Clearer targets

Specialists and allied health workers may be about to feel the heat under plans to broaden the net of the Professional Services Review. Pamela Wilson reports.

LIKE the outer rings of a bullseye, GPs have long been an easy mark for the Professional Services Review (PSR).

But the red centre that is specialists – and, soon, allied health practitioners – is about to get a lot bigger.

The vast majority of practitioners called into question by Medicare Australia and the PSR are GPs, simply because as a group their billing practices are easier to label as being appropriate or inappropriate in the peer-review process.

But the PSR and Medicare have finally identified the anomaly and are working to reduce the barriers to better monitor specialists and broaden the net to include allied health practitioners.

It’s a move welcomed by AGPN chair Dr Tony Hobbs.

“There are significantly more GPs than specialists [and] it is much easier to track GPs’ Medicare and PBS use than specialists’,” Dr Hobbs says.

“Have we been unfairly targeted? We bear an unfair burden is what I would say.”

Since 1999, fewer than 5% of the practitioners (16 out of 321) referred to the PSR have been specialists, according to a review of the PSR released recently.

This is despite the fact that there are more than 24,500 specialists, who account for more than 50% of Medicare expenditure.

One of the main ways GPs are deemed to have engaged in inapprop­riate practice is the 80/20 rule, whereby giving 80 or more professional attendances on each of 20 or more days in a 12-month period will attract the attention of the authorities.

PSR director Dr Tony Webber says that in using this method, it hasn’t been possible to compare the billing practices of groups of specialists to identify what is normal procedure.

“The review recognised this as a deficiency, and the recommendation in the review is for Medicare to come up with different ways of looking at that data,” he says.

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Another reason so few specialists are called into question, Dr Webber believes, is that the unofficial lines of communication through the tight-knit specialist network alert doctors to what is and isn’t appropriate.

“If someone is doing the wrong thing and Medicare alerts them, that word generally travels through the specialist group fairly quickly, and other people who may have been doing similar things will often pull their head in before they get to the PSR,” Dr Webber says.

AMA president Dr Rosanna Capolingua also likes to think that despite the fact that specialists have been flying under the PSR radar, they have largely been doing the right thing.

“Doctors are accountable to themselves, their peers and their patients... and that is a natural mechanism for keeping us acting appropriately as far as Medicare is concerned,” she says.

“Behaviours that would be picked up by the PSR are not things that
happen readily [and] we are not finding a whole bunch of inappropriate behaviours by specialists.”

The question is, then, how does Medicare hope to better pinpoint aberrant specialists if it hasn’t been able to do so in the past?

It is a question Dr Webber can’t yet answer, except to say it is something the federal government and Medicare have to work out in consultation with specialist colleges and professional bodies.

Meanwhile, the president of the Royal Aus­tralian and New Zealand College of Obs­tetricians and Gynae­co­logists, Dr Christine Tippett, points out that it will be very difficult for the authorities to finetune a pro­cess to cover all specialists.

“When you have a small professional group, like obstet­ricians and gynaecologists – who, while there are 1500 within that group, [include] a lot of very different people doing very different things – it’s much harder to set the criteria,” Dr Tippett says.

However, she agrees that specialists should be accountable to the peer review process like any other practitioners.

“Doctors get significant funding through Medicare, so I think the people who oversee these processes have a responsibility to ensure it is being used appropriately,” she says.

“Specialist medical practitioners are no different to any other group in the community, [and] there would be some people who aren’t acting within reasonable guidelines.”

ALLIED HEALTH IN SIGHTS

Allied health practitioners are also soon to fall under the more watchful eye of the PSR.

A Medicare Australia spokesman explains that the only non-medical practitioners who can be examined by the PSR currently are dentists, optometrists, chiropractors, osteopaths, physiotherapists and podiatrists.

“However, the range of allied health providers who can initiate or render services that are eligible for the payment of Medicare benefits has expanded significantly,” the spokesman says.

This is due to the introduction of initiatives such as the Medicare Allied Health and Dental Care Initiative and the Better Access to Psychiatrists, Psychologists and General Practitioners through the MBS measures.

Dr Webber points out that this is a process of simply “updating the legislation so it is current” and not a response to concerns of rorting within the allied health profession.

“The review has recognised that the game has now broadened... that the legislation has to change to include all the groups because they will be accessing Medicare,” he says.

Dr Hobbs has also welcomed this move, saying all practitioners should be subject to the same rules.

DRAMATIC FALL IN NUMBERS

Although Medicare Aust­ralia won’t speculate on how much it hopes to recover from the tightening of pro­cesses, it did identify more than $3 million in incorrect payments for recovery in 2006–07.

Meanwhile, the review into the PSR also reveals that the number of doctors referred has dropped dramatically, from a peak of 94 in 2001–02 to just seven in 2005–06.

At the same time, the num­ber of doctors applying for exemption to the 80/20 rule has dropped, leading to speculation that doctors are getting better at “playing the system”.

“Application of the deeming provision [the 80/20 rule] is now a rare event, suggesting a deterrent effect but also leading to concerns that doctors may be ‘playing the system’,” the review reports.

However, Medicare Aust­ra­lia says the decline in referrals to the PSR is a result of the introduction in 2004 of a two-stage referral process, which proved long and arduous.

Medicare has since revised its procedures for reviewing practitioners to a more simple single-stage process.

Other industry members also disagree that the figures represent an increase in doctors playing the system.

“I wouldn’t say they were playing the game better,” Dr Capolingua says.

“I think there have been lots of factors involved in some changes in practice, [like] the ability for us to use practice nurses, which has been of great assistance in taking the pressure off doctors seeing so many patients.”

Dr Hobbs believes the de­c­line may be due to greater aware­ness of the PSR watchdog.

The review also highlighted a number of other areas that Medicare Australia and the PSR needed to look at more closely.

It recommended that the sanctions be reviewed to ensure they were actually deterring doctors from re-offending, and that the whole process be sped up to ensure a prompt outcome for doctors.

Most industry members agree that improving the overall efficiency and effectiveness of the PSR process is necessary because, as Dr Capolingua says, “we’re all in this Medicare boat together and we have to row together to work well”.

A GP perspective

VICTORIAN GP Dr Alex Burk says the PSR’s new push to better monitor specialists and allied health is long overdue.

For too long, Dr Burk says, GPs have been an almost solo target of the PSR and Medicare Australia, despite being the one group that has little opportunity to rort the system in the first place.

Because most GPs largely work and bill in much the same way, they are a ‘stronger unit’, and it is more difficult for them to veer from normal practice without attracting attention.

“But with specialists, it is a much more diverse group that doesn’t tie together,” he says.

“I have seen specialists on rounds in hospitals and they see patients for 10 seconds and that is counted as a specialist consultation in a hospital.”