and by a patient’s ability to pay/access subsidies or rebates.

The need to improve the level of teamwork in primary health care, encourage greater integration and improve affordable access to a range of non-medical services is well accepted, although there is debate around where the GP sits in the team. There are also some clinical needs that can be addressed through allied health services but that do not necessarily require or involve team-based care.

The most complex issue in reforming current arrangements to better support multi-disciplinary teams is funding for allied health service delivery (currently a combination of state/territory government, community health including private health insurance - ancillary and hospital, MBS and other Commonwealth programs).

A further issue is how to target the support of allied health services to clinically relevant health care services.

This proliferation of funding sources is confusing and difficult for individuals, families and carers but also leaves some with gaps in access to affordable clinically relevant and necessary services. At the same time, the levels of unmet and patient demand for subsidised services are unknown but could be significant.

A key underlying question in this area is what will be the scope, mechanism and extent of public funding for clinically relevant health services provided by nurses, allied health professionals, pharmacists and dentists.

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How do we pay our health professionals?

Financing arrangements for public sector primary health care services in Australia include a complex range of mechanisms. While the majority of funding is provided through MBS patient rebates (often referred to as fee-for-service), there are also a large number of targeted health programs, with some based on pay-for-performance and capitation payments as well as salaried arrangements for services provided through community health centres and Aboriginal Medical Services (AMS). Each of these financing mechanisms provides different incentives (with different arrangements and rules) for both providers and patients.

There are a number of issues in this area: firstly the significance of Medicare fee-for-service and its limited suitability for supporting some models of care, and secondly the lack of information about what happens in primary health care and the incentives to promote quality improvement.

There is widespread agreement that the Australian health care system, in common with many other countries, does not provide the highest quality care for the money spent. Inherent in the current financing mechanisms are disincentives for professionals to supply quality, efficient care side by side with incentives to provide expensive, inefficient care irrespective of health outcomes.³⁸⁴

While the universality of Medicare makes it a readily accessible mechanism for most individuals and providers, the MBS patient rebate for an episode of treatment also has a number of potential weaknesses which are summarised along with the strengths and weaknesses of a range of other funding arrangements in Table 11.

In addition to these limitations, the MBS has been used to finance an increasing range of new service delivery models, some of which are significantly different to the types of care for which it was originally intended. There is a tension between the principle of universal access based on clinical need and the need to manage demand for more specialised services (with higher rebates) within a public insurance system.

Some recent changes have focussed on the types of care that extend beyond an episode of ill-health, for example the chronic disease management (CDM) items focus on ongoing care for patients with chronic conditions. Other MBS items have also been developed which trigger incentive payments to providers for other purposes or other programs (eg the PIP Service Incentive Payment items and bulk billing incentives). Inclusion of these newer models of care has both complicated the MBS and distorted MBS provisions beyond its original purpose of providing a universal patient subsidy for the costs of treatment for episodes of ill-health.

However, targeted health programs continue to be widely used to fill the gaps in ‘mainstream’ services under Medicare or through community health and hospital outpatient clinics. These programs can provide incentives for specific behaviours or health outcomes but are often time-limited and capped.

Pay-for-performance incentives currently form only a relatively small part of the financing arrangements in primary health care but there have been some notable achievements including improved rates of immunisation and computerisation in general practice. Difficulties with identifying suitable health outcome indicators, data collection issues and professional resistance around the need to continually align incentives with desired outcomes have limited the use of these incentives to date. However, there is scope for these types of incentives to play a much larger role in achieving improved health outcomes (see Element 5).

Salaried arrangements support provision of primary health care services through Aboriginal Medical Services (AMSs) and state/territory-funded community health centres and hospital outpatient clinics. While salaried arrangements enable more attractive remuneration for some health professionals, particularly in rural and remote areas, there has been significant professional resistance to Commonwealth direct employment of medical practitioners particularly in general practice relating to constitutional conscription issues dating back to the establishment of Medibank in the 1970s. The dominance of independent private businesses in primary health care and the changing work culture, particularly in younger GPs, has also led to increased participation in corporate practices which can also include aspects of salaried and contractual arrangements for service delivery.

