Category Archives: Contract

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.

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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.

Loving the Job

I reckon the work as a rural doctor is the best that medicine offers. Just heard from a colleague with whom I did anaesthetics last year in NSW.

“Mate I love this job! In the past 7 days I’ve thrombolysed a 44 year old with a STEMI, resuscitated a 5 year old who had a fit in the local pool, drained a 2L pleural effusion off an ol’ fellas chest, gassed 5 people on a gen surg list, managed a snake bite, released two carpal tunnels, resuscitated a floppy neonate after a ventouse and seen a whole load of people in general practise. I LOVE MY JOB! Hope you’re having fun mate. This job just keeps getting better!”

No, he hasn’t been at the drugs cupboard. He is expressing the simple joy of being a rural doctor with the skills to do your work. As I’ve stated before, I reckon that being a rural doc is one of the best jobs around – especially for those with procedural skills.

Sadly skills aren’t all you need – you need the equipment to do your work well and you need structures behind you to ensure that your work is sustainable in what is, ultimately, a high-pressure job. For most of us, that means adequate locum relief or being paid for the work you do.

With regard to equipment, I’ve just submitted my paper on the availability of difficult airway equipment for rural doctors. Of the estimated 448 rural GP-anaesthetists out there, I’ve got responses from 293 – a 65% response rate, which is apparently quite good for an internet-based survey. So paper has gone in for submission…

I won’t give the game away (wait for the paper, if it survives the review process) – suffice it to say that there are common themes amongst the rural GP-anaesthetist cohort – lack of funding for basic and advanced airway equipment predominating amongst respondents. 

I’ve tried to outline in my paper some suggestions for affordable equipment to help advance the cause – for under $4K a small hospital can purchase some of the intubating LMA AirQ-II blockers, plus a fibreoptic device to allow intubation through the iLMA (something like the flexible AmbuAscope 2 or the Levitan malleable intubating stylet). There’ll still be change leftover to buy a KingVision videolaryngoscope – all of this gives a fairly robust kit for the ‘occasional intubator’ or GP-anaesthetist.


A&E Services & Contract Negotiations


Meanwhile, the State opposition Minister for Health has finally twigged to the inequity of country patients being charged for non-admitted A&E services that their metropolitan counterparts receive for free through Emergency Departments. Minister Hill is now on record saying that the ‘only solution’ would involve putting in salaried medical officers which would ‘send GPs in rural towns broke’ (The Advertiser, p15 9/3/12). He neglects to consider the alternative option – pay the oncall rural GP for A&E under existing fee-for-service arrangements, regardless of whether patient is admitted or not.

This solution would ensure patients attending the A&E with problems deemed inappropriate for routine GP would not face fees. It would mean the doctor is paid by the Health Dept without having to chase fees. Everyone is happy…

And it would be fairer to rural patients who already face significant health inequalities due to rurality.

This issue is all the more relevant as the existing contract between rural doctors and CHSA expired on 30/11/11 and has been postponed not once, but twice. I dunno about other rural docs, but I’m a little fed up of CHSA failing to come to the negotiating table and sending missives advising of a 90 day ‘contract extension’ on the last day of the existing contract.

It’s not a good way to do business and seems symptomatic of a relationship whereby CHSA treats rural docs and patients as a hinderance to their bureaucracy, rather than a vital component of the health service.


Back in the saddle

Well, have been a bit hectic the past few weeks since getting back to Kangaroo Island after my year away doing anaesthetics in NSW. Thankfully it’s relatively easy to slip back into the groove of rural medicine – and in fact it’s been a welcome relief after being back in the tertiary hospital system. But still had to get used to running on time, all the paperwork that seems to swamp us as well as catch up with friends and family back home.


Hence no blog posts since early January.


However today I am on call, sitting on the deck with a 12 month old kangaroo that Trish has taken on board in my absence, watching the rains over the north coast of KI.


Being on call again is actually quite refreshing – the Kangaroo Island doctors as a whole are now doing three weeks out of every four on the EM roster…the remaining (4th) week covered by a Country Health SA locum. I believe similar arrangements have been in place elsewhere in the State, where local doctors are struggling to fill the EM roster. Meanwhile between four of us we are providing full cover for anaesthetics and obstetrics, with two doctors doing each discipline.


