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MEDICARE rebates for addiction medicine specialists are so low that they make quality practice unviable and threaten the existence of the new medical specialty, experts say.
Of Australia’s 169 addiction medicine specialists, only eight have registered with Medicare since the specialty was given access to Medicare Benefits Schedule (MBS) item numbers 104 and 105 (group A3) in November last year.
Instead, addiction medicine specialists claim through item numbers attached to their base specialty, commonly general practice or psychiatry.
Under the addiction medicine item numbers, specialists receive $70 for an initial referred consultation plus $35 for a follow-up at 85% of the MBS rebate. The item numbers are also used by other specialists such as surgeons and dermatologists; however, these specialists are able to supplement their income with procedural rebates.
Dr Richard Hallinan, a Sydney addiction specialist at the Byrne Surgery, Redfern, said that the current Medicare rebates only allowed for “6-minute medicine”. He said most patients with addictions do not have the means to pay private gap payments.
“Addiction medicine specialists don’t dare register with Medicare because it would dramatically reduce the rebates available to their patients”, said Dr Hallinan, who has written a Comment article for this week’s MJA InSight. (1)
“The irony is that the Department of Health has simultaneously recognised and strangled a new specialty.”
In a complementary comment article in MJA InSight, GP and addiction specialist Dr Simon Holliday said with 20% of GP consultations involving chronic pain but few GPs receiving specific training, prescribing of opioids had become a frequent dilemma with increased rates of harmful use. (2)
Dr Alex Wodak, director of the alcohol and drug service at St Vincent’s Hospital, Sydney, said addictions were chronic, complex problems requiring thorough, time-consuming consultations.
“Seeing patients once for a pontifical assessment and then seeing them for a few minutes at a time every 3 months just doesn’t work … many of these people do get better but it’s a matter of building a strong therapeutic relationship”, he said.
Dr Wodak said the poor remuneration placed “the evolving specialty at risk”, with only about 10 current trainees nationally.
He said because the specialty “doesn’t appeal to many doctors” and the rate of remuneration is less than that of GPs, “we’ll end up with a flood of people leaving the field and no new recruits”.
The poor remuneration was stifling the development of the private addiction treatment sector, funnelling patients into the overstretched public sector. This limited the referral options for GPs, who were often left to deal with difficult addiction cases without additional training.
He said he wanted to see the development of proper referral pathways as those that exist for other health problems such as heart disease and diabetes.
Along with other addiction medicine specialists, Dr Wodak has been working with the Department of Health for the past 2 years to try to improve the remuneration system.
“We’ve been going through this tortuous process of getting an answer to this question of remuneration and it just hasn’t been fair. Simple as that. We start negotiating, start discussing but by the next meeting the goalposts have changed”, he said.
A spokeswoman for the Department of Health and Ageing acknowledged that addiction specialists perceived that the group A3 item numbers did not reflect the time they needed to spend with patients.
She said a proposal for time-tiered specialist consultation items for addiction medicine specialists was currently being considered by the Medical Services Advisory Committee, but an exact timeline for this process to be finalised was not possible.
Addiction specialists are calling for time- and complexity-based item numbers, similar to those offered to GPs and psychiatrists.
“We’re not looking for, dare I say it, plastic surgery-type incomes. We’re looking for incomes that will attract people and allow for the practise of quality medicine”, Dr Wodak said.
“What I want is for every family in Australia that has a member with a serious alcohol or drug problem to be able to get quality help so that person has a chance to get better.”
– Sophie McNamara
1. MJA InSight 31 October 2011
2. MJA InSight 31 October 2011
Posted 31 October 2011
I was the medical officer for the ACT Remand Centre for 7 years, now some time ago. There was a lot of addiction medicine practised there. Drug dependent persons are difficult to deal with, let alone treat. They arrive with their own agendas, essentially they want a continuing supply of narcotic – few questions asked. There are doctors who make a good living from ‘addiction medicine’. Provide a script, twice a month, no questions asked. Some GPs ‘managing cases’ in this way would even claim they are doing their patients and the community a service. No crime, much less risk of Hep B, C, and HIV. And they experience much less stress than those doctors who – for half the income – genuinely attempt to ‘manage’ addiction.
As a GP for over 45 years, I know very well the problems with treating patients with addiction. Most of the time , the treatment is unsatisfactory and does not address the total treatment program needed to help these addicts.
I applaud the newly trained Addiction Medicine specialists who are able to manage these problems professionally.
Medicare should recognise their skills and their contribution to healthcare and pay them the appropiate specialist rates they deserve.
Addiction medicine specialist are invaluable members to any team dealing with complex health issues. They have the ability to communicate with this difficult patient group and have a rational scientific basis to their speciality and a whole range of evidenced-based approach to management which works. The model is one of biopsychosocial approach to essentially a complex neurobiological disease. As such, their renumeration should be similar to specialist practising palliative care or pain medicine. Items 104 and 105 are designed for surgical (& others) where a straight forward surgical diagnosis suffice and even those renumeration is inadequate as some patients are indeed complex and requiring a psychosocial approach. I wholeheartedly support the Addiction specialist in their quest for more equitable renumeration.
There are also a considerable number of physicians who have sub-specialised in Addiction Medicine. As director of a major teaching hospital addiction medicine unit, I teach addiction medicine to medical students who are interested in the specialty, but cannot be recruited because of the impasse on Medicare rebate. This debate has been going on for too long, and has been far too slow to resolve. Every time there is a step forward it is followed by a Medicare reneg. We are getting impatient with bureacracy.