While there are examples of fund-holding or quasi-fund-holding arrangements including the More Allied Health Services (MAHS) program and Aged Care Panels programs through the Divisions Network which have demonstrated flexibility in providing primary health care services, the limited timing and scale of funding, high reporting and administrative burdens and variability in the management capacity of fund-holders has restricted the use of
fund-holding more broadly.

Across the primary health care system, the various financing mechanisms used are largely unassessed at the program or initiative level as to their effectiveness or efficiency in any particular context. While some assessment occurs during the evaluation phase, it is generally only in terms of implementation parameters. Often these do not consider many alternative funding mechanisms and have lead to a ‘business as usual’ approach to funding with only peripheral changes to existing mechanisms such as the MBS.³⁸⁵

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Table 11 - Relative strengths and weaknesses of current and proposed funding arrangements

Strengths	Weaknesses
Fee-for-service Supports patient choice. Encourages throughput, although can lead to over-servicing (with an emphasis on shorter consultations). Any costs to patient are associated with a particular health need/episode and provide a disincentive for overuse. Strong professional support - decisions about patient care (once the patient has presented) are being made by doctors rather than bureaucrats. Administratively efficient.	Focuses more on treating ill-health, not on keeping healthy. May provide insufficient incentive for quality/prevention - promotes focus on presenting patients not those that don’t attend. Leads to fragmentation and potentially duplication by paying individual providers. Tends to increasing complexity as more, and more complex, services need to be itemised for episodes of care. Not necessarily well suited to flexible team-based approaches nor to potential new modes of care. Structured around acute, episodic care, less well suited to conditions requiring ongoing, pro-active, coordinated care and management. Can lead to under-capitalisation and under-servicing in some areas or for particular populations. Uncapped-demand driven.
Pay-for-performance/incentives Can be targeted at particular priority areas. Promotes focus on outputs/quality instead of just throughput.	Can lead to non-rewarded activities being ignored and keeping incentives aligned with goals can require considerable bureaucratic resources. Difficulty identifying and agreeing suitable indicators; collecting data is resource intensive. Difficulties in attribution for more outcome focussed indicators. Insufficient share of total income to engage professions. Potential professional resistance.
Fund-holding – capitation and other Can support flexibility and local solutions including best use of available workforce. Allow reallocation to priorities. Can be targeted to populations/under-serviced areas. Incentive is to keep people healthy and using the system efficiently. Can support patient registration and population health approaches.	Requires risk allocation arrangements and demand management strategies. Can lead to ‘cherry picking’. Potential for high administrative cost proportion. Incentive to reduce service provision unless outputs are measured meticulously.
Salary Attractive to some health professionals. Medical workforce more responsive to priorities of funder. Funder has greater control over their expenditure.	Can discourage throughput. Professional resistance.
Health program grants/targeted programs Can be tailored to specific circumstances. Not an incentive for inputs or types of clinical care; can specifically relate to outcomes. Time limited and specific in purpose.	May be seen as too directive by health professionals. As time limited, capped programs, may be subject to arbitrary cuts and changes. Funding allocation to nominated fund-holder.

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What the submissions said

How do we allocate funding across the health system?

Many submissions commented on the role that a stronger primary health care sector could play in keeping people healthier, delaying the onset of chronic disease and reducing avoidable hospital admissions with support for additional funding for primary health care:

Governments must significantly invest in this sector [primary health care] to see greater health cost sustainability overall, appreciating that investment in a sustainable future must be long term – results may not be measureable within the short term. ³⁸⁶

However at the same time there is mixed support for where this funding should be sourced, either through a change to the balance of funding within the health system or through new funding:

Australia has a strong political focus on hospitals and on high level clinical activities. A better balance between preventative and remedial services would ultimately lead to reduced hospital admissions and to savings in government expenditure. ³⁸⁷

Yes, more community-based, preventive and early intervention care is required in order for ensure the health system is sustainable, but will resources be taken away from hospitals in order to set up and support a more robust community care system, particularly when any improvement in outcomes will be long tem and not readily demonstrable for some time. ³⁸⁸

Funding should be equitable and efficient. To answer this question, we first need to undertake a national audit of current health expenditure and health need – including barriers to equity – to determine what the current mix is before we can identify what an ‘appropriate’ mix is. Ultimately the Australian people should be able to decide on this, possibly through mechanisms like citizens juries. ³⁸⁹

The appropriate mix of private and public funds should be that which supports a sustainable health system and quality outcomes whist ensuring equity of access and care. Determining this mix will require additional research and consultation with consumers, health professionals, policy makers and health service agencies. ³⁹⁰Top of page

How do we pay for our health professionals?

