Category Archives: Contract

Avoiding Burnout

An interesting week this week, with several stories coming together for me.

First up, a discussion on doctors.net.uk / ausdoctors.net (the members only service for UK and Australian doctors) on ‘tips for new consultants’. Covered the sort of things that don;t get taught at medical school or in postgraduate training. Also tips on setting up a private practice and avoiding burnout. A common theme was to ‘say no’ to unmanageable workload and to try to take control of the work environment, not let it control you.

Of course all of this is relevant to rural doctors, which leads to the second theme – that of managing workload in the bush. Scott Lewis (procedural GP in Wudinna and newly appointed President of RDASA) rightly points out the constant stream of negativity regarding rural medicine. Despite this, I think Scott and I agree that rural practice really does offer the ‘best bits’ of medicine – a varied and interesting mix, with opportunities to be challenged every day.

Concurrently this week the doctor in Penola, SA has left – citing an unmanageable workload & bureaucratic bungling by Country Health SA. As well as managing a day time clinic, poor chap was on call 24:7 every day of the year and reportedly chastised for having the temerity to be more than 20 mins from the hospital on one occasion (CountryHealth SA contract allows a 40 minute response time). Ironically this doctor was brought in a year or so ago, to replace the previous doctor, who lasted only 4 months.

Of course there’s the local issue on Kangaroo Island, with the sustainable model of Island docs doing 21 out of 28 days per month on call for emergencies, as well as 365 day a year cover for each of obstetric and anaesthetic rosters. This workload was sustainable and allowed respite from the onerous emergency roster, as well as to balance the demands of running a private general practice.

Common themes?

(i) Financial Incentives

Historically money has been thrown to entice doctors to the bush. Whilst this helps, it is ironic that the same incentives are offered to fly-in, fly-out locums who live in the city and cherry pick high-paying locum work. Indeed some rural communities are wising up to this and realising that paying locums $2500 per day is a disincentive to establishment of permanent resident doctors who have to bear practice costs. KI docs got into a stoush with the Health Department (and the ACCC) a few years ago, when asking for more money to provide on call services. The money doesn’t compensate for working day & night – but it does allow one to purchase much-needed locum relief.

(ii) Control of workload

There are 168 hours per week, which I think of rather like a Mars Bar – it should be divided into equal thirds of work, rest & play. An 8 hr working day is sufficient, and allows time for rest (sleep) as well as play (hobbies, other interests – but also mundane things like cooking, eating, toileting etc). Of course most of us experience ‘bracket creep’ with work intruding into time off and eventually life can become 2/3rds work, 1/3rd rest. Not a good idea. Having strict boundaries between work and home life, as well as declining extra duties means that workload is sustainable.

Much better though to share the workload – a roster of several doctors working part-time is a better model than the traditional solo small town GP. Which leads into the third theme..,

(iii) Learning to ‘say no’

Which is the unenviable position the KI docs find themselves in currently. A model hashed out with the Health Department a few years ago allows KI docs to work 21 out of 28 days per month for emergency on call, with the Health Department providing a locum for their hospital on just one week per month. Meanwhile KI docs provided 365 day cover for separate anaesthetic and obstetric rosters. Not a bad effort for six part time doctors, and allows us time off for a break as well as mandatory upskilling.

A proposal that KI docs take full responsibility for the emergency roster and fund any locum relief themselves was met with disappointment, It sets a dangerous precedent – for if the number of doctors on KI were to fall in the future (as is likely), the remaining doctors would be forced into paying for a locum to staff the hospital. A sum of $10,300+GST per week has been suggested as typical locum costs.

Taken to a logical extreme, if the Island doctors were unable to provide the service (through ill health, absence, whatever) they could be liable for a bill of $10,300+GST x 52 weeks … all for the privilege of doing EXTRA work to their usual 9-to-5 private general practice.

This really is the crux of the tension and difficulty in rural practice. Not only are their insufficient doctors and problems with throwing money at all-and-sundry, ultimately we are independent contractors. We already have a job that consumes a standard working week – that of running our own private practice. With that come attendant costs of staffing, utilities, rent etc which must be met.

