Grumpy old doctor aside, I really believe this is an issue that is important. Rural Australians are disadvantaged enough, without having to face fees for A&E services.
I should note that this is not an issue of self interest - as a rural doctor, I derive part of my income from charging fees to attend a patient at 3am. And I am comfortable with charging a fee where it is fair. But when the same patient would get the same service for free in a metro ED, I have to question the process. And when patients are afraid to attend the A&E because they fear a fee, something is very very wrong.
It is true that a private fee can be charged as part of a continuing care episode or by prior arrangement for a patient to see a particular doctor privately. Fair enough.
But the people who attend EDs usually have urgent issues that cannot be dealt with in GP private rooms. They often require services that cannot be delivered in rooms (X-rays, anaesthetic, plaster etc). They haven't asked for a particular private doctor to see them - they have correctly self-presented to the emergency department and the hospital has in turn decided to call in the doctor.
Rural health outcomes are already bad - to charge people just makes this worse.
So - I'd be a lot happier if I was paid by the hospital for attending patients who the hospital feels need to see a doctor urgently, through my contract to provide A&E services. I may be poorer if paid by the hospital, but it would be a fairer system
I am pretty sure patients would prefer it!
Anyway, here's my latest missive.
11-03-12
Dear Minister
I read your latest Press Release re: country hospitals charging fees in response to the Press Release of Martin Hamilton-Smith. Regardless of whichever party is in power, I remain perplexed.
The fact remains, country people are charged fees for non-admitted A&E attendances in rural hospitals, for services that are provided for free in metropolitan areas.
These are not, as you suggest, charges for routine GP services - your 2010 contract with rural doctors is very clear - non-admitted patients in the ED are considered to be private patients of the GP
Examples of non-admitted A&E attendances include
- forensic medical examination of a rape victim
- assessment including X-ray, reduction & plastering of a fractured limb
- repair of a complex laceration
- assessment of victims of a vehicle rollover
- urgent assessment of a complex mental health crisis
- administration of a neuroleptic agent for reduction of a dislocated shoulder
These are not routine GP services. These services are appropriately provided through an Emergency Department and are provided for free everyday in metro EDs.
When the Hospital calls the oncall doctor, it is through his/her contract with CHSA to provide A&E services, not as a private arrangement betwixt GP and patient.
Many patients are rightly fed up with being charged fees for services in an emergency. Sadly some patients do not seek medical attention with urgent problems that SHOULD be seen in an ED, for fear of cost. I have recently been told of a patient who delayed seeking medical attention for fear of fees...then presented in extremis several days later and died.
Your press release intimates that the only alternatives are for either GPs not to charge patients their gap fees, or for CHSA to put in salaried medical officers and 'put rural doctors out of business'
You neglect to mention the third option - simply to pay the oncall doctor for the work he or she does, regardless of admission status. Existing fee-for-service arrangements would be more than adequate and would be in line with conditions interstate.
Surely it's not that hard to grasp? If a patient presents to a CHSA hospital with a problem that is deemed urgent, the hospital needs to call a doctor as part of the A&E roster, and the service cannot be provided in routine GP rooms....then the patient should receive the service for free and the doctor be paid by CHSA.
The matter has been needless obfuscated by lack of confusion over what is and what isn't an admitted service..and a continuing reference to provision for private patients to be treated by their own doctor when they request as part of a prior arrangement or as part of continuing care. None of these apply for the patients I am called to see when on your A&E roster.
I rang Medicare last week. They reckoned it was illegal for me to be charging patients for services provided in the A&E department and referred me to the National Healthcare Agreement which states that:
States and Territories will provide health and emergency services through the public hospital system, based on the following Medicare principles:
(a) eligible persons are to be given the choice to receive, free of charge as public patients, health and emergency services of a kind or kinds that are currently, or were historically provided by hospitals;
(b) access to such services by public patients free of charge is to be on the basis of clinical
need and within a clinically appropriate period; and
(c) arrangements are to be in place to ensure equitable access to such services for all eligible
persons, regardless of their geographic location.
As far as I am aware there is no section 19 exemption between SA and the Commonwealth.
How then can CHSA continue insist that doctors on the A&E roster charge patients for A&E services in CHSA EDs for conditions that are certainly serious but may not require admission for the requisite four hours to satisfy admission criteria?
I look forward to your response. These questions have been asked by me previously to CHSA CEO's George Beltchev and Clare Douglas without response.
I hope you can finally answer this, not with political spin, but in the interests of rural patients who deserve a better deal.
Kind regards
tim leeuwenburg (dr)
kangaroo island
south australia
kangaroo island
south australia
