Aniello Iannuzzi: Irresponsible rule

THERE was an interesting comment attached to my last blog comparing firefighters and doctors.

Dr Ian Hargreaves wrote: “Had Dr Iannuzzi treated 100 patients, locals and fireys, in a horribly busy day of burns, breathing difficulties, and eye foreign bodies; he would have automatically been the subject of a disciplinary review by Medicare and the Professional Standards Review Committee. Woe betide him if he failed to maintain comprehensive clinical records. A wound infection when treating while fatigued could lead to a lawsuit, a death certainly to an inquest. A high-speed drive past a speed camera to save a life would guarantee a charge.”

Busy GPs would shudder at this comment, as it brings to mind the dreaded “80/20” rule. On the surface, this rule seems easy enough — see 80 patients per day for more than 20 days per year, and you get investigated under Medicare Australia’s Practitioner Review Program.

However, there are stings in the regulation that many may not realise:

• The number 80 relates to services, not patients. Some patients may require two or three services. For example, if a patient receives a GP Care Plan and a Team Care Plan, it counts as two services. In contrast, a patient receiving a consult, skin flap and excision of three lesions still counts as one service, even though five services have occurred.

• Until last year, for GPs who exceeded the 80 services, referral by Medicare to the Professional Services Review was discretionary. However, amendments made to the regulations late last year make that referral automatic. Our medico-political representatives appeared to roll over and just cop this one.

• As the rule only applies to services Medicare pays for, a GP can bulk bill 60 visits to Medicare and then proceed to perform another 50 cosmetic visits or workers compensation visits not covered by Medicare without raising an eyebrow. There is also no accounting for visits to public patients in public hospitals.

• The rule only applies to GPs and “other medical practitioners”, the latter being non-vocationally registered GPs — that group of doctors Medicare and our professional associations do not want to know (a subject for another blog). In other words, a dermatologist can see 85 patients per day, an ophthalmologist 85 per day, a fracture clinic orthopaedic surgeon 85 per day, and so on for all other specialists and that is fine by Medicare.

• The rule does not consider the length of time of visits. Billing 80 Level A consultations (5 minutes or less) is very different from 80 Level Bs (5–20 minutes), and very different from a day that includes longer and more complex items.

• If a practitioner ventures to offer over 70 services a day too many times, he or she may be “counselled” and other aspects of his or her servicing history may be examined.

• No consideration is given at all to quality, such as the assistance of practice nurses. In many modern GP practices, practice nurses provide great assistance and efficiencies by triaging and assisting with procedures and administrative tasks. For instance, working up a patient with chest pain takes less than half the time if the ECG, BP, pulse, bloods and initial history have already been done by the practice nurse.

Dr Hargreaves cannot be accused of being overly cynical because as I can vouch from personal experience, workforce shortage and times of need can easily push some GPs to over 70 patients per day.

Those of us in rural and remote areas are often in situations where we have to work very long hours and see many patients, and even then to have waiting times running into several weeks for routine visits.

And what about other health professions? Like the solo pharmacist processing 300-plus scripts per day?

Why isn’t Medicare concerned about “quality and safety” in that setting?

The 80/20 rule should be taken for what it is — a blunt, discriminatory tool to intimidate hardworking GPs.

If quality and safety were the real concerns of politicians and Medicare, the 80/20 rule would apply to all health professionals and be better defined.

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

Posted 25 February 2013