I wonder what’s going on at the Department of Health

Australia’s health system is based on a hospital-centric model. I doubt this will change anytime soon, as Government expenditure on hospitals continues to grow – at the expense of primary care.

The recent outrage about changes to the Medicare Benefits Schedule (MBS) is symptomatic: it looks like GPs will no longer be able to charge for electrocardiogram (ECG) item numbers that include reporting. The Department of Health (DoH) seems to believe this is a job for hospital specialists only.

Earlier this year, all hell broke loose after a departmental campaign targeted GPs who deliver mental health care to their patients alongside physical care. And then there was the DoH’s intimidating ‘opioid crackdown letter’ to GPs, affecting the effective delivery of palliative care.

The DoH continues to disrupt healthcare provision in Australia with a ‘penny wise, pound foolish’, management-by-spreadsheet approach. General practice remains largely undervalued.

Yet, the long-term benefits of primary care are well known. Adequate support for general practice is associated with slower growth in health expenditure and better system quality, equity and efficiency, as well as savings to the health system.

State hospitals are facing unsustainable cost blowouts and ever-increasing waiting lists in the face of significant population growth.

Increasingly, there is talk about supporting general practice to deliver more care in the community through collaborative models of care.

Yet the DoH believes GP should not be providing care that includes skills such as interpreting ECGs to ‘reduce low-value care’ and because it is ‘safe and best practice’. I wonder how safe the DoH’s new ruling is for patients presenting with cardiac symptoms to their GP.

It appears the recommendations by the 12-Lead Electrocardiogram Working Group, originally made four years ago, were reworked by DoH. The end result did not go down well at the time.

The RACGP responded in a submission in early 2018, stating that it ‘does not support the proposed recommendation … as it fails to recognise or acknowledge that GPs perform ECG interpretation, report results in the patient record and determine actions without referral’.

The feedback clearly fell on deaf ears. Stakeholder engagement by the DoH appears to be little more than a tick-the-box exercise.

The fact this ECG news came out of the blue and amidst a second wave of COVID-19 is awkward.

Effective care provided in general practice reduces the need for more expensive hospital specialist care. Health systems with a greater focus on primary care are more equitable, have lower costs and better health outcomes.

The poor departmental decision-making of late sadly encourages health inefficiencies and deskilling of the general practice workforce. It goes against efforts to deliver patient care closer to home. It is highly demotivating for general practice teams, especially amidst the COVID-19 pandemic, and demonstrates a concerning absence of a long-term vision.

This article was originally published in NewsGP.

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.

MBS Review: A stronger primary care system in sight?

Implementing healthcare reform in Australia is always an uphill battle. After a disappointing outcome of the much-anticipated Healthcare Homes program, some of the members of the Primary Health Care Advisory Group regrouped when they were appointed to the Medicare Benefits Schedule (MBS) Review Taskforce.

The recommendations by the taskforce to improve the MBS are refreshing in many ways. There is a move towards strengthening GP stewardship, voluntary patient enrolment, more non face-to-face care, a simpler careplan program and increased support for home visits – which seems sensible and is addressing the frustrations of many about the current Medicare system.

It appears there are a few things missing. For example, there is no recommendation to spend more time with our patients by committing to an increase in the schedule fee of longer consultations (item numbers 36 and 44). This would have been more useful for most patient encounters than a new one-hour plus item number.

I believe the residential aged-care item numbers will need more investment when the SIP incentive ceases to exist. There is mention of outcome-based payments which requires an explanation. The lack of detail about the dollar values makes it challenging to predict the impact on general practice and primary care.

In an ideal world the recommendations could result in an invigorated, modern, patient-centred health system. However, if history repeats itself, the result will be a simple cost-saving exercise, dressed up as clinician-led, evidence-based healthcare reform.

A typical case of make it or break it.

You can’t have your cake and eat it too

The Practice Incentive Program is shrinking but the government expects new quality improvement systems and general practice data.

Most GPs were underwhelmed, to say the least, when they heard about the changes (read: cuts) to the Practice Incentive Program (PIP). Cutting the funding for nursing home visits is a hard sell for the Department of Health and the Federal Health Minister.

This is the wrong message at a time when there are more elderly people with complex chronic health problems in need of appropriate medical care, preferably in the community.

I have heard about various ‘fixes’, including improvements to the Medicare Benefits Schedule (MBS) schedule (good idea) and introducing nurse practitioners (not necessarily a good idea) – but nothing has been confirmed and it all sounds a bit like policy on the run, not a planned and coordinated strategy.

Quality improvement

The scrapped incentives, including the aged care service incentive payment (SIP), will be used to set up a quality incentive payment system (QI–PIP) in GP practices. There are certainly arguments for supporting an enhanced quality improvement system in general practice, but was it the right decision to sacrifice the aged care payments?

