Issue 23 / 24 June 2013

MOST Western societies appear to be shifting more and more to reliance on governments to fill roles once played by families, churches and other community associations.

The notion of self-reliance being supplanted by reliance on government is nowhere more apparent than in the health sector. In Australia, the addiction to free medicine grows by the day.

In the effort to keep things free, politicians create ever-multiplying health bureaucracies, which in turn manipulate the normal rules of supply and demand, price, and — sadly — the rules and customs of clinical medicine and referrals. A good example is waiting lists to get onto surgery waiting lists in NSW — something the AMA (NSW) is trying to tackle.

This has led to what is increasingly referred to as “gaming” — where patients are used as pawns in the funding game.

Within the inpatient hospital system, we have for some time seen “coders” taking on a greater importance, as funding is increasingly linked to particular diagnoses.

Pressure is put on doctors — especially junior doctors forced to fill in preliminary patient history sheets — to list every possible diagnosis and procedure, so that more money can be squeezed out of the government. The irony is that it is just a cost-shifting game, as it is one government entity squeezing another.

In private hospitals the same game occurs, with health funds partially replacing government departments as the cash cow.

Sadly, Australian nursing homes are now caught in this same trap as hospital wards — it is all about coding and funding, rather than about the residents.

Rather than being asked about how to treat a patient’s depression, I am now asked about why I do not list it in the health summary so the aged care facility gets more funding.

The 4-hour rule for emergency departments will result in all sorts of “games”. Patients will be re-classified, shifted, renamed and ultimately discriminated against in order for the departments to meet targets and protect funding.

Hospital outpatient clinics and staff specialist clinics are also caught in the web.

Once a doctor could write a referral to such a clinic, the patient would ring to book and be seen soon afterwards. The new pattern is for the clinic to insist on the GP faxing or emailing the referral before the patient is allocated an appointment.

If we are honest with ourselves, the motivations for this are to maximise income, for political expediency and just plain laziness.

The referring doctors are told it is “so that the right patient sees the right doctor” but does anyone really believe that? Why would a referrer want to send a patient to the wrong doctor?

It all appears to be a game to make the numbers work rather than provide timely, quality care to the patient.

And to complete the disaster, the game is now alive and well in general practice.

When a patient moves from one practice to another, it is common for the new practice to be more interested in when the patient last had a care plan and health assessment (attracting MBS primary care items), rather than what is actually wrong with the patient.

As Medicare Locals, large corporations and super clinics play more of a role in general practice, it is likely patients will suffer more discrimination, as they are made to fit within the services provided by “the system” or “the organisation” or “the team”.

Woe betide Mrs Jones if she wants to see a podiatrist, as our Medicare Local only funds diabetic foot checks. Thank goodness for smaller private practices. They may be the last bastion of the doctor–patient relationship before much longer.

Even for a nation that loves to gamble, gaming with our health may be taking it one step too far.

Dr Aniello Iannuzzi is a GP practising in Coonabarabran, NSW.

2 thoughts on “Aniello Iannuzzi: A risky game

  1. Australian Red Cross Blood Service says:

    It is indeed an addiction to free medicine from the community, followed by reactionary funding policies, flowing through to each medical department and each health care provider looking at self preservation in this environment. Take pathology as an example, the rebate of GP requested tests from Medicare is coned to the top 3 requests, all the rest are “coned” – what does it mean by “coned”? – it is not paid for. that is right, the pathologist and the lab did the work for free. how can that even happen? if you ask the surgeons to operate every fifth patient for free, there will be an outrage. If you ask the physicians to have a free clinic every friday, they will say no. so why expect pathologists and laboratories to work for free? isn’t this addiction to free medicine followed by reactionary policied?

    Effort should be made for efficiency of medicine – what the most direct way of diagnosis and treating the patient is. Efficiency should be sought in enable the most appropriate tests done in the cost efficenctly earilest possible time to enable early correct diagnosis. Efficiency should be sought in educating doctors and quality benchmarking doctors so they will diagnose and managemnt rather than requesting tests. Efficiency should be sought in encouraging early referrals as well as streamlining referrals. Efficiency should be sought in managing some doctors ego so they will accept their own limitation in their knowledge and accept and follow expert advice.and stewardship.

  2. John Boyd says:

    ‘Addiction to free medicine’ is a bit perjorative. The big issue is to keep the total national health bill down to a minimum in terms of GDP that can be achieved while providing quality health care that can be accessed by all equally. This outcome can only be achieved through a well run government system, with the government as the sole purchaser and thus able to negotiate with suppliers to minimise costs. Of course the AMA and the big pharmas have fought this concept consistently. Obviously the current system in Australia is not perfect, but to argue that a greater reliance on the private sector is the answer is just rubbish. If you feel that you must have private health insurance to ensure access to quality care, then it is in effect a tax; and a very inefficient tax. Look at the USA. Total health care cost is close to 20% of GDP, with overall outcomes worse than many ‘third world’ countries.

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