Public Hospitals and money

It is a known fact that the public hospital system is straining to cope all over Australia.

Amongst doctors it is also a well-known fact that most, if not all, public outpatient departments increase their revenue by blatantly double-dipping. Doctors who are being paid a salary by State or Territory Government to run a clinic will not see the patient unless there is also a current referral letter from their GP – this is then used to bill Medicare for the visit as well (Even though it is often only a Resident/Registrar seeing the patient and not the Consultant to whom the letter was addressed). There are all kinds of creative schemes around to deal with this money but generally it goes into some sort of fundholding that the relevant Department has created to supplement their income. The net effect is that a State/Territory Hospital is propped up with a massive stream of Commonwealth Medicare funding that effectively subsides these clinics on a grand scale.

I don’t usually have too much of a problem in dealing with this scenario (after all who am I to judge if Medicare obviously casts a blind eye to this mass rorting) but I do have a problem when sick, often elderly and/or dying, patients are being threatened that they would not be seen unless there is a current referral letter in place (and, no, I do NOT do indefinite referral letters) or when I get messages from my Receptionist that “a Professor’s” staff member had called and insisted on a letter being written as the patient was there and needed to be seen but they needed a letter before.

I may be “just a GP” Prof but my patients are also important and I will not make them wait while I run around doing paperwork for your billing purposes. Don’t even get me started on those requests for backdated referral letters.

The worst example was a a pro-forma letter that our local Radiation Oncology Unit used to send to GPs – it was something along the lines of:

Dear (GP’s name was mostly handwritten in here – sometimes this field was not even filled out), A specialist (did not identify who) has referred (patient’s details always fully given) to us for treatment ( no indication what for). Please provide us with an indefinite referral letter so that we can provide him with this service”

This was usually just initialed at the bottom by a Clerk in the Department – obviously the powers that be had a clear idea where GPs belong in the greater scheme of things – a source of $$$ for the department, no more, no less!

What really started my rant today was a notice from our local Northside public hospital. As most doctors would know the art of applying a proper circular cast on a limb with a fracture is a dying art amongst junior doctors. They are taught to apply a backslab/half-cast on limbs in the Emergency Department, at no cost to the punter, and the patient is then off-loaded to the Physiotherapists to apply a proper circular cast a few days later. Today I was presented with a list of the various “public physiotherapy clinics” at our Calvary Hospital.

The lists of the various fracture, lymphoedema, etc. clinics provided me with handy contact numbers and waiting times BUT they also clearly stated that all consumables, walking aids, etc would be charged to the patients at costs.

I had to read it twice to make sure I was seeing right – we are talking about public hospital patients who present to a public hospital clinic with their backslab from the ED who are told to pay for the cost of their cast and the crutches if they want a formal circular cast applied. All of this in Canberra, the good old Labor battler’s heartland – one can only wonder if Andrew Leigh is aware of this ?

How on earth does this happen? I tried to see if our Southside cousins face the same costs but my searching did not give me any answers. Regardless this is simply an amazing state of affairs and I do wonder what happens elsewhere in Australia

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3 Responses to Public Hospitals and money

  1. Interesting. The “rules” indicate that a specialist in a public hospital outpatient clinic can only bill Medicare for a service if the patient _elects_ to be seen as a private patient (and if the specialist has rights of private practice… which they usually do).

    With regard to backslabs vs full casts, it is generally more appropriate to initially apply a backslab (or split cast) in ED and revise it with a snugly fitting full cast when the acute oedema has had time to subside, so while I agree that the ability of most junior doctors to put together a reasonable cast is less than stellar (as unless you’re doing orthopaedics it’s rarely required), it’s fair to say that ED is generally not the place one should be getting their definitive cast. Referral to fracture clinic should result in (a) a proper cast at the appropriate time, and (b) no cost to the patient; they are a public patient being seen in a public hospital clinic.

    I’m not sure of Calvary’s arrangements… I guess if they lack an ortho-driven fracture clinic (and since the ortho guys over there are only interested in elective joint replacements, etc. and don’t do anything acute / trauma, it wouldn’t surprise me) and it’s physios sorting out the subsequent casts, etc. there may be different rules at play… ?

    • Thinus says:

      The point is though that the Specialist is being paid by the public hospital to run that clinic so they are being paid twice to do the work. And sometimes they get their Registrar to do it. I am keen to see these “rules” pertaining to this situation – do you have a reference for me?

      In regards to Calvary and the casts – I understand and agree about the use of backslabs – this has always been the teaching. The issue though is that the junior docs have palmed off the skill of more definitive management to the Physios. Not only that, at Calvary that will cost the patient the cost of all the consumables and walking aids. Once again you are correct that there is not a dedicated public Orthopaedic fracture clinic on the entire Northside of our Nation’s Capital. If they cannot afford to pay for Calvary’s Physios they can get a booking a TCH’s fracture clinic which for some Northsiders can be as much as an 80km round trip to attend. This is a long trip in a car if you have a sore leg in a flimsy backslab and is really a waste of time for a busy Orthopaedic Registrar to deal with. This is basic stuff that should be managed locally by the Primary Health team.

  2. I think the Australian Healthcare Agreement is quite clear about this – public patients are NOT to be charged under medicare unless elect to go private. Hospitals are blatantly doubledipping.

    Quite why this cost shift has been allowed to go unchecked amazes me. Either there is a rule, or there is not…

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