Open Letter to the Minister

Well, it’s finally happened. I’ve succumbed to the urge to fire off Victor Meldrew-like letters of indignant fury to the Health Minister over the recent exchange of press releases between Liberal and Labor Health Ministers regarding the issue of country patients being charged fees for A&E services.


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

12 responses to “Open Letter to the Minister

  1. I agree. The way I read it the National Healthcare Agreement states everyone in Australia should have the same free access to emergency review in A & E.Where I live there is a different problem. People in residential care who need an after hours G.P. have to be sent by Ambulance to A & E for review.

  2. Thanks Anon…that is a real shameIt's a sad fact that after hours GP services are few and far between. Of course, once could argue that an urgent condition at 2am warrants an A&E review…but the fact is that A&Es are not exactly the right place to be treating nursing home patients.I read a rather scary statistic recently – something along the lines of over 85% of Australians now dying in hospital rather than in their home or a hospice. I've been witness to lots of examples of 'cover your arse' medicine – a nursing home resident deteriorates, carers are unsupported (lack of after hours doctors), an ambulance is called, resident is shifted to the ED, emergency doctors spring into action…and a peaceful death that should have happened in own bed becomes a horrendous death under bright-lights, with rib-crunching CPR.Bottomline, we need to encourage GP after hours services. There is a National Health Advice phone line. I've heard that doctors can cream $250 per hour for answering calls (which are first screened by a nurse following protocol). If the rate for answering the phone is now set at $250 ph, then one would imagine that doctors will want more to see a patient face-to-face. And I doubt anyone would want to pay that!It's a dog's breakfast.

  3. Tim, I am a partner of a practice in a medium sized SA country town, and we actually quite like the system and would be reluctant to see it change. In fact, when speaking to rural GPs in other states about our ability to bill ED patients, they are green with envy. Rather than trying to emulate the inefficient and dysfunctional situation that is seen in metropolitan EDs, I would suggest that a modest co-payment charge should be charged to all patients presenting to ED, whether they be in the city or country.The problem with a free ED is uncapped demand. In metropolitan ED's the price is often paid in waiting time, which means the cash poor but time rich will be attracted to the ED, and the cash rich but time poor will seek out after hours GP services. If you try to minimise waiting times (ie the 4 hour rule) the demand increases further, and there is very inefficient use of resources as departments need to be resourced at all times for peak demand to meet waiting time targets (occasionally resulting in the bizarre situation I have seen in WA where doctors are queueing up to see patients). Ultimately someone has to pay to provide these resources, be it the individual or the taxpayer.If a GP is responsible for providing both GP and ED services simultaneously, the price mechanism can be used effectively to guide patients to attend at the most appropriate time and place.Clearly from a patient's perspective there is always a preference for something that is free over something they have to pay for. However a true non-admitted emergency department presentation should be an infrequent event in an individual patient's life – if they have to attend on a frequent basis they are almost certainly attending inappropriately. If a doctor is ideologically comfortable with charging a patient a fee for an in-hours pre-booked consultation, then there is no reason why they should feel morally compromised by charging a fee for an after-hours emergency consultation.We have adopted a few principles to ensure fairness to our patients under our system.;1] We have a booking system that guarantees a patient an on-the-day appointment with a doctor at the practice on weekdays and Saturday mornings(though does not guarantee choice of doctor).2] Although the out-of-pocket cost to be seen at the hospital is set at a higher level than being seen at the surgery, it remains modest and is not billed at point-of-service.3] Every doctor has the right to waive the gap for a particular patient attendance.Although we do get some bad debts (in fact surprisingly few) the 90 day rule ensures that at least the Medicare component is received. We figure that this is offset by the on-call payment provided by CHSA to provide the emergency service at the hospital.As a consequence we have a well-trained and largely grateful town population who by and large present to the appropraite venue at the appropriate time. I am unaware of any intances where patients have avoided presenting due to the cost, though I suspect it could occur if there was an aggressive insistence of payment at point of service. Having a robust workforce certainly helps keep both doctors and patients happy. Many patients who have experienced the unfriendly and chaotic environment of a metropolitan ED comment that they are happy to pay for the quality of service they receive in a country hospital ED.I respect your right to voice your opinion on this matter but please be aware that on this issue a good proportion of conutry doctors in SA are comfortable at least with the basic premise of the existing system, if not entirely satisfied with the nuts & bolts, hence the push to seek a better deal from CHSA. Although I disagree with many things stated by Minister Hill, on this matter I have to agree with him.

