Health funding in an acute care setting, especially in a Primary Care setting is always an challenging situation. Bringing small business owners, entrepreneurs, corporates and non-medical stakeholders interests together and then expecting Public Servants to make sense out of all the issues was, is, and always will be, a dog’s breakfast.
General Practice has always been an easy target for the Bureaucrats when they needed a scapegoat. The Public perception of rich greedy doctors is an easy myth to perpetuate despite Medicare’s own statistics showing that Total Professional Attendances had increased by a mere 6% over the last calendar year.
The focus in the media has also been on bulk billing rates and no amount of factual information seems to shift the public perception. The belief that a Standard Medicare rebate for a GP with ten years of formal training should be less than $ 40 is ingrained and seemingly accepted by the majority of the population. The same population who would pay a plumber over $ 200 to fix a tap or a phone technician $700 to spend the same time to reboot a system.
Putting the incongruity of these beliefs aside for a moment I would like to focus on ways that the various Authorities have tried to address these issues. In particular I would like to focus on the perceived crisis in after hours care that exists and what was done to try and alleviate it.
When the after hours “crisis” is mentioned in the media it is usually within the context of the pressures on the Emergency Departments. The perception is that the pressure on these departments are due to a lack of access to GP care – something which is actually not true. Studies shows that GP presentations make out only 10% of ED cases and accounts for less than 5% of the total length of stay in the EDs
It is therefore ironic to see how our Politicians ignore these facts and spend extraordinary amounts of our tax dollars on schemes that are sometimes just unbelievably stupid in their costs and at other times are clearly a case of the system being gamed.
Here in the ACT one of the most glaring examples are the various Nurse led Walk-in Clinics. Analysis has confirmed that the people attending these clinics are attending for matters that are either so trivial that they should not have been seen by a health professional at all (ear wax and head colds) or where it was merely a delay in a definitive treatment given that the patient was then sent on to a GP or ED anyway.
One could still ignore the sheer stupidity of this venture if it was not for the fact this service costs you and me FOUR TIMES more than seeing a GP (table 17; page 114)
Regardless of the clear economic failure of the model the ACT Government is storming ahead and there are now three of these clinics functioning in Canberra
Then we get to the next big adventure – happening on a National level and since 2014 happening in the ACT – the National Home Doctor Service
This is a massive organisation that is extremely effective in it’s marketing skills. They run promotions in print, radio and television media and can do this as they are promoting a business model and not a specific doctor – something that the average doctor and clinic is not allowed to do due to Medical Board Restrictions
The organisation functions with a powerful board led by an executive chairman with extensive business skills , a CEO who is a heavy weight Labor Politician and doctors who have leading roles within the AMA, RACGP and other leading medical organisations
Offering a home visit with no out of pocket costs is obviously a model that lends itself to exploitation on multiple levels.
I and many other colleagues have reported over the last few years how we are seeing evidence of patients exploiting this in the clinical feedback we receive from the organisation – I have personally seen multiple examples of call outs for issues that would not even have justified a visit to a GP during the day nevermind a bulkbilled tax-payer funded home visit after hours.
One potential aspect that there is a lot of speculation about is whether the more lucrative after hours Medicare item numbers are being rorted by Doctors and organisations providing after hours services.
I have been unable to find any publicly available information on these billing practices that would specifically identify who billed which item numbers however Medicare provides a very functional statistical search engine that provided some eye opening information regarding this matter Nationally and specifically in the ACT.
I have focused specifically on the last ten years’ data and the changes since 2014 when the NHDS became active in the ACT:
- Urgent after hours item numbers:
- Stable from 2005-2013
- From 2013 -2015 this item number increased by 1,320 % !
- (total items in 2015 – 4,543)
- Unsociable hours urgent after hours numbers (the most expensive item number):
- From 2005-2013 the number of claims for this item number decreased by 50%
- From 2013-2015 it increased by 507% !
- (Total items in 2015 – 273)
- Non-urgent after hours numbers (not at GP rooms):
- From 2005-2015 these item numbers increased by 315% over the eight year period
- From 2013-2015 it increased by a further 151% !
- (total items in 2015 – 1, 533)
- All after hours numbers:
- In 2005 urgent after hours item numbers added up to being 78% of all after hours visits
- In 2013 this figure was only 37%
- In 2015 emergency item numbers made out 76% of all after hours visits – and this should be seen in the context that the total number of after hours visit had increased by a whopping 840% !!
- One should try and place this in context against the total number professional attendances over this period:
- From 2005 to 2013
- Total attendances increased by 28%
- All after hours attendances increased by 315% over the eight year period
- Urgent after hours attendance decreased from 78% to 37%
- From 2013-2015
- Total attendances increased by 6 %
- All after hours attendances increased by 151% within two years
- Urgent after hours attendance items increased by 219% !
- From 2005 to 2013
All of the above would be a moot point if it had actually resulted in improved care and a reduction of the workload on our Emergency Departments – sadly that proved not to be the case
So it call comes back to whether it is an efficient use of the Tax Dollar to:
a. Fund a Nurse to see patients at 4 times the costs of a qualified GP doing the same
b. Fund a Doctor, who in many cases is not a fully qualified GP , to attend to patients at home and perhaps charge urgent Medicare codes for conditions that are not urgent and at the same time might be handing out medication that are often funded by a private health insurance company (bypassing the checks and balances that would happen in a pharmacy)
Or perhaps they could just unfreeze the rebate, allowing GPs to get a reasonable income via Medicare for their services and thus be able to make a decent living without charging large co-payments.
Now you will have to excuse me – I have to go and pay that plumber and phone technician that I mentioned earlier on
Edit: 5 April 2016
A friendly Immunologist has done a bit of further work on the raw data from Medicare – I have kindly been allowed to reproduce the data for the ACT here: