Obfuscation & the 'Blame Game'

Well, I was not expecting that the letter in my last post would be referred to in 'The Weekend Australian' in follow-up to a previous report. Thanks to Dr Scott Lewis of Wudinna for telling me.

Oh dear.

There seems to be confusion about the issue of ED patients being charged fees in rural SA hospitals. It's something that has been an issue locally every since I have been on Kangaroo Island, and my colleagues tell me has been going longer still. I refer to the fact that patients presenting with serious problems (examples might include assessment after a car crash, a suspected fracture/dislocation, a forensic medical exam after sexual assault, repair of a complex laceration) are forced to pay the attending doctor, whilst they would receive the same service for free in a metro ED or interstate.

This is counter to the Australian Healthcare Agreement and the letter which is referred to in the Weekend Australian support this. The practice has been longstanding in South Australia, and I reckon arises over confusion over what is an emergency and what is a GP-type service.

The Australian college of Emergency Medicine have recently issued a media release that dispels the myth of triage 4/5 patients being 'GP-type' attendances, and highlights concern for such cost-shifting between State and Federal coffers.

Me? I am just fed up having to charge people for conditions that are more serious than your usual GP attendance, more so when they have been referred to the ED by another GP or a GP after hours service like HealthDirect. Don;t get me wrong, I am happy to charge privately for my services when it is appropriate - but charging a mental health patient, a rape victim or a car crash victim several hundred dollars just seems wrong. Much better to be paid by the Health Department, after all the doctor is attending in his/her role on the on call A&E roster, not as a private arrangement.

Today I received an email from the Rural Doctors Association of South Australia, which appears to cling to paragraph G21 of the Australian Healthcare Agreement, which allows for medicare billing in the specific circumstance of "eligible patients may obtain non-admitted patient services as private patients where they request treatment by their own GP, either as part of continuing care or by prior arrangement with the doctor" (my emphasis underlined).

The RDASA email states:

There has been a lot of email traffic and concern from you about the article appearing in the Australian over the weekend inferring that charging patients for after-hours services in publicly funded hospitals was contravening the National Health Care reform document. 

Please be assured that the RDASA Executive have taken immediate action on this issue, writing to Minister John Hill referring him to section G.19 of that Agreement and the assurances from CHSA that the current arrangements are acceptable to the Federal government. We have sought written confirmation that:

·         Doctors can bill Medicare for triage level 4 and 5 after-hours consultations that occur at public country hospital facilities

·         Doctors will not have to pay back any money to Medicare for money already collected

Maybe I am being thick, but it seems unfair to use clause G21 to then slug rural patients for services that would receive for free in a metropolitan ED or interstate.

RDASA seem curiously quiet on this issue of equity and I fear that this approach may be regarded as more about preserving doctor's incomes than in equity for their patients. Given that many of these patients are genuinely in crisis or not-medicare compensable (particularly in a tourist location like Kangaroo Island), I would much prefer to be paid by the Hospital for my services rather than bulk bill or chase bad debts. After all, the Hospital called me as the A&E doctor for the hospital, not the patient as part of a prior arrangement or agreed private service.

Anyway, here's my letter to the RDAA on this issue. It will be interesting to see what eventuates.

Comments, as always, welcome.

Paul Mara

President

Rural Doctors Association of Australia

10 May 2012

Dear RDAA

You may be aware of the recent ‘Weekend Australian’ article regarding billing of public patients attending public emergency departments in South Australia (http://www.theaustralian.com.au/national-affairs/state-politics/warning-for-states-on-hospital-charges/story-e6frgczx-1226347278031). Last month I received a letter from Minister Plibersek’s office (attached) which supported my concerns regarding the practice of charging public patients in public EDs for non-admitted services. This letter was posted on my blog site and subsequently referred to by The Weekend Australian without my knowledge. 

I have been seeking clarification on this matter since 2007 from the South Australian Health Department, as there exists significant potential for cost-shifting from State to Federal Health budgets. Specifically, patients who attend the Emergency Department are annoyed at having to pay fees for non-admitted attendances in rural areas.

I should clarify that these fees are being charged not just for GP-type attendances, but for ED attendances that require the resources of a hospital and can chew up considerable time for assessment and treatment. Many of these patients have been referred to a rural ED by GP-after hours services such as HealthDirect, and are not typical of GP attendances in metropolitan areas. Examples might include the assessment of car crash victims after a rollover, forensic medical examination after sexual assault; urgent mental health assessment of patient brought in by Police; the assessment, X-ray, manipulation under anaesthetic and plastering of fracture/dislocation; repair of complex laceration etc. These are services that Country Health SA has in the past deemed ineligible for admission and hence cost-shifted to Medicare by refusing to remunerate doctors on the A&E roster.