We need practice data to review and improve patient care. I agree with the RACGP position that the development of a QI–PIP should assist general practices to undertake quality improvement activities.

However, the RACGP has also indicated that it will not support measuring performance against key performance indicators (KPIs) or so-called ‘quality indicators’ in combination with performance payments. There is just not enough evidence that this will significantly improve care in the long-run, but there is evidence of harm, including detrimental effects on the doctor–patient relationship and practitioner burnout.

Although we have had verbal assurance from the Department of Health that the new QI–PIP – to be introduced in May next year – will not be a pay-for-performance system, the longer-term plans are unclear. This has raised many concerns and it will hinder business planning for general practices.

Data deal

In return for the quality improvement payments, practices will be required to hand over their patient data to Primary Health Networks (PHNs) under the current proposal. From there, the data will flow to other agencies but – just like the My Health Record data – we have not yet heard for what purposes it will be used, and what the implications will be for individual GPs within practices. Many GPs have indicated that they are not prepared to hand over data to their PHN or the Government.

Another big issue is the eHealth Practice Incentive Payment (ePIP), which was originally introduced to strengthen practice IT systems, but is now used to make practices – often practice nurses – upload shared health summaries to the My Health Record. As we are moving to a My Health Record opt-out system later this year, the time may have come to review the ePIP and make it more meaningful for general practice.

Lastly, the practice incentive funding was introduced in the 1990s and has never been indexed. In 2016, $21 million was earmarked for removal and used to partially fund the Health Care Home trials.

It all sounds like another example of the Government wanting more for less. You can’t have your cake and eat it, too.

This article was originally published on newsGP.

Can we deliver high value care with one eye on the clock and the other on the screen?

Given longer consultations are associated with better health outcomes, the Medicare Benefits Schedule should be restructured to incentivise appropriate consultation time in general practice.

It is estimated that doctors are making an incorrect diagnosis in up to 20% of cases, and up to 30% of investigations may be unnecessary. It is often thought that medical knowledge and skills are the culprit, but there is another reason for the majority of medial mistakes.

Doctors need time to listen and think. General practice’s inherent time pressures, interruptions and the need to record information on computers can be distracting and cause cognitive errors. Our thinking process is also influenced by our emotions; for example, as a result of work stress or running late.

This is not rocket science and has been well documented. For example, in his New York Times bestseller, How doctors think, Harvard professor Jerome Groopman described how snap judgments and other cognitive errors by doctors can lead to medical mistakes.

In a television interview, Professor Groopman explained how over the years the consultation time gradually had to drop from 30 minutes to about 12 minutes. A doctor can’t think, he said, with one eye on the clock and the other eye on the computer screen.

Increasing complexity

In Australia and New Zealand, chronic conditions account for 85% of the total burden of disease, and a chronic disease is a contributing factor in nine out of 10 deaths. The increasing multimorbidity and complexity of care requires that doctors spend more time with their patients. Managing several medical and psychosocial problems in a 15-minute consultation is increasingly challenging for doctors and many patients.

It is not surprising that longer consultations seem to be associated with better patient outcomes. The benefits of extended consultations of 20 minutes or more for certain patient groups have also been explored overseas. More time with patients may lead to higher patient satisfaction, fewer errors and a lower volume of prescriptions, investigations, referrals and hospital presentations.

It is time to slow down. At the moment, the Medicare Benefits Schedule (MBS) fails to recognise this growing problem as it encourages throughput. For example, seeing patients in blocks of four 15-minute appointments per hour is valued at $148.20, but two 30-minute consultations per hour is worth a total of $143.40.

Health Care Homes

Is block funding such as proposed in the Federal Government’s Health Care Homes model encouraging more time with patients? Probably not. In fact, one could argue that it incentivises less face-to-face time with the GP and more contact with nursing staff and other team members.

Our patients deserve our time. The MBS schedule could support our patients with chronic and complex health conditions by better rewarding longer GP consultations.

This article was originally published in newsGP.

5 reasons why the Medicare rebate freeze is bad policy

When I tweeted about the Medicare freeze last week, someone asked “Care to explain other than meaning you get less money?”

I thought it was a really good question as it highlights the complexity of the issue. Most people seem to think that it’s all about doctors’ income – but it isn’t. The Medicare rebate is also about the money patients get back from Medicare.

As we speak, around Australia GP practices are adjusting their fees as a result of the government policy. Our practice increased the fee of a basic consultation with five dollars for people without a concession card. Other practices have decided to charge a once-off $30 payment to previously bulkbilled patients.

I expect that if the freeze is not lifted these amounts will have to go up again soon.

Greedy doctors?

Everything gets more expensive over the years, including the cost of running a medical practice – think for example about rent and employing receptionists and nurses. If GP practices would not up fees, their Medicare rebate income would drop with 7.1% by 2017-2018!

