Category Archives: Fees

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

Country Emergency Department Fees

Well I’ve just received a letter from the Federal Health Minister which seems to broadly confirm my suspicions that the charging of fees for country patients attending a public hospital ED is incorrect.


You may need to click and open separately to view



Of course there is a grey area in what is a ‘GP after hours’ type attendance and what is an emergency attendance – and with that comes the potential for massive cost-shifting from the State (charged with providing free public emergency treatment) and the Commonwealth (providing Medicare compensable services).


Country patients are caught up in this, as in South Australia they have been charged fees for attending the ED in rural hospitals. Now historically there was an arrangement (not defined in a contract, but in an agreed schedule of fees for paying doctors called SARMFA) that allowed a rural doctor to charge a private fee in circumstances where a patient requested private treatment by a particular doctor, or where care was provided in the country hospital as part of ongoing care or prior arrangement.


This seems a sensible compromise to allow rural doctors to attend patients at the hospital both in and after hours for GP-type consultations or private care. Example might be an agreement between doctor and patient to meet at the hospital after routine consulting for a review of an eye injury, utilising the hospital’s slit-lamp. or arranging to be seen for a skin excision or to administer intravenous therapy.


All well and good.


Then in 2010 a new contract (in fact the first time a written arrangement about rights & responsibilities) between CHSA and rural doctors came into being. This is a good thing and it was hoped that would create a level-playing field with rural doctors getting equivalent deals, rather than the hotch-potch of ‘local deals’ that saw some doctors getting lucrative locum rates for being oncall, others struggling to balance the impact of providing oncall work for the hospital with their private practice.


The negotiating teams of both AMA and RDASA invested a lot of time and effort into getting the ‘best deal’, but as time wore on the AMA walked away from the offer whilst the RDASA recommended to their members on a temporary basis, expecting a new and better deal to be negotiated by the end of November 2011.


My concern has been that, for the first time, there is a contract that is explicit about the charging of fees. Whilst the SA Health Minister acknowledges that CHSA are responsible for the provision of public emergency services in the country, there is a catch. The contract specifies that only ADMITTED patients are entitled to free treatment – non-admitted patients are to be charged by the attending doctor.


This seems to fudge the previous arrangement designed for private services or ongoing care between patient and treating doctor. Instead, people who present to a rural ED in South Australia are charged fees unless they are admitted….and yet patients with similar problems who go to a metro ED are provided the service for free.


The Health Minister says this is because rural hospitals do not have a salaried medical officer on site. Fair enough. I’d just argue that if the Hospital feels they need to call in a doctor, that that doctor is paid for their services – and the patient does not.


Of course, if the patient presentation is trivial (a GP-type attendance) then it would be appropriate to divert them to a GP-after hours service or to GP clinic the next day – and Medicare or private fees would apply.


It’s all down to definition. What is an admitted patient? The bean-counters take the view that a patient has to be present for > 4 hours, although occasionally this requirement can be relaxed for certain things (type C attendances, a definition derived from mostly day surgery units).


So we have a position now enshrined in a contract, where rural patients may be charged for things like reduction of a fracture, IV fluids, X-rays, assessment after a car crash, mental health emergency in a country ED…on the basis that these are ‘GP services’. These are things that a GP in the city may well refer patients to an ED for.


Medicare advisors tell me this is illegal and that doctors should not charge for such non-admitted ED services where patients attend a public ED. The Dept of Health & Ageing letter suggests the same.


The only explanation from CHSA is that this is allowed because of a ‘longstanding arrangement for treatment of private patients as part of ongoing care or prior arrangement by a specific doctor’. 


I am all for this – when such care is agreed and is genuinely private. I have no qualms charging a private fee for my private GP services. 


Seems hard to explain that all this to the carload of NSW tourists who have crashed and seek assistance at the local hospital only to be saddled with a bill. Or the patient with a fracture-dislocation that requires X-ray/reduction/plastering…and many more examples.  Understandably some patients refuse to pay on the basis that they are attending an ED. CHSA insists that the doctor charges Medicare..who say that this practice is illegal…and CHSA doesn’t answer this query.