A recurrent theme in many of the submissions was that impacts resulting from the limitations of current financing mechanisms underpin many of the shortcomings of the primary health care system. While the submissions focussed on the benefits and disadvantages of various financing mechanisms there was general consensus that there needs to be consideration of adjustments to the current mix of blended payments.

The National Primary Health Care Strategy should be linked to a payment system which aligns the payment modality (fee for service, capitation, blended payments) with the expected outcomes. The College agrees with the evidence that suggests blended methods lead to efficiencies as they can out perform pure fee-for-service and pure capitation. ³⁹¹

The guiding principle to be applied to consideration of funding models is that no one model will be appropriate for a health system as a whole. In order to expand the scope for innovation, funding models must be adaptable to reflect local circumstances and should have the capacity to be applied and modified on a sub-jurisdictional or local basis. ³⁹²

Most submissions considered the primary health care system funding should include some mix of fee-for-service, pay-for-performance, capitation and salaried arrangements. However there was no clear and consistent view of the most appropriate mix to provide for the long-term sustainability of the primary health care system. Following is a thematic analysis of what the submissions said about each of the main financing mechanisms identified.

Fee-for-service

A recurrent theme from submissions was that mainstream fee-for-service arrangements do not meet the need for access to primary health care services for disadvantaged groups such as Indigenous Australians, refugees, the intellectually disabled and Australians from low socio-economic backgrounds. There was support for the idea that the MBS provides disincentives for practitioners to provide care for these consumers who tend to take longer to care for due to their more complex health problems and communication needs.

Many submissions presented various alternatives including moving to a population-based approach, making greater use of blended payments, salaried arrangements, ‘cashing up/out’ the MBS or adopting regional-based funds-pooling for primary health care services. However, there was some acknowledgement that the MBS works well for straight forward episodes of care and should be retained for these simpler types of services. A consistent theme was the need for financing models to allow for local flexibility to meet the needs of the community.

Similarly, there was broad coverage of the limitations of current MBS arrangements for access to allied health services through the Enhanced Primary Care (EPC) items including issues relating to referral requirements, service cap and rebate levels. There was mixed support for individuals having direct access to subsidised allied health services.

There was also some support for better utilisation of the MBS to support a broader range of professionals in providing preventive care including health promotion, educating and supporting individuals, their families and carers in self-management through covering support services provided via email or telephone and including provision for longer consultations. However there was recognition that the MBS does not often remunerate practitioners who have additional training or experience which may be required to provide this care.

A number of submissions were not supportive of further expanded roles of medical practitioners within fee-for-service arrangements given the perceived time constraints in medical consultations resulting from treating the urgent care needs of patients. A few submissions also suggested that the time constraints implied in the fee-for-service model provide strong disincentive for medical practitioners participating in research.

Many submissions noted that inequities in current MBS funding arrangements are a barrier to participation in true multi-disciplinary care for individuals with complex chronic disease, particularly for allied health professionals. Many submissions called for allied health professionals to have direct access to MBS items and specialist referral. Another issue raised with the current team care arrangements was that they are not available for early interventions which are considered effective for many conditions.

Several submissions also cited the limitations of the MBS in allowing coordination of care by appropriate team members. Many proposals also included various options for ‘cashing up/out’ the MBS to finance other funding mechanisms for provision of coordinated
multi-disciplinary care for people with chronic conditions and complex care needs including resourcing for collaboration and care coordination.

Pay-for-performance/incentives

There was support for various practice-level remuneration such as incentives for using accredited frameworks which support team-based care, participation in patient registration/enrolment or for implementation of systems to support practitioners to provide preventive care such as recall and reminder systems.

There was also significant support for extension of the PIP practice nurse incentive.

A few submissions supported the introduction of performance payments in combination with other financing mechanisms such as capitation payments based around patient enrolment in order to encourage effective and efficient service provision while maintaining flexibility.

