Scott Masters: Medicare needs an audit

THE current “bipolar” attitude in the federal health department towards managing complex patients in general practice was highlighted in a recent MJA article.

The authors discussed the worrying trend of declining long consultations in general practice that has occurred in tandem with a 400% increase in the number of audits performed by Medicare.

This is occurring despite the federal Health Minister Nicola Roxon indicating a preference for GPs to spend more time with patients to deal with multiple health problems and provide valuable preventive care.

“Audit anxiety” has been postulated to be responsible for around one million fewer long consultations between September 2008 and February 2009 compared with the same period in 2007–2008.

The decline in long consultations and a rise in brief level A consultations has not been offset by the use of special MBS item numbers, such as for health assessments and care plans.

For people with complex health needs, this is very bad news.

It would seem that Medicare and the Professional Services Review (PSR) have created a climate of confusion and mistrust on the frontlines of primary practice.

A 2009 survey of GPs showed more than 90% did not have confidence that the Medicare auditing and compliance process provided natural justice.

A further 80% did not feel certain they would pass a compliance audit on the use of enhanced primary care (EPC) item numbers.

Combine this with the recent proclamations from the PSR over issues such as pathology ordering, CT scan requests and Medicare dental item numbers and it is no wonder that many GPs feel confused, exposed and are considering early retirement.

Now would be a perfect opportunity for some rationalisation of the MBS and the PSR.

We need both schemes operating well to optimise health care in this country.

Some pragmatic suggestions for improvement include:

• A dedicated response line for GPs who have queries regarding interpretation of the MBS. There are multiple phone and email inquiry lines available but reliable quick responses are rare.

• A PSR that sticks to its role of policing correct use of the MBS instead of commenting on clinical practice, as it has recently with regard to antibiotic and opioid prescribing, pathology requests and CT ordering. Unilateral proclamations that there is over-prescribing and over-ordering of investigations undermines patient confidence and frustrates doctors trying to do their best in often difficult clinical circumstances.

• Spreading audits to all Medicare providers not just GPs. For example, specialists are responsible for more than 50% of Medicare expenditure yet account for less than 5% of referrals to the PSR.

• Increased transparency in the Medicare audit process, with more debate about the assumptions used in the audit process, especially that all GPs are the same.

• Improved transparency of the PSR referral process. Medical defence organisations consider the current process unpredictable.

• Procedural fairness — currently there is no practical appeal mechanism.

• Individual determinations from Medicare/PSR for doctors who are not sure if they are practising appropriately. The Australian Taxation Office provides this service for taxpayers so it would be reasonable to expect Medicare/PSR to do the same, as penalties for failure are severe.

Increased co-operation by Medicare/PSR with doctors and their professional bodies will benefit the community and lead to an improved health system.

This needs to happen immediately so doctors can treat patients with the most complex health problems without the constant threat of an audit.

Dr Scott Masters is a GP in Caloundra, Queensland, and was subject to a Medicare audit.

Posted 29 November 2010