Over the years more and more services will require an out-of pocket payment by patients, including pensioners and healthcare card holders. Rural doctors expect that bulkbilling in the bush will soon be a thing of the past.

But the freeze has also affected urban areas. That’s why the the RACGP and AMA have labelled the government policy a ‘copayment by stealth’.

Five arguments

The freeze is bad policy and should be reversed for five reasons:

1. Many practices will stop bulkbilling. This means higher out-of-pocket costs for patients. As a result fewer people will visit the doctor in the early stages of a disease. This will often make treatment later on more difficult, more stressful and more expensive.

2. The policy disproportionately affects disadvantaged people who cannot afford a copayment. Research shows that increased out-of-pocket costs stop people from going to the doctor.

3. The freeze undermines important Australian values such as equity of access and therefore encourages a two-tier health system.

Some argue that a copayment would cut unnecessary use of medical services. But higher out-of-pocket-costs will not weed out unnecessary visits. Many of my colleagues know that often their sickest patients will not seek medical care if it becomes more expensive.

4. Research indicates that areas with poor access to GP services have higher hospital costs. It is likely that more people will visit places where healthcare is free, such as already overloaded public hospitals and emergency departments. Dr Google will become more popular too!

5. Practices continuing to bulkbill will have to change their business model: doctors need to see more patients per hour, or practices will have to hire less staff which will affect service. Some practices will close their doors – such as Dr Adrian Jones, a Redfern GP who decided to close his practice as the margins were getting too small.

Is the freeze a necessary policy?

Medicare is not unsustainable. This is a false argument by the government. In fact, Federal Health Minister Susan Ley admitted at the national AMA conference: “The Government is not claiming we’re in a healthcare funding crisis.”

Australian healthcare performs well in comparison to other countries. The increase in health expenditure in general practice has been slow, and in line with overall economic growth and GDP.

Freezing the patient Medicare rebate will not make healthcare more efficient or reduce waste in the system.

Medicare freeze

The Medicare freeze: A storm is coming

Health Minister Sussan Ley said at the annual AMA conference in Brisbane that the Government is not claiming we’re in a healthcare funding crisis.

At the same time dark clouds are gathering as the frustration about the patient Medicare rebate freeze rises.

The Medicare rebate is the amount patients get back from Medicare after they visit their doctor. This amount is supposed to go up every year to compensate for inflation and higher costs. The government has frozen the annual indexation for four years.

The Consumers Health Forum said in its analysis of the latest Budget: “The retention of the $1.67 billion freeze in Medicare payments to doctors may mean many patients are likely to face higher medical bills.”

The Guardian reported: “The AMA president, Brian Owler, used his opening address on Friday to call for both sides of politics to lift the ‘damaging’ freeze which could force GPs to start passing costs on to their patients, amounting to a so-called co-payment by stealth.”

And: “The federal government could face another fierce campaign from one of the nation’s most powerful lobby groups if it does not lift its freeze on doctors’ rebates before the next election.”

The RACGP has also indicated that it would consider a new campaign. It looks like we’re going to get some fireworks again.

How do you put up with this, doc? Red tape in medical practice

“How do you put up with this, doc?” She looked at me while I was on the phone. We were waiting for almost ten minutes.

Every time she comes in we go through the same ritual: I ring the PBS Authority hotline, we wait, sometimes for a couple of minutes, and sometimes longer – like today. I always get approval, and then print off the script for her. In the meantime other patients are waiting in the waiting room or trying to get an appointment.

According to the AMA thirty per cent of medical practitioners reported spending ten minutes a day or longer waiting for calls to be answered. So here we are: we have a shortage of doctors and we make them jump through bureaucratic hoops instead of seeing patients.

An estimated 25,000 patient consultations are lost every month while doctors are making phone calls to the PBS Authority hotline. At the same time various reviews have shown that this procedure is unnecessary and does not lead to any savings.

I was very pleased to see the Australian Medical Association submission to the National Commision of Audit earlier this month. The AMA states in the introduction:

Though there has been some recent progress in reducing regulatory burdens in a few areas of medical practice, the amount of regulatory burden and red tape remains excessively high without any real justification. Internal AMA research shows that a large number of GPs spend up to nine hours or more each week meeting their red tape obligations. Every hour a GP spends doing paperwork equates to around four patients who are denied access to their doctor.

The submission focuses on six areas:

  1. PBS phone authorisations.
  2. Medicare provider numbers
  3. Medicare payments
  4. Personally Controlled Electronic Health Records (PCEHR) registration for medical practices
  5. Centrelink and Department of Veterans’ Affairs documentation requirements
  6. Chronic Disease Management items under the MBS

Although there are lots of other areas that need improvement, this seems like a good start.