So, where are we at now?


There have been two extensions to the rural doctors contract (which was to expire 30/11/11) so far…the current extension ends in just under four weeks and still no contract offer available for perusal.


In an effort to address this anomaly, RDASA had proposed that triage 1-2-3 patients are to receive free treatment. Seems fair, although it does ignore the issue that triage is just about treatment priority, not complexity and is ill-suited to decisions about whether ED attendance is appropriate or not. There is a myth that triage 4/5 patients are ‘GP-type’ presentations, when in fact these patients are often elderly, complex and require admission or the services of an ED not a GP (minor fractures, plastering, X-ray etc). ACEM have issued a media release on this which is informative.


Despite that, I’m still struggling to get paid for attending a triage 1 call in…with CHSA insisting the patient be billed under Medicare.


So, there you have it. 


- A contract that seems to be in breach of the National Healthcare Agreement.
- Cost-shifting fees onto patients who are already rurally disadvantaged. 
- And only a few weeks to go until the most recent contract negotiation expires.


Really, is this any way to do business? It seems that Country Health SA hold both rural patients and the medical workforce with a lack of respect. I despair, because this sort of thing does little to encourage recruitment and retention of rural doctors to South Australia.


I guess there’s no votes in the bush.

Had a gutful

Well, it’s kind of ironic that over the weekend there’s been a small flurry of interest in the issue of non-admitted hospital patients being charged a fee in South Australian country hospitals (see The Australian p7 24/3/12)…and yet at the same time this issue arose locally.


I understand that the Minister of Health is not a happy bunny currently – being the Health Minister must be an unforgiveable job, especially when the budget is squeezed tight. 


And I’ve recently been criticised for raising this issue – on the basis that it’s been going on for a while and may impact on doctor’s hip pockets (some rural docs are doing OK charging a $50 gap for non-admitted patients and may be reluctant to see a change in the status quo). 


It’s also a fairly intense time at the moment – the contract between Country Health SA and rural doctors remains ‘in negotiation’ – even though a finalised deal was supposed to have been in place by 30/11/11…and we are on our second 3 month extension. There may be anxiety that politicising this issue will affect negotiations.


I agree and think this issue transcends whichever party is currently in power.


Anyhow I was on for anaesthetics this weekend and was called in by the hospital for a ‘cardiac arrest’. I arrived ahead of the A&E oncall doctor and the patient, who was transported by ambulance.  


Suffice it to say that when they arrived at the hospital, the patient was very much alive and indeed combative from another cause. 


After a quick ABC assessment I was stood down and left the patient in the capable hands of my A&E colleague. I understand that the patient left the ED some time later, discharged to the care of a capable adult.


Today I emailed the head of Country Health fee-for-service, asking how this attendance should be billed.


The response? Well, as the patient was not admitted, it is apparently ‘a private matter between the patient and the doctor and CHSA is not liable


I’ve had a gutful of this. I really don’t mind being called in, whatever the hour, whatever the reason. If the hospital feels they need my services, and I am oncall, then I am available and will come in.


But to then turn around and say they won’t pay?


Now, this will no doubt be sorted out after the usual barrage of emails to-and-fro until someone (usually the CHSA medical advisor) makes a determination. I will expend many hours chasing the debt, my BP will climb…but ultimately I will get paid.


But it is all so tedious and mind-mumbingly unnecessary. I am fed up with having to chase payment from a health service that seems to apply rules inflexibly and illogically.


I sure as hell am not going to charge the patient – they arrived by ambulance with four paramedics in attendance, two doctors, extra nursing staff etc and were transported to the appropriate place – a nice shiny hospital.


My expectation is that if the hospital feels a matter is urgent, and calls a doctor, then they should pay that doctor regardless of outcome, of subsequent diagnosis or of triage score. I think most common sense people would agree. However the wording of current arrangements opens the door to cost-shifting from State funds (public hospital) to the patient (Medicare reimbursement if compensable).


I don’t care, I just want to get paid without fighting every bloody time!


Is this really so unreasonable or hard to understand?