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Urgent after-hours GP visits under scrutiny but no urgent action

Health Minister Greg Hunt announced last month that he had instructed the Health Department’s Medicare Integrity division to investigate media reports about potential substandard quality and inappropriate Medicare billing claims for after-hours services.

In a comprehensive article below, Dr Lesley Russell notes that the issues around after hours home visiting services are both important and multi-layered, but that the Minister has yet even to act on detailed recommendations proposed earlier this year from the expert MBS Review Taskforce.


Lesley Russell writes

It’s an ongoing issue, aggravated by busy lifestyles, that lacks an effective, modern solution in Australia: how to get access to primary care when needed, regardless of the time of day.

In recent years there has been explosive growth in the use of after-hours home visiting services which are increasingly operated by for-profit, medical deputising services and now there are concerns that some of these services are rorting Medicare.

Organised medicine has spoken out about their concerns that these services are often staffed by doctors with no formal training in general practice and who have no existing relationship with the patients.

It’s fair enough to claim that these services are best delivered by the patient’s own GP – but if that doctor is unwilling or unable to provide after-hours services, then the business sector will see a business opportunity and respond. That’s exactly what has happened (the number of Medical Deputising Services has grown from 66 in 2012 to 116 in 2017).

However, while some Australians have ready access to after-hours care (in some areas of Australia, more than 10 per cent of Medicare benefits paid for GP and primary care services are paid for urgent after-hours attendances), many others, especially those outside metropolitan areas, have few options available.

Over the years a succession of Australian governments has attempted to improve access to after-hours care through a variety of Medicare-funded programs, most of which have garnered less-than-glowing evaluations and all of which have been endlessly tinkered with (see for example my summary of after-hours programs 1990-2012 and the 2014 review by Professor Claire Jackson).

Health Minister  Greg Hunt has referred allegations of improper Medicare claims to the Department of Health’s Medicare Integrity Division for investigation but is yet to act on detailed recommendations from the expert MBS Review Taskforce. Indeed, on the day in September when he announced the investigation into improper claims, he said, “I expect that Taskforce to provide recommendations for change and the Government is minded to accept such recommendations” – seemingly ignoring the fact that he has had the report since May.

Perhaps his hesitancy to act is because polling shows most Australians would view a reduced home visits program as a violation of Prime Minister Turnbull’s no-cuts-to-Medicare pledge and likely  there’s been some strategic lobbying by those who see their business model being undercut.

Issues that go to the employment of unqualified medical personnel, the safety, quality and appropriateness of the services delivered, improper Medicare claims and loopholes that allow these must be quickly investigated (for all doctors providing after-hours services) and remedied.

Any new proposals must recognise that patients and their families will have perceptions about the urgency of their medical problem that may differ from those of clinicians. Due consideration must also be given to the (realistic) feasibility for them to seek medical attention during normal office hours and their access to other sources of medical care.

A further area for improvement is the need to ensure that when medical care is provided out-of-hours by a deputising service, there is coordination and feedback with the patient’s usual GP.

Urgent vs non-urgent after hours care

In essence, there is a need to cover off two separate but related issues: urgent (or perceived as urgent) out-of-hours primary care and a growing demand for non-urgent care provided outside of normal doctors’ working hours.

This will require some astute decision-making and a willingness to put best medical practice and the needs of doctors working at the coal-face and their patients ahead of corporate interests and the posturing of medical groups.

It’s never easy for families with two working parents, small business owners or farmers to get to see their GP during normal office hours.  Small children and the frail elderly are often worryingly ill during the night. And this is an age where expectations are for 24/7, on-demand services.

At the same time the general practice workforce is increasingly feminised and part-time and there is a growing push for a better GP work-life balance with flexible work hours, opportunities for leisure activities and good physical and mental health. The Medicare rebate freeze has imposed financial strictures on practice budgets that are already strained.

With these inherent tensions, small wonder that finding after-hours GP services is a major problem for patients and their families and carers and providing these services is often seen as financially unrewarding for their doctors. Currently only 38 per cent of GPs work in practices that provide their own after-hours services and a recent survey found that just one in 10 GPs visit their patients after hours.

