WA News Guest Opinion / Editorial Value Does Have a Price
Value Does Have a Price
Written by Dr Rohan Gay
Tuesday, 29 August 2017

25082017-Doctor-tightrope-revalidationThe Department of Health has released for public consultation six clinical committee reports from the Medical Benefits Schedule Review Taskforce – urgent after-hours primary among them, which as a GP Principal I am most interested in.

The focus of the urgent after hours report is aimed at preventing inappropriate use of urgent after-hours items. There is no attempt to change the descriptors for after-hours to enable appropriate after-hours attendance by the local GP. There is no attempt to strengthen the relationship of deputising services to the principal practice through either agreements or communication and medical records requirements.

We have the absurd situation in which my patients are not eligible for non-urgent after hours rebates until after 8pm, yet if I have already closed my door and return to the surgery, they can access these items from 6pm. Do I recall the nurse and receptionist for this? A deputising service with no prior relationship to a patient can access these rates after 6pm!

We do open until 6pm. We’ve decided it is important to cater for those who can’t attend in office hours. I’m pretty tired by then but I’d make it 8pm if it were worthwhile. The irony is that I will be spent when others commence their lucrative business.

The real money, of course, is in urgent after-hours calls. A lot of what I see during the day is urgent. Last week three of our doctors attended overdoses on two occasions: one brought to the surgery from the neighbouring pharmacy and one at the nearby bus stop.

Urgent can be anytime

Both were resolved with teamwork in under an hour and so no Item 160, and it’s ‘draw straws’ to be the doctor who receives the patient’s rebate. And don’t forget to beg the ambulance to replace consumables as no other fee can be raised for a bulk-billed attendance!

MBS reform for urgent attendances thus goes beyond descriptors of hours and urgency but also extends to issues of payment of several practitioners and nurses for team management of a patient, and co-payments for consumables.

I am also really interested in the report on MBS attendance items. I my opinion, Item 23 is the greatest evil at the heart of our primary health system. The ‘standard level B’ attendance is defined in part as a consultation lasting less than 20 minutes, i.e. no bottom line in time. The content descriptors are broad.

In contrast, ‘standard’ appointments are either 10 or 15 minutes. This makes sense: why spend more than 10 minutes on a problem when you need to double the time to receive an increased fee of less than double the amount? For a corporate player it would be irresponsible to shareholders not to minimise compliance with time and content.

Time is money

After 22 years as a GP I can usually tell if someone is sick or not in a few minutes and confirm this with examination and prescribe, or not, and give a little advice in a few minutes more. To educate the patient how to manage themselves and avoid seeing me takes longer. To address prevention of the things that are most likely to kill or make them chronically unwell takes even more time. After 10 minutes, however, I am effectively losing money.

I support the RACGP position laid out in the paper, Working towards a sustainable healthcare system, (Version 1, February 2015), which proposed six time tiers for GP attendance Items (I would even have gone for six-minute intervals). Analysis of the College survey results found 73% respondents agreed with the proposed six time tiers and noted the lack of recognition of increased efficiency conferred by experience.

Our surgery has been shortlisted for the Health Care Homes Trials. We analysed 212 consecutive patients drawn from our appointment books. I compiled a list of 105 conditions I felt warranted the description of chronic conditions. About 80% (170) of our patients had two or more of these chronic conditions. The greatest number of chronic conditions listed for one patient was 22.

I suspect the Health Care Homes descriptors will be much more restrictive given their estimates (on a population basis) of about 20% of Australians having multiple complex and chronic conditions. The danger, of course, is that the incentive of the system appears to be to identify as much chronic disease as possible then to do as little about it as possible.

Gaming the system

When visited by our local Primary Health Network representatives we did some back-of-envelope calculations and determined that we could well be out of pocket with some of our more complex (Tier 3) patients. It was suggested that such ‘frequent fliers’ not be registered and treated on a fee-for-service basis!

This was alarming. Does this mean gaming the system is already being practised with attendance items and chronic disease items? If so, this potentially disadvantages the very patients Health Care Homes is meant to support. Another possible way to game the system could be to exclude conditions necessitating high attendance (e.g. chronic pain, conditions requiring warfarin) from the registered conditions of participants. Yet another would be to refer patients to casualty once their ‘allowance’ is up.

The response from our local reps was, “but you wouldn’t do that, would you?” and in our case, they are right. Like many GPs, our loyalty is to our patients rather than any corporation or institution. As always, the main governor of our charges is ourselves.

Unlike any other branch of medicine, it is our enduring relationship with our patients, generally spanning years, often decades, and economic circumstances, which ultimately limits our impost on them and contributes to our declining remuneration made worse by the Medicare Freeze.

That’s in our case. I’m sure in other cases, cooler heads will rationalise the model to greatest financial advantage and patient care be damned.

By Dr Rohan Gay