Tag Archives: Minister Hill

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.

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.


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