  4. Thanks Anonymous for taking the time to comment on this issue.There are certainly perils with offering free treatment to all and sundry – 'Free at point of abuse' is a cry often heard from the UK's NHS and from many busy EDs.As a private GP, I derive a significant part of my income from oncall work.However, some facts remain- the Australian Healthcare Agreement p9 pt6 between Commonwealth specifically states that patients are entitled to free treatment at a public hospital- Medicare have told me that to raise a bill in such instances would be contrary to the agreement- billing IS allowed where a patient requests treatment by his/her GP as a private patient, or as part of ongoing or continuing care. To my mind this is appropriate for GP-type after hours arrangements…but I don't reckon it is applicable to patients who have been raped, assuaulted, involved in a car crash or sufer a ?fracture-dislocation etc – services that need to be provided at 3am and often require facilities not present in routine GP clinic (X-rays, medications, time-based consults of over an hour etc)The idea of a co-payment has been mooted before and I think has merit – however it is not in place as yet and so rural patients continue to suffer a fee whereas metro do notYou talk of interstate doctors looking at our arrangements with envy…that is not my experience, but of course this is not quantified. Neither is the statement that 'many country doctors are happy with current arrangements' – anecdote or hard data? We simply do not know.On a practical level, if the Health Dept would be prepared to pay a doctor for A&E attendances where a doctor IS required, then at least patients get appropriate treatment, the doctor gets paid and neither the AHA or Medicare breaches occur.Of course, if a patient is deemed NON-URGENT then one would be encouraging the RN at triage to defer their attendance until routine GP hours…and if a patient INSISTS on being seen for a non-urgent proboem, then by all means charge like a wounded bull.My understanding is that the oncall payment to country doctors is to reimburse them for availability, not to offset fees & charges through A&E. If the latter, then the oncall payment would need to go up – and I'd happily bulkbill everyone…a savvy health-service would of course collect the fees themselves and pay the doctor.If I read correctly, you are saying that are happy to continue with current system, despite breaches of NHA, Medicare and in absence of an exemption from the Commonwealth. Despite a lack of equality for metro/rural patients (such as a universal co-payment scheme), you are happy to charge for services that metro get for free.No wonder patients talk about greedy doctors!Regardless of where you stand (and a lot of this is ideology), this matter has never really been discussed 'out there', just allowed to continue as another of the travails of living rurally. I don;t think it's fair. My patients don't think it's fair.What do others think?

  5. Actually, just looking at this another way.The issue seems to be the 'grey area' of patients who require hospital-based services (X-ray, plaster, reduction of dislocation, prolonged assessment, complex laceration repair etc)…not routine GP or after hours GP type consults 9which are private services)The problem is that CHSA (at least in my locality) declines these as 'admissions' (free for patient, doctor paid by fee-for-service with CHSA)…on the basis that an admission requires attendance and ongoing treatment for >4 hrsNow, ,ost rural docs will sort out a Colles with Bier block, or use a bit of neurolept to pop a shoulder back in, or spend an hour and a half sorting out a mental health patient…in under this time frameI'd rather the Govt paid me for these services and the patients (who needs treatment) gets for free as they would in an ED.For the non-urgent GP services, by all means charge a fee. And a sensible triage setup would appropriately defer such patients to routine GP the next dayClarity on what is and what is not, an emergency admission would be helpful.At present such clarity is missing from arrangements between CHSA and rural doctors…and is a cause of concern locally.

