So you have a sore knee Mrs Smith?


1

And you have no private insurance but you are still working?

2

If this was 1985:

  • Come in, sit down, let me examine you thoroughly – don’t think it should take more than ten minutes and you can be back on your way to work.
  • We are so lucky – we now have this thing called Medicare and that pays me really well for seeing you. It might only cost you $ 5 out of pocket to see me today or I could just bulk bill you given how well Medicare pays me for this visit
  • I think you have Osteoarthritis. Lose some weight, take some Voltaren and Panadol and don’t work that knee too hard with the exercises. See me if it does not get better.

3

If this was 1995:

  • Come in, sit down, let me examine you thoroughly – it should take us about 15 minutes. Do you think you can go back to work after this or do you need a certificate?
  • I think you have Osteoarthritis. Let me show you what I mean on this nice model of the knee the drug rep gave me. Lose some weight, take some Voltaren and Panadol and don’t work that knee too hard with the exercises.
  • I know of a recent case where a rare condition was missed so we had better send you for some x-rays just in case (I get sued)
  • We might consider sending you to an Orthopaedic Surgeon at the hospital as they have now starting doing these wonderful things called knee replacements. Still a bit controversial as it does not last long and does not always work and the operation is rather huge.
  • Can you afford to see a Physiotherapist?
  • I’m afraid the Government has not really kept their part of the bargain with the Medicare rebate so there will be a small out of pocket fee of $ 8 today

4

If this was 2000:

  • Come in, sit down, let me examine you thoroughly it should take us about 15 minutes. I assume you are not going back to work today – do you need a certificate?
  • I think you have Osteoarthritis. Let me show you what I mean on this nice model of the knee the drug rep gave me. Lose some weight, take some Vioxx and Panadol and don’t work that knee too hard with the exercises. Please throw away that Voltaren I gave you last time for your sore back as it can cause blood pressure issues
  • I know of a recent case where a rare condition was missed so we had better send you for some x-rays just in case (I get sued). If there is a lot of damage we might order a CT scan just to make sure before we send you to an Orthopaedic Surgeon at the hospital.  Yep – lots of radiation but the Specialist will not see you without a CT scan. Will be a bit of a wait but worthwhile to see if you would qualify for a knee replacement
  • In the meantime I could give you a steroid injection in the knee that will help a lot for the pain
  • Can you afford to see a Physiotherapist? I can send you to the one at the hospital if you can’t.
  • Unfortunately the Government has started to push for all kinds of new things that we have to do at the Clinic. What with the costs of Computers and this new Accreditation thing, more staff and higher wages and the Medicare rebate not changing much at all I have no choice but to make my gap a bit more – it will be $ 10 out of pocket for our consult today

5

If this was 2005:

  • Come in, sit down, let me examine you thoroughly it should take us about 15 minutes.  How longs should I be booking you off work for  – a week ? Given that you work for the Public Service you may want to consider taking to your Manager about a return to work program. What was that? The pain started while climbing the stairs at work and you want to make this  Compo claim? OK, fair’s fair but we don’t have time for this today so you will need to go and get all the paperwork and book a long appointment so that we can do all the paperwork for that
  • I think you have Osteoarthritis. Let me show you what I mean on this nice model of the knee the drug rep gave me. Lose some weight, take some Indocid and Panadol and don’t work that knee too hard with the exercises. Please destroy the Vioxx that I gave you last year for your sore back. Oh, you already have – sorry to hear about your husband’s heart attack (so glad another GP had given him his Vioxx and not I)
  • Let’s send you for x-rays and a CT scan and if they confirm the severe osteoarthritis we should send you to the Orthopaedic Clinic at the hospital. They could possibly look inside the knee with a camera and tidy things up a bit. If it is bad enough they may consider doing a knee replacement for you but the wait is long – three years at least.
  • Can you afford a private Physiotherapist? The hospital does have a Physiotherapy Department but they no longer accept referrals from GPs
  • Medicare pays me a fee for doing the injection in your knee and that, along with the consultation is enough for me to Bulk bill you today

6

If this was 2010:

  • Come in, sit down, let me examine you thoroughly, it should take us about 15 minutes. Oh, this is a Work injury. Pity you did not tell my Receptionist – this is going to throw our day out badly as the paperwork will add another 15 min to the consult. Who was the lady with you in the waitingroom ? A Rehab Consultant from Work Cover who wants to sit in on the Consult. Not today
  • I think you have Osteoarthritis. Let me print you some hand-outs and show you a video about this. Yep, I realise you have done extensive research on the causes of knee pain and we will try and go through as many of the print-outs that you brought along as time allows. Lose some weight, take some Indocid and Panadol and don’t work that knee too hard with the exercises.
  • Let’s send you for x-rays and a CT scan and if they confirm the severe osteoarthritis we should send you to the Physiotherapist at the Orthopaedic Clinic at the hospital (assuming the Work Cover Claim is rejected) . Unfortunately I can no longer send you directly to an Orthopaedic Surgeon in the public system as all GP referrals are first screened by a Physiotherapist to make sure we are not wasting the Orthopaedic Surgeons’ time.  Usually they will send you for some further Physiotherapy and you may see the Orthopaedic Registrar in a year or so.
  • I do appreciate all the radiation involved and that a MRI does not involve radiation but Medicare does not fund MRIs ordered by GPs so unless you have about $300 to spare we cannot order a MRI
  • I could also send you for an ultrasound or CT guided steroid injection of the knee. Unfortunately Medicare no longer pays for GPs to do joint injections so we have stopped doing these procedures.
  • We can also get you to come back for a Careplan – this would mean that you would need to book a further 30 min appointment with me to fill in a stack of forms but once we have done that you would have subsidised access for five allied health visits – unfortunately we will have to split these between a Physiotherapist and an Exercise Physiologist.
  • So this turned out to be a rather long consult. Are we putting it through Work Cover (and I get paid three months later if the claim is accepted) or Medicare in which case your out of pocket costs will be $ 20