I’ve also been getting to grips with delivering anaesthetics on KI – two lists so far which have been uneventful, although I’m still trying to work out how to make the anaesthetic machine display a minimal alveolar concentration of anaesthetic agent, and struggling with an end-tidal CO2 monitor that reads in unknown units (3.5-4.5 seems the average, not the 35-40mmHg I’m used to). One for the hospital to work out…


When not at work, I have been analysing the results from the GP-anaesthetist survey – over 370 responses so far, and a fair proportion are dedicated GP-anaesthetists as well as ‘occasional intubators’ (rural docs who are on an EM roster and may be called upon to intubate seldomly). Results have been interesting, with no surprises that rural docs don’t have access to a lot of the airway kit that would be taken fro granted in the city. More worryingly, a session at the local (mostly volunteer) ambulance station last week showed me that they’ve got some kit on the ambulance that we don’t have in our hospital! Had some helpful insights from airway giants like Paul Baker (NZ) and Minh le Cong (RFDS Qld), as well as lots of comments from the wider GP-anaesthetist cohort who seem to share similar frustrations as we do locally. But more on that later, as I polish my manuscript and hope to get published later this year. Meanwhile, will try and give a few talks during the year to interested parties.


But back to on-call….I’ve realised that it’s been almost two years since I’ve done an EM shift on Kangaroo Island – away for all of 2011 doing anaesthetics and for 2010 the docs on KI were reeling from all the nastiness over contract negotiations with Country Health SA and the ACCC. Now I am on-call for anaesthetics for half the year and doing one emergency shift a week….and wondering where we are at with contract negotiations – the last contract was due to end Nov 2011, rather than the usual three years…as rural docs were generally unhappy with the contract terms but were prepared to accept an interim contract hoping things would improve.


Back on 30/11/11 the head of Country Health, Belinda Moyes, wrote asking for a three month extension to contract negotiations. That extension is due to expire on 28/2/12 and I’ve not heard peep from Country Health over contracts. One has to wonder if they are serious about negotiating a new contract, or will just keep ‘extending’ the current contract rather than negotiate.


A big issue for me (and many other doctors) has been the sheer unfairness of Country Health insisting that people presenting to the emergency department are billed privately by the on call doctor, unless they are admitted to a hospital bed. This seems plainly unfair – whilst patients in metro areas are treated for free in the Emergency Dept of public hospitals, their country cousins are charged. 


Many of these services are for things that are not routine ‘general practice’ ie: X-raying a fracture and setting a limb in plaster, suturing an extensive laceration, pulling a dislocated shoulder back into shape, dealing with an alleged rape or victims of a motor vehicle accident. Country Health has managed to formalise this in the most recent (well, in fact the first) contract from 2010 with a clause stating that:


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, CHSA shall not be liable to pay any fee for such services”


Their rationale is that such patients are an extension of the doctors private practice. Indeed, CHSA states that:


“This funding model with MBS being paid for public patients attending state hospitals, is acceptable to the Commonwealth due to an exemption in the National Healthcare Agreement that ‘in those hospitals that rely on GPs for the provision of medical services (normally small rural hospitals), 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.’ 

As far as I know, South Australia doesn’t have an exemption under the National Healthcare Agreement but continues to obfuscate this issue. What really twists my melon, and that of the patients who I see who are charged for their attendance, is that they have neither requested treatment by their own GP, nor is there treatment part of continuing care or a prior arrangement with the doctor. Basically, it’s not a private service…it’s just Coutnry Health SA cost-shifting dollars from State to Federal expenses.

In fact, the on call doctor is called to attend patients in the ED as part of his/her role as the doctor on-call for emergencies in a contract with CHSA. There is no prior arrangement, they are not private patients and usually this is not part of continuing care.

Quite how the Health Department continues to get away with this blatant cost shift from State to Federal (Medicare) coffers amazes me. And it is cold comfort to our patients – the rural ones are already disadvantaged enough, and the metro or interstate ones are flabbergasted to be charged fees for services in ED that they would receive for free at home. And of course the overseas tourists (and we see a fair share on Kangaroo Island) are less than impressed to receive a bill and aren’t covered by Medicare.

Bottomline, the doctor on call for emergency medicine for CHSA doesn’t get paid to come and see emergency patients, unless they are admitted to hospital for over four hours…



Let’s hope this issue will be resolved in contract negotiations – although with two days to go until contracts expire, I am not optimistic.