  6. Tim, I accept that I must rely on anecdote to draw conclusions about what other rural doctors (interstate or local) think about the system operating in rural SA. My purpose in reporting these anecdotes was simply to bring it to your attention that there are at least some doctors who do not necessarily share your opinion on this matter. We simply do not know what majority opinion is amongst local rural doctors, or even whether there is much awareness that alternative systems exist.I suspect that local circumstances and workforce levels may influence how individual doctors feel on this matter. When more than 90% of the patients presenting to ED are patients of the towns only practice (as in my case) then the system operates very smoothly. No two country towns are the same, and I imagine your situation on KI is significantly different to that of GPs working in towns that have relatively stable and non-mobile populations.It is my understanding that these arrangements have been in place historically for a considerable time, certainly preceding Minister Hills tenure as Health Minister. These arrangements are mentioned explicitly in the contact with CHSA to provide emergency services to CHSA Hospitals. It would seem very odd if Medicare has only just noticed aberrant billing behaviour by rural GPs in SA after decades of such practice occurring. I do not pretend to be qualified to determine whether the agreement between the SA Govt and the Federal Government regarding such billing is 'legal' or not, but as it has been done on tens of thousands of occasions by many hundreds of doctors over the years it would seem there is at least historical precedent to fall back on.I am puzzled and a little offended by your line 'No wonder patients talk about greedy doctors!' in your reply to my previous post. There is a valid argument regarding equity and fairness to be had, but I don't think that billing Medicare and charging a modest co-payment instead of billing the state government constitutes greed. In fact under most circumstances billing under the current system results in a lesser fee and a greater administrative cost to the doctor than would your proposed system. The merit of the existing system to me lies in allowing doctors the autonomy to organise their practice in a more lifestyle frindly fashion, whilst continuing to maintain high quality clinical care and timely access to services for patients.It seems that this issue is becoming more and more high profile, as there is an article in the national press about it today (The Australian, page 7). I also note that the RDASA (of which I am a member) has also started to speak publicly on the matter, seemingly supportive of your position. I think this debate needs to be handled with some delicacy, otherwise there is a real risk of a schism amongst SA rural doctors, which benefits no one.I hope that other rural GPs post their opinions on this blog to see what other views are out there.

  7. Absolutely, your ponts are well argued and what works in one place may well not work in anotherI am not sure about the history behind this – AFAIK there was NO written contract on this until 2010…befoer that there was simply no written arrangement betwixt rural docs and CHSA, except for those places with 'special deals'.SARMFA/SARMER or whatever it is called should replace all that. But it is the first time that it has been explicit about this whole cost-shiftingBelieve me, I;m all for charging a fee when it's a genuine private arrangement. And I am more than happy to not be called and enjoy a lifestyle – my experience has been that it's often too easy to call the doctor 'patient here for you – click' when there's a private set up – whereas if CHSA have to justify call ins, then there will be an incentive NOT to call inappropriately- at least that's been my experience of working interstate in the past year.More debate on this is to be welcomed – that's what this site is designed for – we tend to operate in silos as rural docs and there's no representationAs far as rural docs association goes, I've recently resigned – apparently they don;t have the majority when it comes to rural docs – but then again nor do the AMA. There's a helluva lot of people out there who aren't members of either and seem to 'go with the flow'That's not a good thing – we would have better strength in numbers. And more discussion on this (and other) topics is to be encouraged…I'm happy to be the lightning rod if it gets debate going in a forum where can be read by people…so long as there are no ACCC implications!!!

  8. Hi. I currently work for RFDS in cairns and we bill remote patients under the Medicare 19(2) exemption. What is being done in SA is technically a violation of the NHA as Tim has asserted. Its been done for years I know, even when I worked in Loxton on MUrray river, we did it. Probably still do. Its because the private and public services are performed by GPs and the grey area between whats a privAte GP consult and whats a public domain.Tim is right to challenge this state of affairs. Why should city folk not Get charged when rural folk in SA are? Should all ED presentations get charged a copayment regardless of location? I strongly argue no.Are you going to charge someone who has been sexually assaulted? That is lacking compassion.Just becasue we have been doing it for years does not make it right.

