Departmental ‘GP hunt’ may affect mental health care

This week, hundreds of GPs will receive a warning letter from the federal Department of Health about Medicare claims related to care provided to patients with a mental health condition.

An unintended consequence of this latest departmental campaign – in which some GPs apparently will be asked to pay back Medicare money – will be a lower standard of care for people living with a mental health illness.

The problem appears to be coming from this MBS note:

“If a consultation is for the purpose of a GP Mental Health Treatment Plan, Review or Consultation item, a separate and additional consultation should not be undertaken in conjunction with the mental health consultation, unless it is clinically indicated that a separate problem must be treated immediately.

In other words, if someone goes to the doctor for a mental health issue, GPs are not supposed to claim for general health or wellbeing services provided on the same day (unless it is urgent or an emergency).

In my book, it is unethical to deny treatment of co-morbid health concerns because someone has a mental health condition. It also goes against the latest thinking around the benefits of optimising general wellbeing to improve mental health.

Mental health services across Australia are increasingly focusing on lifestyle and preventive physical health because of strong evidence that this assists their clients’ mental health – but at the same time GPs are not allowed to charge for doing just this.

“Evidence-based and effective lifestyle therapies are indicated for people with mental illness in addition, or as an alternative, to usual care. Strong evidence shows that lifestyle interventions, such as nutrition, movement, sleep, stress management and substance cessation, are efficacious and cost-effective therapies that improve mental health, physical health and quality of life.” Source: Australian Journal of General Practice.

Don’t forget the 10-20 years shorter life expectancy of people living with a chronic mental health condition.

If the GPs, targeted by the department for claiming mental and other health items on the same day, were taking the appropriate time to provide genuine care, they should receive recognition for outstanding services instead of a being treated like racketeers.

2 thoughts on “Departmental ‘GP hunt’ may affect mental health care

  • Attendance for a separate issue during a consult for mental health issues is a common occurrence. Edwin, you are spot on with your analysis there and it goes to show how much Medicare are out of touch with the reality of how General Practice functions. Where does the RACGP stand on this issue?

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  • Thankyou for this fantastic article. Unfortunately it is the patients who will be the ones who suffer as a result of this increase in compliance activity.
    To use a medical model, we need to correctly diagnose the problem, and then we need to prescribe a treatment. Some might say that this letter is a single oversight by an over zealous department. But, to quote the referenced RACGP article, “The mental health letter is the latest in a string of ramped up compliance efforts by the DoH that rely on statistical detection of outliers in Medicare Benefit Scheme billing for specific items and billing ratios. The increase comes after the Government announced almost $10 million to increase MBS compliance in May 2018.” So I suggest that the correct diagnosis is that Medicare is being shut down by targeting statistical outliers, and when those have been removed, by targeting new statistical outliers. Even if only the top 1% is removed every month, after four years that means Medicare will be targeting those on the 48th centile, namely those billing right in the middle of the bell curve.
    These letters are just part of the coordinated attack on patient care. The PRP is growing, and now offers employment conditions so attractive that GPs are choosing to work for them rather than work in general practice. Dare I say it, some of those GPs are senior in the AMA. Some also are senior in the RACGP. This presents a problem, but it also presents a solution, as we will see below. The PSR also continues to grow, and became self funding a few years back and has grown 60 fold in under a decade. The have run out of GPs to prosecute under the 80:20 rule, so now are targeting GPs seeing more than 60 patients. When they have finished with those, it will be 40, then 30. They proudly claim in their annual report that they are doubling every year.
    The diagnosis is that General Practice is under attack.
    There are a number of ways to treat this problem. Three that come to mind are legal, political and via advocacy.
    Legal avenues might seem attractive, but it is worth reading through all past challenges to the PSR and PRP. Every single one has failed, except one. That one resulted in the board and chair of the PSR resigning, but I would suggest it was a Pyrrhic victory as the PSR never even missed producing an annual report. Medicare law has been written so well that it is impossible to challenge.
    The second avenue is political. Yesterday, Chris Bowen, Shadow Minister for Health asked for people to share a statement on social media saying that Medicare was under attack. He referenced in particular the loss of the bulk billing incentive for many areas. He did not mention the increase in compliance activity, and this is an avenue that can be highlighted if needs be. The RACGP has made a number of important statments in the last year about compliance activity and it may just be a matter of packaging these in a way that politicians can mention in sound bites that highlight how patient care will be affected. An example might be how GPs are too scared to do nursing home visits due to the threat of $500,000 fines for ‘seeing too many patients’ or ‘prescribing too many sedatives’.
    The third avenue is advocacy. All that might be needed right now is for every member of the RACGP to be encouraged to contact the organisation if they receive any correspondence from Medicare, including PSR investigations, PRP reviews, audits or ‘Review and Act’ letters. Maybe these can all be collated in some way and fed through to a committee or working group which can advise members for their specific situation, and also look for patterns and respond to these with position statements and media releases.
    I mention this last point as the RACGP may be in a far stronger bargaining position than it realises. If we go back to the RACGP member(s) who might be on the PRP or PSR review committees, they have a clear set of rules that they must abide by in any investigation, and that is that they must make decisions that would be accepted as reasonable by a body of peers. Now, I can’t think of a better ‘body of peers’ than the RACGP, so if the RACGP declares something to be reasonable, that becomes the new rule. An example would be the statement by the RACGP that they have concerns about targeting statistical outliers. If a doctor working for the PRP receives a printout from a Medicare computer saying that someone is in the top 1% for,say, billing item 23 in conjunction with item 2715, the final arbiter is not what the investigating doctor thinks, nor what the Medicare computer thinks, but rather, what a group of peers think. Any PRP/PSR investigator who decides to override this would place themselves at great risk. The government might decide to let them continue their work for a few years, get all the money they can, then declare those doctors to be ‘rogue investigators’ and remove their legal protections. “They were not listening to what the big GP organisations were saying”, the government could declare, and then our erstwile MPs sit back and watch doctors sue doctors for millions.
    So GPs can fight back. Make statements about what a group of peers think is reasonable, then ask members to send in their personal stories, and if a doctor is being threatened for doing something that most of their peers would consider quite reasonable, tell the investigator (who is most likely also a doctor) that they are out of line and on their own if they wish to consider pursuing the matter.
    Let’s not do this this for ourselves. Let’s do this for our patients.

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