To ask us to either take time out of practice to work at the State-owned public hospital (for considerably less money) and yet still pay pay own practice expenses seems unfair. And the demands of working extra hours on call takes it’s toll.

In the city, public hospitals are staffed by doctors and nurses working shifts. They are salaried and also get benefits like annual leave, long-service leave and superannuation. In the bush? Doctors work running their own private practices and traditionally have worked ‘on call’. Sadly workloads have increased (particularly in tourism destinations like Kangaroo Island) making on call a significant burden and at the expense not just of doctor’s health, but also ability to service own clinic patients. There is no Super, no annual leave. The Health Dept just wants to staff the roster, but doesn’t really care how this is fulfilled so long as the cost is shifted elsewhere.

Add to this the demands of a Medicare Locals policy that seems to be more about ‘wants’ than ‘needs’ … and the abhorrent policy in South Australia of charging public patients a fee for non-admitted A&E services (contrary to section 19(2) or National healthcare Agreement). It all seems that costs and services are being shifted from State responsibility to private practice.

Hence it is sometimes better to ‘say no’ and do only what you can do.

Any other thoughts on preventing burn out?

Contract Negotiations (again!)

Well it seems that some country doctors in SA remain embroiled in dispute over on call contracts with Country Health SA.

The last contract expired in Nov 2011 and was supposed to be replaced by a contract offering improved terms for rural doctors who offer on call VMO services to public hospitals in addition to running their private practices. You can imagine the disappointment of many doctors when no contract materialised in Dec 2012. Protracted negotiations ensued between Country Health SA and both the Rural Doctors Association of SA and the AMA(SA).

As I understand it, the AMA(SA) advised their members not to sign as there was a failure to reach an acceptable outcome for members.

The RDASA continued to negotiate and reached a compromise of sorts in July 2012 (seven months after the previous contract expired). You can read a press release from them here.

The difficulty in the relationship revolves predominantly the tension between doctors running their own private practice and the need to service a public hospital run by CHSA. As workload in both primary care and hospital-based services increases, the impact of being on call for the hospital becomes increasingly negative on running a private practice.

Contract wins included 

  • a payment to recompense the impact of being called out of private practice clinic to attend hospital patients (note life-threatening emergencies excluded from this payment) and,
  • a payment to compensate missed clinic sessions the next day after a busy overnight on call (note only applies to admitted in-patients; A&E patients excluded).

Disappointments included

  • no increase in on call allowances
  • refusal to pay attending doctor through fee-for-service arrangements for WorkCover, motor vehicle accident or other non-Medicare compensable patients (such as overseas visitors). In a location such as Kangaroo Island where motor vehicle crashes involving overseas tourists are not uncommon, chasing bad debts for on call work is a hassle that doctors would rather do without.
  • continued situation where patients presenting to the public hospital with non-GP conditions needing A&E care (broken bones, lacerations, acute psychosis out-of-hours, forensic medical exam etc) are charged private fees as CHSA maintains that the doctor will only be paid for admitted patient services. Interestingly this situation does not occur interstate, with State Govt taking responsibility for provision of A&E services and paying doctors who are called to attend
  • a move by CHSA to insist that the responsibility for providing A&E services moves from the State Govt to one or more practices in each location, with practices required to continue cover even if doctor numbers decrease or practices withdraw.

As I understand it, existing ‘sweetheart’ deals offering better terms of service continue in rural SA and have been excluded from contract negotiations – these include locations such as Whyalla, Naracoorte, Mt Gambier, Riverland and Gawler. Suffice it to say that terms and conditions are considered more favourable than the contract offered to other doctors through the standard contract, recognising the particular needs of each location.

Several other rural locations are unhappy – the media report dissatisfaction in Victor Harbor, Snowtown-Clare, Quorn and Kangaroo Island. Millicent is rumoured to be in a similar position and there may well be others who have declined to sign the contract or remain unhappy with terms.

Locally on Kangaroo Island?

The doctors who provide A&E services on Kangaroo Island (through a single entity, Island Locums) have been allowed to continue to provide services until 30/1/13 under existing arrangements – basically Island Locums works 3 weeks per month and CHSA provides a locum service for the fourth week, allowing the local doctors a break.

