Category Archives: Medicare Locals

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.

Emergencies & GP after hours

Well there’s an interesting article this week from Emergency Medicine Australia (Nagree et al 2012 ‘Telephone triage is not the answer to ED overcrowding’ EMA 24 123-126) as well as a media release from the Australasian College of Emergency Medicine regarding triage.

Before rural medicine I was an EM trainee. I’m pretty passionate about emergency medicine – sadly one of the reasons I got out of the specialty was frustration with things I could not control, not least the phenomenon of ‘access block’ – too many people in the ED, waiting for beds on the ward. I must admit that as a junior doctor I would bemoan ‘GP-type’ patients clogging up the ED…but as time went on and I matured clinically, I realised that:

(a) these low acuity problems were quick and easy to fix
(b) they were not a burden on time or resources
and
(c) often even the low acuity patients had complex health needs that required admission to a hospital for sorting out.

As a rural doctor I do my utmost to avoid turfing patients unnecessarily to my overworked colleagues in the ED, trying to smooth my patients’ admission to the appropriate unit without them having to be stuck on a trolley in the ED awaiting review.

Whilst it is tempting to imaging the ED clogged up with non-urgent problems, the reality is that such presentations are easily dealt with (even the most junior of resident medical officers can treat a UTI or reassure parents of a child with otitis media). What clogs up the ED are complex patients requiring investigation and admission, as well as the labour and resource-intensive presentations such as critical illness.

It’s also relevant to the ongoing issue of what is and what isn’t an emergency – with a blatant cost-shift between State and Federal funds trying to classify many ED attendees as ‘inappropriate GP-type attendances’.

But there is a problem.

Politicians need to be seen to ‘do something’. They have latched onto the concept of the idea of triage 4 and 5 patients as being GP-type attendees and in a non-evidence based approach have poured hundreds of millions into schemes such as GP after hours, co-located clinics and the disastrous healthdirect phone line.

Phone triage sounds good. But it doesn’t work – experience from overseas (not least the ill-fated NHS-direct in the UK proves this). Put simply, a nurse or a GP following a protocol will not be able to diagnose over the phone 100% reliably. It may be a sop to the worried well, but my grandmother can do this job just as well and won’t cost the estimated $200 million that healthdirect costs the taxpayer.

The Health Minister has stated that healthdirect has deterred 30,000 patients from a million calls from visiting the ED. Sounds good…but that’s only 3% of calls…surely better to spend that money on beds and more clinical staff…not a phone service.

We don’t do phone triage in the ED, instead advising patients to present to the ED for a face-to-face assessment – because it is a safe approach – history and examination cannot be done reliably over a phone. In fact, the more medicine I do the more I realise how medicine doesn’t fall into neat protocols or boxes. The skill of a good Emergency Physician or GP is to spot the severely abnormal amongst the morass of mostly normal. A protocol (or my grandmother) will get things right most of the time – but will miss the more unusual or atypical presentations. The UK’s NHS-direct has learnt this, with several lawsuits after missed diagnosis – the headache that was a subarachnoid, the febrile child with meningitis etc.

So Prof Nagree’s paper neatly debunks the idea that phone triage alleviates pressure on Emergency Departments. What then of triage as a measure of ED vs GP-type attendances?

Triage is a score of urgency of treatment – not complexity. Many triage 4 or 5 patients have been sent to the ED by GPs. To then proclaim that they are ‘GP-type’ attendances misses the point that such patients are complex, require extensive investigation (usually using facilities not present in a GP surgery, such as X-ray, bloods etc) and often require admission.

This may not sound like a big deal – but it is an issue in the country where patients who are not admitted are charged a fee for attending the ED, on the spurious basis that they represent routine General Practice.

Which then raises the issue of GP After Hours services – what is the appropriate level of service needed after hours and will pumping money into GPAH alleviate pressure on EDs?

The Government clearly thinks so and is throwing around money like a drunken sailor. We met with the Medicare Locals mob last month on Kangaroo Island (formerly they were the Southern Division of General Practice in Adelaide, then GP-Network South, and now the unwieldy Southern Adelaide-Fleurieu-Kangaroo Island Medicare Local). They were canvassing opinion on GPAH services but seemed to have no grasp of the issues locally nor how to address them.

I always think of GPs like plumbers – you need us during working hours for scheduled things like routine maintenance…but we might have to deal with the occasional urgent job like a dripping tap. However you don’t really need these things fixing at 3am. On the other hand, if the hot water service blows up or a water main bursts, this needs to be dealt with. These are the medical equivalent of an emergency medicine service and as rural GPs we provide this too. However is this routine GP or is this an emergency?

I’m a simple chap – I think that primary care generally deals with most things…but if it cannot wait 12 hours or needs the services of a hospital then the problem is ipso facto an emergency.

Nagree’s paper establishes that phone triage does not alleviate pressure on EDs – the issue is access block, not inappropriate attendees. The corollary is that most patients are in ED because they belong there – throwing money at afterhours services by GPs doesn’t really address their complex health needs requiring hospital services (imaging, same day bloods etc)

However the issue of non-admitted emergency patients remains unaddressed. I can cite numerous examples (not least from the current busy Easter weekend oncall as I type) of people presenting appropriately to the ED – but being forced to pay for their attendance because they are not admitted (State Govt cost shifts to Medicare)

Examples include

- fall from a roof, 25 cm incisional wound requiring formal debridement under local anaesthesia and repair taking 90 minutes

- fall from a horse with possible cervical spine injury

- four tourists in a medium speed (60kph) rollover on unsealed road, presenting to hospital for forensic blood alchohol, assessment of injuries

- 13 year old fall from skateboard with angulated Colles fracture requiring manipulation and casting

- mental health patient brought in by Police for assessment

- 45 yo with ?fracture-dislocation shoulder requiring analgesia, X-ray and reduction

All of these patients chew up a few hours of time. I think they were appropriately seen within the ED and not deferred for a routine 15 min GP appointment in the week.

However the false reliance on triage as a marker of GP vs ED attendance will continue to encourage misguided strategies to reduce ED overcrowding that are doomed to fail. It also allows cost-shifting from State (emergency) to Medicare (GP) budgets.

As ACEM say “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’

Quite.

What do others think?