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Fund-holding – capitation and other

A number of submissions supported targeting of services based on data at the level of individual general practices to enable monitoring of the outcomes of the services provided at a local level. This implies fund-holding at least at the practice-level or higher.

Several submissions supported funds-pooling in combination with patient enrolment, and in some cases pay-for-performance incentives, as an effective means for engaging primary health care in prevention and improved care coordination and planning activities. There is also some support for pooling of public funding from national and state/territory-based chronic disease programs as a first step in improving integration between the public and private sector provision of primary health care.

Many submissions have espoused regional organisations with responsibility for purchasing/commissioning primary health care services as being able to better plan for the health service and training needs of local communities. However there are also many submissions which identify potential risks around the funding levels, scale, insufficient population-level information and the lack of organisations ready to undertake such roles.

There is also some support for partial pooling of funds at the local level for more complex care combining national, state/territory and local government funding while maintaining the MBS for routine episodic care.

Salary

Teamwork and care coordination were identified as being strongly supported by the utilisation of salaried service provision and block funding of multi-disciplinary community health centres. Aboriginal Community Controlled Health Organisations (ACCHOs) were also supported as a salaried model which promotes continuity of care particularly for vulnerable groups such as Indigenous Australians.

There was also recognition that health workers require time to learn research skills and conduct research projects and that this required supporting salaried professionals in further study.

Health program grants/targeted programs

Health program grants and targeted programs were seen as more able to accommodate flexibility for disadvantaged groups such as Indigenous Australians, rural and remote populations and people with intellectual disabilities through providing specialised services for target populations. This includes programs for direct service provision through block funding, prevention and early intervention, promotion of health literacy and self-management.

There was also some support for the utilisation of targeted programs in implementing change in the workforce particularly to encourage participation in research activities as well as to promote workforce up-skilling and re-distribution.

Comments on the way forward

There was however strong support for the need for evidence of effectiveness and efficiency of financing mechanisms, as much as the model of care employed. Indeed the Royal Australian College of General Practitioners in their submission stated the need to choose the financing mechanism most suitable to achieving the expected health outcomes in any particular area.

As a step towards achieving this goal many submissions identified the need for investment in primary health care research to identify appropriate evidence in determining the benefits and effectiveness of both models of care and the most appropriate financing mechanisms.

In order to have a sustainable primary health care system, evidence of benefit and effectiveness is needed. A strong investment in primary care research, including research into overseas studies, would enable the identification of evidence and its effectiveness. Investment in research should be a pillar of the National Primary Health Care Strategy.³⁹³
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What is the way forward?

There is general agreement that there are complex issues around making substantial changes to the way resources are allocated across health, how these are targeted across Australia and different population groups, and through what mechanisms they are distributed. It has been suggested that there needs to be a clear view on the future demands of the health system and a plan for how to efficiently align the financial incentives to meet that demand.³⁹⁴

To make significant changes to the price, location, volume and quality of care requires informed debate, including with the community, on how to pay providers.³⁹⁵ Many health economists, in considering how to achieve efficient, effective and sustainable improvements, have espoused the need to consider what fundamental changes are required in current financing arrangements and if any incremental rewards or penalties could be added to encourage the changes sought. Many of the pay-for-performance programs are about adding a new layer of rewards and incentives on top of current payment systems but there is a growing consensus that this alone is not enough to address the disincentives inherent in payment systems.³⁹⁶ This is borne out by many submissions which support investigation of major changes to the payment mechanisms alongside implementation of incremental changes.

In the USA, there are moves away from fee-for-service arrangements with the Commonwealth Fund Commission on a High Performance Health System recommending policies to enhance payment systems to encourage adoption of the medical home model of care to ensure better access, care coordination, chronic care management and disease prevention and to correct price signals in health care to improve alignment with value.³⁹⁷

In the UK, while the majority of services are still provided by salaried professionals, there have been many financing reforms over the last decade. The introduction of Primary Care Trusts, Payment by Results, the Quality Outcomes Framework and practice-based commissioning have all been major reforms in their own right and the evidence is still being gathered on the effectiveness of these changes in driving improvements in quality, efficiency and effectiveness.^{398 399}