Bear in mind that some of the doctors contracted to Island Locums are also on call for anaesthetic and/or obstetric rosters, as individual contractors. Having the locum relief for one week in four for A&E provides an important ‘safety valve’ for doctors who are otherwise on call for the hospital every day for around two thirds of the year, plus have to work running their own private practice.

CHSA now want to get rid of the locum and make Island Locums responsible for 24 hr cover 365 days of the year. With a limited number of doctors, (some of whom may leave in future) the pressure on those remaining would be untenable – unless the doctors in turn employ locums for around $2000 per day to provide hospital on call services – a cost currently borne by CHSA. This is not affordable.

CHSA have also made the ability of individual doctors who provide anaesthetic or obstetric on call services to be dependent on the ability of Island Locums to provide 365/24/7 A&E on call – despite these rosters being contracted to different entities. Having been hauled before the ACCC a few years ago by CHSA for alleged anticompetitive behaviour over rosters, the lumping together of rosters provided by different entities by CHSA seems truly perverse and in itself appears anti-competitive.

I’ve indicated the CHSA my willingness to sign a contract for anaesthetic on call – but after three months have still not been allowed to sign as CHSA insists that this service is dependent on another group of doctors providing A&E services.

In short, KI docs face loss of admitting rights and clinical privileges under standard contract terms for procedural on call, unless a solution is found.

The preference would be for existing arrangements to continue ie :the responsibility for staffing A&E remaining with CHSA and doctors contracted to Island Locums providing as much cover as possible without the collapse of local primary care services. Meanwhile procedural on call provided by individual doctors to continue so that Islanders and visitors have access to obstetric, anaesthetic and A&E services all year round.

In the last month the CEO of CHSA (Adj Prof Belinda Moyes) indicated that unless Island Locums assumed responsibility for A&E cover 365/24/7, there would be a threat to procedural services on the Island. As I understand it, Ms Moyes has now moved on (this will be the fourth CEO of CHSA in a decade, they seem to last 2-3 years on average) and is succeeded by Dr Peter Chapman as acting CEO. Perhaps NOW we will see some real action ?!?

Personally I am sick of the failure of Country Health SA to engage in meaningful discussion or acknowledge the different needs of different locations.

As a doctor I want to provide services to my community. Currently I am still in dispute with CHSA over fees for attending hospital patients to the tune of several thousand dollars. This and ongoing contractual disputes and threat of loss of procedural services make the tension for a rural doctor between running own business and working for CHSA almost unbearable.

The grass is looking increasingly greener elsewhere. But if doctors leave rural areas, the on call demands on those remaining escalates…in turn making the need for locum relief more acute.

There has to be a decision about whose responsibility it is to staff the hospital – individual doctors doing so in addition to their own business, or the State Government as a responsibility to provide rural services to taxpayers.

You can read more about some of the other SA contract disputes below :

Adelaide Now online http://www.adelaidenow.com.au/news/south-australia/south-coast-district-hospitals-on-call-conditions-may-impel-gps-to-work-30-hours-straight/story-e6frea83-1226514731619

Situation in Victor Harbor (same health cluster as Kangaroo Island, different on call arrangements) http://www.victorharbortimes.com.au/story/741920/hesitation-about-doctor-handouts/

Situation in Quorn-Hawker http://www.abc.net.au/news/2012-11-15/doctor-to-end-on-call-service-for-hawker/4373654

Situation in Clare-Snowtown http://www.abc.net.au/news/2012-11-13/snowtown-health-care-under-cloud/4368530

Rural Doctor Magazine http://www.ruraldr.com.au/news/sa-gps-resisting-after-hours-deal

Australian Doctor magazine http://www.australiandoctor.com.au/news/latest-news/gps-in-dispute-over-on-call-contracts

MP Michael Pengilly speaking on Country Health in Parliament http://www.michaelpengilly.com.au/news/default.asp?action=article&ID=345

DISCLAIMER : The opinions here are my own. The reported situation on circumstances elsewhere in SA is from the media using links above. There has been no discussion of roster arrangements between separate practices or individual entities. I remain committed to the maintenance of current status quo – local doctors providing A&E services to the level appropriate to available workforce, as well as the continuation of individual procedural doctors providing anaesthetic and obstetric services to their island community under standard contract terms.

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