Dr. Austin Byrne:

-----by 40%. Let us consider patient demand and those complex patients who are on eight medications or more. These are people generally with diabetes, hypertension and complex multi-morbidities who attend hospital services if they are not properly managed with preventative care. Between 2004 and 2014, this cohort of patients rose by 300%. Therefore, the number of the most unwell in those ten years tripled and the demand for services among the most unwell tripled but the capitation remained fixed and, in fact, it fell off because of the financial emergency measures in the public interest legislation. The problem is one of contract design. We have an inflexible contract where all of the risk is on the provider and the purchaser gets off scot free. If we flip it on its head and consider the contract that exists in pharmacy for dispensing, all the risk is on the purchaser and the provider takes no risk. As we scale the amount of medicine dispensed, we scale the fee paid. When a patient is on eight medications, the dispensing fees are about 4.5 times the fee that is paid for medical care in the community. That is no fault of anyone but that is a fault of contract design and that is something that we need to look at very carefully.