There are no quick and easy answers. Governments and health organisations in most countries continue to struggle with a lack of information about what mechanisms will achieve desired health outcomes in a sustainable way. There is increasing evidence that while reimbursement models influence some aspects of practitioner behaviour there is a lack of evidence about the impacts on health outcomes. Indeed Glazier et al suggest that there is no single model which can achieve the full range of policy objectives and information to support decisions around blending of different elements and the incentives and disincentives outside the model to achieve improved access is extremely limited.^{400 401}

Top of pageFundamental reform requires a new approach to resource allocation, not simply based on the population or the size of the problem which are as old as the principles of the Resource Allocation Working Party developed in the UK in the 1970s. The concepts around ‘needs-based funding’ have been canvassed in a number of submissions to the Draft Strategy and the National Health and Hospitals Reform Commission (NHHRC).

In an attachment to his submission to the NHHRC, Professor Mooney takes these concepts a step further providing some new insights into making the most of public funding based on the ideas of populations ‘capacity to benefit’ from additional resource allocation and the need to recognise that some jurisdictions/regions function better around allocation of resources. This new methodology overcomes many of the limitations of existing methodologies and indeed he notes that aspects of this methodology have been incorporated into the UK’s NHS Plan. Professor Mooney also recognises that much more research is needed to allow measurement of capacity to benefit and variation across jurisdictions and populations. Consideration could then be given to investigating the appropriateness of this and other developed resource allocation methodologies in consultation with consumer and professional representatives.

In addition to developing new ways to distribute resources, there is also a need to ensure new programs and initiatives make the most effective and efficient use of public funding once allocated through identifying key evidence-based measures against which they all can be measured. These can then also be applied to existing programs and initiatives.

This will enable:

• assessment of health outcomes and quality of care comparative to other modalities of care including broader preventive initiatives addressing social determinants of health;
• consideration of broader financial implications including improvements in workforce participation, cost reductions in other parts of the health system, and impacts on social determinants of health; and
• additional investment in comparative health outcomes research to further improve evidence-based assessment of programs/initiatives.

To make the most of any gains, evidence-based measurement of efficiency and effectiveness will need to be embedded in publicly funded programs. This will require development of mechanisms for regular review and adjustment of financing arrangements to ensure that programs/initiatives remain consistent with government priorities and community health needs as well as promote continual improvement in efficiency and effectiveness.

The Government has already started down this path through a commitment to funding the Medicare Benefits Schedule – a quality framework for reviewing services initiative in the 2009-10 Budget. This initiative will include the development of a framework for the Department of Health and Ageing to review services listed on the MBS and to inform, when necessary, appropriate amendments or removal of existing MBS items.⁴⁰²

Under the new arrangements, services will be evaluated and aligned with contemporary evidence to ensure clinical relevance and appropriate pricing. New services will be evaluated three years after being listed. This will improve health outcomes for individuals, their families and carers and contribute to maintaining the financial sustainability of the MBS.

The challenge for the future is assessing the most appropriate financing arrangement for particular objectives and initiatives, and ensuring a balance of financing methods to achieve the changes in service delivery arrangements sought and in light of other considerations including broader fiscal considerations.

While funding decisions will need to be supported by available evidence, equally the gaps in the current evidence base for primary health care need to be recognised.

In the longer term, a similar approach could be incorporated across all primary health care funding mechanisms to improve health outcomes for all Australians by ensuring publicly provided or subsidised services remain efficient, effective and sustainable.

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371 World Health Organization, The World Health Report 2008: Primary Health Care Now More Than Ever, p. 43, available from: http://www.who.int/whr/2008/whr08_en.pdf (accessed June 2009).

372 Atun R, 2004. What are the advantages and disadvantages of restructuring a health care system to be more focused on primary care services? p.9, available from: http://www.euro.who.int/document/e82997.pdf (accessed June 2009).

373 Jensen S, 2004. Back pain – clinical assessment, Australian Family Physician, vol. 33, no. 6, pp. 393-401.

374 Australian Acute Musculoskeletal Pain Guidelines Group, National Health and Medical Research Council, 2004. Evidence-based management of acute musculoskeletal pain: a guide for clinicians, Australian Academic Press, Australia, available from: http://www.nhmrc.gov.au/PUBLICATIONS/synopses/_files/cp95.pdf (accessed June 2009).