On questioning this in the past, South Australian doctors have been directed to clause G21 of the Healthcare Agreement which states:

"in those hospitals that rely on GPs for the provision of medical services...eligible patients may obtain non-admitted patient services as private patients where they request treatment by their own GP, either as part of continuing care or by prior arrangement with the doctor"

The most recent (indeed, only) contract between rural doctors in SA with Country Health SA goes further, to state :

“after hours GP services and non-admitted emergency services are provided under the Medicare system (ie the patient is charged by the medical practitioner and seeks reimbursement from medicare). For the avoidance of doubt, Country Health SA shall not be liable to pay any fee for such services”

This statement in our contract neatly ties both emergency attendances and after hours GP services under the same umbrella, ie: to be charged to Medicare. This is at odds with legislation.

I understand the RDASA has recently written to the RDAA on this matter. From the email to SA members, the issue has been obfuscated by confusing triage 4/5 patients with GP-type attendances, an assertion that is not reflected in either the National Healthcare Agreements or current contracts in SA. Indeed, the Australian College of Emergency Medicine gave recently issued a media release on this very issue, dispelling the myth that “ED triage 4 or 5 patients = GP attendance” and highlighting the concern for State to Federal cost-shifting by such ploys (see http://www.acem.org.au/media/media_releases/GP_Patients_ED_attendances.pdf).

I am concerned that this issue disadvantages rural Australians In SA who may defer ED attendance for potentially serious conditions due to fear of fees. I am concerned that the SA Health Department is promulgating an interpretation of the Australian Healthcare Agreement which is at variance with other States and which both Medicare and the Federal Health Minister’s office have told me is not allowable. I am concerned that genuine GP after hours or private arrangements (where I am more than happy to charge a private fee) are being used as a cover to defray State health costs.  For the record, can I ask for your assistance to clarify with the Health Minister and RDASA:

1. that the Australian Healthcare Agreement states that eligible public patients are entitled to free emergency care in a public ED,

1. that the South Australian Department of Health is responsible for provision of emergency medical services in both metropolitan and country areas,

1. that the contract between rural doctors and Country Health SA is to participate in on-call services for Emergency Medicine (A&E), not GP-after hours services,

1. that whilst clause G21 does allow for rural doctors to charge privately (with Medicare rebate) this is only in the situation where patients “request treatment by their own GP, either as part of continuing care or by prior arrangement with the doctor”. Many patients who present to the ED have either been referred there by a GP or an after hours service (HealthDirect) or else have needs that require ED attendance. They have not requested treatment by their own GP nor is their a pre-existing prior arrangement with the doctor on call for the A&E roster for the State Health Department.

1. that in situations where a patient elects to be treated privately by their own GP then clause G21 applies and Medicare fees are allowed,

1. that the assertion that triage 4/5 patients are to be billed under Medicare is not supported in the Australian Healthcare Agreement and indeed is counter to advice from the Australian College of Emergency Medicine who dispel this myth in a recent media release and state “It is in the political interest of state governments to ensure that any definition of general practice patients seen in EDs yields high numbers. This helps perpetuate the myth that EDs have too many GP patients.”

1. that the situation as it stands in South Australia is at odds with arrangements interstate.

I would be grateful for your clarification on the above points. To my mind it is vital that rural Australians are not disadvantaged when attending the ED with a genuine need. Similarly there may be concerns from rural doctors that such Medicare-billing is not supported and there needs to be clarification that such practices are allowable in certain circumstances (eg: as part of a GP after hours service utilising the local hospital premises, ie: private arrangement, ongoing care). I am happy to charge privately for my services when it is appropriate - but charging a mental health patient, a rape victim or a car crash victim several hundred dollars just seems wrong. Much better to be paid by the Health Department, after all the doctor is attending in his/her role on the on call A&E roster, not as a private arrangement.

I am sure you would agree that it is important for rural doctors to be seen to uphold the same standards in each State and to ensure that neither patients nor doctors are disadvantaged.

Sincerely

Dr Tim Leeuwenburg

Kangaroo Island, South Australia www.ki-docs.blogspot.com