7

If this was 2015:

  • Come in, sit down, let me examine you thoroughly and do what is needed, it should take us about 30 minutes.
  • I think you have Osteoarthritis. Let me print you some hand-outs and show you a video about this. Yep, I realise you have done extensive research on the causes. Lose some weight, take some Indocid and Panadol and don’t work that knee too hard with the exercises.
  • Oh, you cannot take anti-inflammatories and have a long list of allergies. Excuse me a moment as I need to make  a quick call to the Doctor Shopping Hotline before I decide to give you an opioid script
  • OK we will need to spend a few minutes discussing the medical issues around the use of Oxycodone and similar drugs. If we are going to have you on these drugs for a while I will need to call for authority prescriptions from the PBS and get written permission from the ACT Chief Pharmacist. There are also concerns re driving, use of alcohol, etc.
  • Let’s send you for x-rays and a CT scan and if they confirm the severe osteoarthritis we should send you to the Physiotherapist at the Orthopaedic Clinic at the hospital.
  • Now you may get to see an Orthopaedic Surgeon in a year or so but if you need surgery that could take a few more years on a waiting list
  • I do appreciate all the radiation involved and that a MRI does not involve radiation but Medicare does not fund most MRIs ordered by GPs so unless you have about $300 to spare we cannot order a MRI in this particular case
  • I could also send you for an ultrasound or CT guided steroid injection of the knee.
  • So this turned out to be a rather long consult. Your out of pocket costs will be $ 40

8

Then we get to 2020:

  • Come and sit down – I apologise that it took a month to get in to see me but I had to take a few weeks off to get through all my annual revalidation requirements, my CPD requirements and getting my Clinic re-accredited. We do these now instead of taking (unpaid) holidays a few weeks a year. A scheme that is working so well in the UK
  • As you know we now have a Capitation system in place and you have elected us as your Medical Home with Medicare – I thus need to first just check if we have done your blood pressure, weight check, mental health evaluation, Pap smear, Cholesterol check, etc. before we can focus on the reason for your presentation. After all, every time we miss one of those it will cost us money.  Of course if your medical Home was elsewhere, that’s easy then, we would not deal with any of those type of issues and just focus on your sore knee but as things stand we need to focus on these chronic issues first.
  • I think you have Osteoarthritis. It does not however matter what I think as you have done extensive research on the matter and we will spend at least ten minutes reviewing the websites that you visited.
  • Then off course there is the small matter that this may actually be a work injury. Your Employer’s representative wanted to be attend but she had another urgent matter to deal with and she asked that we do a quick Teleconference at the end to discuss your “fit to work” certificate.
  • I finally manage to get a quick five minute examination of the knee and I still think it is osteoarthritis and we then get to the point of actually dealing with the issues
  • We book you in for a separate careplan visit since we are not allowed to do a careplan at the same time as a normal consultation (or perhaps in 2016 careplans will have new rules or funding for it will disappear altogether like the joint injection codes did) – in the meantime I advise you to go and get some physiotherapy at the Student-led clinic. They may not have a clue but it is better than nothing
  • We don’t refer you for any imaging – we cannot be seen as exposing you to harmful radiation or waste precious Medicare funds on MRIs
  • We don’t refer you to a Specialist – knee arthroscopies are no longer funded and 20% of knee replacements don’t result in improved pain so why bother.
  • I prescribe you opioids and other strong medication for your pain and do a referral to the Chronic Pain Unit. They may see you in a couple of years (only to pat you on the back and send you back to me with no changes). Yes off course you will get addicted to the drugs but there are drug and alcohol services for that and we can always do a Mental Health Plan for you if you are not coping.
  • Let’s just spend a final 5 minutes on updating your records to the PCEHR – just in case someone other than you GP is ever interested in looking at it
  • Given that that we are your Medical Home this 45 min consult will be Bulk billed. We may not have done much for you but I do have a warm and fuzzy feeling afterwards. How about you?

There is no doubt that Medicare’s own data supports the fact that GP consults are getting longer – six minutes medicine is a myth.

Looking at trends for the entire Country for the most common GP consults (excluding non-vocationally trained GPs, home & Nursing home visits and after hours visits):
Number of consults 1993-2015:
Short consult (< 5 min)- 63% increase in total
Standard consult (5-20 min)- 29% increase
Longer (20-30 min)- 193% increase
Longest (>30 min)- 165% increase

Per Capita 1994-2015:
Short consult – 31% increase in total
Standard consult – 6% DECREASE
Longer – 88% increase
Longest – 78% increase

We are thus seeing patients longer yet, as GPs, we care too much about our patient’s financial stressors and continue to Bulk bill over 80% of our consults.

Sadly the Government could not care less and has systematically eroded the value of the Medicare rebate over the years.

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And now the next hurdle lies ahead – a “spring-clean” of the entire system

What does this mean? It is very likely that we are facing a blended capitation system that will be a bizarre mix of US styled managed Health and UK styled Socialist Health.

Sadly this will not work in a Country that is one of the most expensive in the world in which to run a small business and GP owners such as us would be wise to start seeking a rapid exit strategy

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