375 UK Medicines Information Central, 2008. ‘Usual care’ for back pain in primary care varies and often not as in guidelines, National Health Service, available from: http://www.ukmicentral.nhs.uk/headline/database/printstory.asp?NewsID=7123 (accessed June 2009).

376 Fritz J, 2008. Standardizing management of patients with low back pain in primary care and physical therapy, available from: http://clinicaltrials.gov/ct2/show/NCT00769626 (accessed June 2009).

377 Chou R, Loeser J, Owens D, Rosenquist R, Atlas S, Baisden J et al, 2009. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society, Spine Journal, vol. 34, no. 10, pp. 1066-1077.

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379 Moffett J & McLean S, 2006. The role of physiotherapy in the management of non-specific back pain and neck pain, Rheumatology, vol. 45, no. 4, pp. 371-378, available from: http://rheumatology.oxfordjournals.org/cgi/reprint/45/4/371 (accessed June 2009).

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380 Cherkin D, Sherman K, Avins A, Erro J, Ichikawa L, Barlow W et al, 2009. A randomized trial comparing acupuncture, simulated acupuncture, and usual care for chronic low back pain, Archives of Internal Medicine, vol. 169, no. 9, pp. 858-866, available from: http://archinte.ama-assn.org/cgi/content/short/169/9/858 (accessed June 2009).,

381 Ratcliffe J, Thomas K, MacPherson H & Brazier J, 2006. A randomised controlled trial of acupuncture care for persistent low back pain: cost effectiveness analysis, British Medical Journal vol. 333, available from: http://www.bmj.com/cgi/content/abstract/bmj.38932.806134.7Cv1 (accessed June 2009).

382 U.S. Preventive Services Task Force, 2004. Primary care interventions to prevent low back pain in adults: Recommendation statement, Agency for Healthcare Research and Quality, USA, available from: http://www.ahrq.gov/clinic/3rduspstf/lowback/lowbackrs.htm (accessed June 2009).

383 Chalkidou K, Tunis S, Lopert R, Rochaix L, Sawicki PT, Nasser M et al, 2009. Comparative effectiveness research and evidence-based health policy: experience from four countries, The Milbank Quarterly, vol. 87, no. 2, available from: http://www.milbank.org/quarterly/8702feat.html (accessed June 2009).

384 Miller H, 2007. Creating payment systems to accelerate value-driven health care: issues and options for policy reform, The Commonwealth Fund, vol. 72, available from: http://www.commonwealthfund.org (accessed July 2008).

385 Gross P, 2008. The high performance, transparent health system: improving population health, the patient experience and chronic disease management via provider payment reform and a national concerted action plan, Health Group Strategies Pty Ltd, Australia, available from: http://www.health.gov.au/internet/nhhrc/publishing.nsf/Content/home-1 (accessed May 2009).

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386 Submission from Australian General Practice Network (Sub #141)

387 Submission from Australian Health Professions Association (Sub #232)

388 Submission from Royal District Nursing Service (Sub #134)

389 Submission from Australian Health Care Reform Alliance (Sub #212)

390 Submission from Australian General Practice Network (Sub #141)

391 Submission from The Royal Australian College of General Practitioners (Sub #173)

392 Submission from NSW Government (Sub #187)

393 Submission from The Royal Australian College of General Practitioners (Sub #173)

394 Walsh J, Feyer A, Francis C, Armstrong K, Acheson L, Jessop R & Iglesias M, 2008. National Health and Hospitals Reform Commission Submission response: Governance, accountability and coordination – the keys to person-centred health care, PriceWaterhouseCoopers, Australia, available from: http://www.health.gov.au/internet/nhhrc/publishing.nsf/Content/home-1(accessed May 2009).

395 Gross P, 2008. The high performance, transparent health system: improving population health, the patient experience and chronic disease management via provider payment reform and a national concerted action plan, Health Group Strategies Pty Ltd, Australia, available from: http://www.health.gov.au/internet/nhhrc/publishing.nsf/Content/home-1 (accessed May 2009).

396 Miller H, 2007. Creating payment systems to accelerate value-driven health care: issues and options for policy reform, The Commonwealth Fund, vol. 72, available from: http://www.commonwealthfund.org (accessed July 2008).

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