FROM 1 March 2019, the government has changed the Medicare rebates for GP visits to residential aged care facilities (RACFs), which most of us know as nursing homes. The government has pledged $98 million over 4 years to “fund increased payments to GPs to attend RACFs … This recognises the important role of GPs in supporting the health and care of patients in residential aged care”.
This decision is in response to what the government perceives to be a lack of engagement by GPs in nursing homes.
Given that we live in a time of rebate freezes (perhaps there is a mini-thaw at present) and Medicare Benefits Schedule (MBS) review, it seems extraordinary that the government is pitching what it calls an “increase” in the rebates.
This is not the first time. In 2007, before Kevin Rudd’s landslide election win, there was a substantial increase in the rebate for RACF visits. Not long after that, an Aged Care Access Incentive (ACAI) was introduced to further incentivise GPs to visit nursing homes.
It all begs the question: why do most GPs not bother with nursing home visits in the first place?
Let’s not beat around the bush. If visiting a patient in a nursing home paid as much as a facelift, a botulinum toxin session or a robotic prostatectomy, I’d not be writing this article.
The new Medicare items feature a flag-fall fee of $55 to most GPs for every new visit to an RACF. This applies for every new visit, so if one gets called to a nursing home four times in a day, four call-out fees of $55 can be charged. This is to compensate for the travel time and disruption of each call.
Let’s analyse what this means for a standard visit of 5–20 minutes by a vocationally registered GP.
|Number of patients seen||Old cumulative amount||New cumulative fee with $55 flag-fall||Difference|
One may see this is a stroke of actuarial genius: a small reward for those not so busy, a good reward for those who see a good number of patients, and a punishment for those who overservice.
However, I see it as nothing but window dressing. At a time when the Medicare rebate for standard consults is lagging about $45 behind what it should be (comparing the Medicare scheduled fee to the Australian Medical Association fee of $81), suggesting that the above increases are an incentive is delusional.
Let’s be clear. A GP sees five patients on a visit and is $7.50 in front, a grand total of $1.50 per patient.
And what makes all this much worse is that it is sold to us as an increase. To see why I make such an allegation, let’s look at the ACAI payments:
Practice Incentives Program (PIP) GP ACAI payments and requirements
|Tier||Qualifying Service Level (QSL)||Service Incentive Payment (SIP)|
|Tier 1||60 services per year||$1500|
|Tier 2||140 services per year||$3500|
According to the Medicare website:
“The PIP GP ACAI payments are based on a GP providing a required number of eligible MBS services in RACFs in a financial year. The PIP GP ACAI has 2 payment tiers.”
The GPs who access this payment have to wait for a quarterly payment, but it rewards those who consistently visit nursing homes to the tune of $25 per consultation.
What many have not realised is that the ACAI is about to be removed under forthcoming changes to the PIP. Therefore, the GPs who have been reliably visiting RACFs are in fact going to be significantly disadvantaged.
Another money problem with nursing homes is that GPs find it very hard, if not impossible, to charge private fees. This is a combination of the nature of the patient, the administrative difficulties in issuing invoices and chasing payment, and general attitude in the industry and community that one should bulk bill nursing home patients.
The other major frustration is time.
The reasons why visits to nursing homes are so time taxing include:
- it takes time to get to the nursing home;
- it takes time to find the nurse in charge (if you can find the nurse);
- it takes time to get the patient into a private situation do to a consultation;
- it takes time to take a history and examine the frail and elderly;
- it takes time to have to write both a script and a medication chart;
- it takes time to have to write notes both for the nursing home and for one’s own surgery notes;
- it takes time to field inquiries from pharmacists who often want to have scripts ahead of time for the medication packs;
- it takes time to make specialist appointments; and
- it takes time to transport patients to specialists and allied health professionals.
In 2019, everyone is busy and time-poor. All the factors above – and the list is far from exhaustive – mean that most doctors simply throw their hands in the air and do not bother with nursing homes.
While not as bad as having patients on a ward or being on-call for a hospital, having nursing home patients is disruptive. The calls and messages interrupt the flow of the office day and personal time after hours.
Other frustrations GPs face at nursing homes were outlined in my recent article on the Aged Care Royal Commission.
Therefore, I remain sceptical about the “government improvements” to RACF Medicare rebates.
In fact, for the reasons outlined above, I think they are a failure.
Dr Aniello Iannuzzi, FACRRM, FRACGP, FARGP, FAICD, is a GP practising in Coonabarabran, NSW, and a clinical associate professor at the University of Sydney.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.