  9. I’m sorry to have caused offence.From a patient perspective, they don’t really care about the politics behind all this. They just want to be seen by a doctor.Now, when this is a genuine private arrangement, I’m happy to charge a fee….and I think patients are prepared to pay for a quality, bespoke service. That’s how my private clinic runs. And I think that is how a genuine GP after hours service should work. Of course, what differentiates a GPAH service from an Emergency Service is the important issue.When I’m acting as the oncall doctor for the Health Dept, then things are a little different to a private arrangement. Patients are presenting to the emergency department of a public hospital. At present, the ‘free at point of (ab)use’ issue applies to CHSA – they can call in a doctor at 3am, safe in the knowledge that it costs the Health Dept nothing – the cost is shifted onto the patient who may be entitled to a rebate if medicare compensable.At the moment there is no disincentive on the hospital to call a doctor – because it costs the hospital nothing.And as you mention, there is a requirement for administration of after hours billing – I reckon that chasing bad debts alone is a burden that many of us could do without.I’m a nice guy. I recognise financial hardship in my patients. I’m probably more likely to bulk bill someone who’s been involved in a car crash, or been raped, or has a mental health issue or has suffered a nasty laceration at 3am, than I am for an in-hours consult in my private clinic. But sorting this things out takes time (often an hour or more). And the medicare rebate is risible.Bottomline, how do you explain to a patient they are to be charged a fee for an emergency service, when they’d get it for free in the city?I’m not talking about standard GP consults (that’s an after hours GP service issue – although it’s worrying that Paul Mara of RDAA reckons many rural GPs will give this up once the Govt pulls PIP funding).We’re talking about things that need the services of a hospital and aren’t standard GP consults like sore throats, grotty ears, back pain etc. I seem to be called in for ?fractures, acute pain, mental health etc – stuff that needs to be sorted then and there…but under current system does not require a hospital bed.Paying them under fee-for-service and making cost-neutral to the patient would seem fairer, guarantee the doctor is paid and also improve lifestyle as there’s a financial disincentive for CHSA to call the doctor out unless it’s a real emergency!It’s a bugger.

  10. A couple of quick points:1] The old SAMSOF agreement around in the early 2000's did in fact mention explicitly the delineation between publicly funded and privately funded hospital based services, with an absurd argument about the time that the decision to admit was made determining who should pay.2] As a general rule, a patient sick or injured enough to require a doctor to get out of bed overnight to see them urgently is sick or injured enough justify admission to hospital for at least 4 hours.3] Compassionate patient care can be provided by caring and empathetic doctors under any billing system. Asking a patient to sign a form in order raise an account (which may be ultimately paid by a third party) in no way suggests a lack of care or compassion on the part of the service provider, irrespective of the circumstance.4] Medicine is a continuum and it is impossible to objectively separate patient presentations neatly into GP type and ED type, as every case is different. In rural towns the same doctor is often responsible for provision of both services, and in many cases the service could be provided just as safely in a well set-up private surgery as in a hospital ED.

  11. I have no problem if you bulkbill those emergency patients. The problem I have is when you start charging copayments. This is a violation of the NHA…if you dont believe it, call Medicare headquarters and ask…like Tim did. Your point 2 contradicts your point 4.You should not post anonymously

  12. Aw look, I agree – medicine is a continuum and we are generally a compassionate mob. Dunno about the old SAMSOF – my understanding was that this was a fees schedule…not a contract. Now we have a contract and it specifies terms and conditions that may 9and I cannot get a clear answer on this) raise the ire of Medicare unless we bulkbill everyoneInteresting case last night – called to a pr1 'cardiac arrest' – drove hell of leather to the hospital as the anaes oncall. Arrived before ambulance and was met by the A&E oncall doctor.Patient arrived, very much not in cardiac arrest, just intoxicated having suffered a ?seizure. After a quick ABC, A&E doc was happy and I was dismissedTurns out the patient was discharged within an hourNow, CHSA say that as the patient was not admitted, then they are not responsible for my feeThe patient certainly isn't going to pay.So – here we have a case of a doctor being called in, in good faith, to attend an incident that could have been serious…but wasn't.That's OK, I don't mind being called in. But I do expect to be paid.Is that unreasonable?Moreover, if I were to charge the patient my standard fee (and I would use a plumber as a baseline, not the risible medicare rebate), then how is that fair to him or her?Bottomline, what do you tell the patient with a genuine A&E problem who asks "but I get this service for free in the city or free interstate?", when that service cannot be provided in GP rooms.Please don;t think I am advocating a free service for all – genuine GPAH should be paid as a private service, for that is what it is. But non-admitted A&E is a different kettle of fish, as the above case illustrates. There are also mutterings of GPAH disappearing as the PIP funding expires in July 2013…quite how that leaves patients is going to be very interesting.Ironically, I had the president-in-waiting (curious title) of the RDASA with me at the time of that call out…I wonder what he made of it all?Quick Q to "anon" – what do you tell patients who ask why they are charged a fee for a service that they would get for free in town? And are you happy with the rebate for coming in at 2am, spending two hours sorting out a mental health client, who is not admitted? Cos I reckon you're getting paid less than a plumber unless you charge a gap…which of course is (a) unfair and (b) may be considered a copayment by medicare.I'm puzzled by this stuff.

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