In 2015-16, 10 per cent of Australians stated in an ABS survey that they had needed to see a GP after-hours at least once in the previous 12 months, but 22 per cent of these people were unable to do so. Of patients who saw a GP after-hours, 41.3 per cent did so at their regular GP practice, 22.4 per cent attended a late night clinic, and 21.4 per cent received a home visit (up from 17 per cent in 2014-15).

Many of those home visits were classified as urgent and billed at the highest Medicare rate.  Medicare figures show that annual billings for urgent after-hours items (597, 598, 599, 600) in 2016-17 were $233.2 million (234 per cent increase from 2006-07), of which $187.5 million was for item 597 (297 per cent increase from 2006-07). In contrast, the cost to Medicare for non-urgent after-hours GP visits (items 5020, 5023) was $403.7 million in 2016-17 (157 per cent increase from 2006-07).

‘Not driven by clinical need’

The MBS Review Taskforce finds that the growth in the provision of urgent after-hours services “appears not to be driven by increasing clinical need for these services, but has coincided with the entry of new businesses into the market with models that promote these services to consumers, emphasising convenience and no out-of-pocket costs.”

The Taskforce also found little evidence to support arguments that the growth in use of urgent after-hours home visits has helped reduced the impact on hospital emergency department services; rather much of the dramatic growth in expenditure is from patients who are being diverted from daytime general practice with a cost increase to Medicare from $37.05 (MBS item 23) to $129.80 (MBS item 570).

Alternatively, Medicare is paying $129.30 when the service should be billed as non-urgent ($49 MBS item 5020). None of this cost is visible to the patient if they are bulk-billed.

Some idea of inappropriate servicing might be gauged by looking at Medicare billing for GP services provided during what are called “unsociable hours” (11pm – 7am).

Medical emergencies pay small attention to the hour, but presumably patients looking for a non-urgent home visit and the doctors who attend them do. Billings for these MBS items 599 ($153) and 600 ($124.25) cost Medicare $37 million in 2016-17, up 143 per cent from 2006-07, but according to the MBS review, they are now falling  as a percentage of all urgent after-hours services.

Perhaps the best indicator of where this sector of healthcare services is potentially headed with increasing corporatisation is that a number of long-established medical deputising services have recently withdrawn from the National Association for Medical Deputising Services of Australia. They have cited the importance of complementing rather than competing with daytime general practice, stating One thing that the services that have withdrawn from NAMDS have in common is a dedication to acting for and on behalf of GPs first and foremost.” 

Clearly many general practices rely on medical deputising services to care for their patients and are happy with the results, so the solutions that are implemented to address the highlighted problems must not throw the good out with the bad.

The important question that must be answered goes to the proportion of urgent, after-hours home visits (especially those provided by for-profit deputising services) are really what might be called “concierge services” and are therefore delivering low value to taxpayers (albeit high value to the people who are lucky enough to access them).

Sadly, there is no evidence of any policy work from the Department of Health to ensure that unmet needs for primary care services (both urgent and non-urgent) outside of normal office hours can be met for all Australians, regardless of where they live.

Dr Lesley Russell is an Adjunct Associate Professor at the Menzies Centre for Health Policy at the University of Sydney. On twitter @LRussellWolpe

Comments 1

  1. Vicki McCartney says:

    AFTER HOURS – an essential part of good health care but are we be creating a 24/7 expectation of services? A “Supermarket mentality of convenience.”

    I have been watching the debate about after-hours care. There are many valid concerns & viewpoints. However, GPs should not be duped into thinking that we need to solve the disconnected Federal/State health system by working longer hours.
    It would be easy to make the Medical Deputising Services (MDS) the “bad guys” & the hard-working low paid GPs the “heroes”.
    Of course, this is not the case.
    Many original after-hours services were in fact cooperatives, based on an organised group of GPs banding together to provide services for their own patients.
    In recent times things have changed. MDS have evolved based on a profit focused, market approach to medicine – create a demand & provide the service the public believes they need. Health is emotive & many patients are vulnerable to feeling it is best to get advice & professional care now…” just in case”
    I was involved in a recent discussion about patients as “consumers”. Consumerism appears to empower them to not just be informed but to demand more services & products that may improve their health. Why not a service that gives you peace of mind when you are worrying about a symptom at 10 o’clock at night, especially when it appears to be provided for free.

    A significant number of conditions that require urgent care are best managed in an ED setting, as it provides the ability to investigate, treat & most importantly, monitor over time. This model of care is difficult for General Practice in the present model both structurally & financially. It is impossible for a MDS doing a home visit to achieve this level of care. Many concerns that patients have after-hours could best be triaged over the phone & many could afford to wait till the following day for review in “normal hours”. Phone triage is often done by GPs in rural areas, but it requires the GP to be available without any financial reward for this expert advice.

    Medicare is a great system of universal health care & one, that I would think, every Australian support. Any system using taxpayer’s money should have checks & balances. It seems strange, therefore that a Medical graduate who has completed their registration requirements in a hospital, can apply for a provider number to work for an “Approved Medical Deputising Service Program” & hence access Medicare payments. Their rebate may be lower (non-VR) but that just means they will need to see a lot more patients. The system essentially opens the door for MDS to provide a service that the “consumer” demands. There is no need for informed financial consent & in fact there is a lack of transparency when it comes to the price of the service.

    The reviews of ED presentations have not shown the expected outcomes. There are massive rises in afterhours Medicare claims without reductions in ED presentations. However, the dislocation of care & lack of communication is a concern perhaps less well understood by the patient.

    Is there a political will to actually control waste in health care?
    Should the Government:
    • control costs by limiting bulk billing to those truly in need rather than leaving it “up to the GP or MDS” to make these decisions.
    • be honest about the rebate being the patient’s universal health care benefit not the doctor’s payment
    • control provider numbers, (the real “hot potato”), especially as we start to produce excessive numbers of doctors?

    I don’t claim to have all the answers but I am concerned that suddenly changing the business model for MDS so they become unsustainable, is not the best solution.
    • I am concerned that asking GPs to work more or be available to refer patients in the after-hours period does not fit with a safe working hours approach.
    • I do believe there needs to be the ability for doctors to be appropriately trained if they are going to work in a MDS. If we are trying to reduce costs & presentations to EDs then it is possible MDS have a place in the system, and may be a model of afterhours care in which we need to invest. All parts of the Health care system need to be linked so the patient can have: “the right care, in the right place, at the right time.”
    • If MDS were required to have a true working relationships with General Practice & their rebates were tied to this requirement, we may provide what the consumer demands – place based care. Rather than take a punitive approach it makes more sense to reward high quality services that are able to develop these relationships & extend the capability of General Practice.
    • Could an in-hours GP follow-up appointment (specific item number) be required for the patient to be able to claim their “after hours rebate”?
    • Do patients have a right to “non-urgent services” such as a work certificates or scripts in the after-hours period? Perhaps the answer is “yes” if they are prepared to pay for it & know Medicare does not cover this. That is truly the consumers’ ability to make informed choices. If the MDS & GP are linked, then the information would be shared with the usual GP.
    • Lastly, if we believe that anyone claiming Medicare rebates needs to be appropriately trained, or in training, is it time to have a tighter control on provider numbers? There will always be debates about this but the taxpayer’s health dollars should be used judiciously.

    In summary, it appears that politicians from all persuasions want to promise an unsustainable amount of health care to prove they support Medicare. After-hours appears to have become a yardstick for this commitment. Is it time for an honest debate?
    The requirements of improved training for the doctors providing the service is a relatively easy “fix” especially as an oversupply of doctors is looming.
    The more important debate is whether greater accessibility of healthcare at any hour is a realistic & cost-effective goal. Do we want to promote a “supermarket mentality of convenience” as the goal for our health system?

    Dr Vicki McCartney
    Principal GP at Moss Street Medical Practice
    Nowra NSW.
    Rural GP for 31 years.

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