Pay VAD providers appropriately or lose them

MEDICAL practitioners are urging the federal government to re-evaluate the current funding model for voluntary assisted dying (VAD) or risk a shortage of willing providers.

A Perspective published in the MJA highlights that there are no Medicare Benefits Schedule (MBS) item numbers dedicated to VAD. Conversely, euthanasia is flagged as a procedure that won’t attract benefits.

The MBS general explanatory notes (GN.13.33) state that “euthanasia and any service directly related to the procedure” will not attract Medicare benefits but note that “services rendered for counselling/assessment about euthanasia will attract benefits”, the authors wrote MJA.

The Department of Health confirmed to InSight+:

“While there are no specific items on the MBS for VAD, existing items, such as the GP time-tiered general attendance items, including home visit items, can be used for end-of-life care and planning, which can include counselling or assessment in relation to voluntary assisted dying. The longest of these GP items (level D) is for attendances with patients of 40 minutes or more.”

The lack of funding for VAD

However, one of the authors of the Perspective and Western Australia Chief Medical Officer Dr Simon Towler told InSight+ that this isn’t enough.

“GPs are the largest group [of VAD providers],” he said.

“And for them, taking the time which is required … to assist a person, particularly with the administration phase (and in the end, that’s what we’re largely talking about) is actually many hours. And if you have to leave your general practice to do that [it] means you’re not making money through your normal work,” he explained.

For specialists, there’s even less funding.

“The other thing to remember is that a whole lot of VAD occurs in people’s homes. If you are like myself, an intensive care practitioner, there is no number for me to charge for a service at home because Medicare does not conceive of an intensive care doctor providing a service in somebody’s home,” Dr Towler said.

According to the Perspective article, the time commitment to the VAD process can be onerous.

“Owing to the rigorous nature of the process, the time commitment by medical practitioners who support patients through the VAD process is considerable,” the authors wrote.

“This is particularly so for the coordinating practitioner who assumes primary responsibility for the patient during the VAD process, which based on [Simon Towler’s] experience, typically requires 6–8 hours of commitment, all of which will be unremunerated (unless privately billed),” they wrote.

How VAD funding could look

Community support for VAD is growing. Laws have now been passed in the six states and just last week, the Senate voted to repeal a 25-year-old law to allow the Australian Capital Territory and the Northern Territory to make laws on VAD.

There is also support overseas for a different funding model. New Zealand last year launched a specific VAD funding model, which supports medical practitioners and the steps they need to take in the process.

“For example, the additional payment for clinical notes, a payment for a complex case of NZ$483, a standard payment for managing the application where they actually recognise that it may take up to three hours to take a patient through the process, a payment of $724. These numbers are hugely different to anything that’s currently available under the standard MBS,” Dr Towler told InSight+.

According to the Department of Health, there are already around 6000 MBS item numbers which creates a significant workload for medical practices.

“Adding thousands more condition-specific MBS consultation items (eg, a consultation for VAD, a consultation for a patient with cancer, a consultation for a patient with asbestosis and so on) would create unmanageable red tape for practices, particularly GP practices, when non-condition-specific time-tiered general attendance items can be used in most situations to provide rebates for clinically-relevant services,” the Department spokesperson said.

Dr Towler believes in this instance, there does need to be a clinically relevant MBS item number.

“If you look at the schedule of payments in New Zealand, it absolutely acknowledges that the times required to do the important things, of providing respectfully, and spending the time with a VAD applicant and, potentially, with their family … are very different to the routine, appointment structures that are available for GPs in particular,” he said.

Private billing for VAD

The MJA authors highlighted that although private billing is an option for VAD practitioners, not many opt to.

“While it is open for doctors to privately bill their patients for this service, medical practitioners have indicated reluctance to do so, expressing the view that this would be insensitive,” the authors wrote.

According to Dr Towler, there are other issues with privately billing VAD.

“There is an equity issue if you end up having to do that … There is a conversation around VAD that it’s all about wealthy Western, middle class men. I can assure you if you look at the VAD report from Western Australia for the first 12 months, that is not the profile. Extremely disadvantaged people have accessed VAD.

“Most of the events in WA have been done pro bono. For people like myself, for whom there is absolutely no suitable Medicare number, I have been providing many hours of my personal time with patients completely unremunerated, because the [MBS] not only doesn’t acknowledge the effort, it doesn’t have an approach which recognises any registered currently practising health practitioner should be able to provide this service,” Dr Towler said.

The Perspective authors fear the underpayment will disincentivise practitioners from offering VAD services.

“One of the problems is having sufficient active practitioners,” said Dr Towler.

“This is not an easy activity for practitioners, the ones who do it feel a deep commitment to the process. It is a voluntary process and the provisions in all jurisdictions are that people need to be already dying from their condition, and already suffering in a way they feel unacceptable.

“So to leave practitioners dealing with these fee challenges, with no reasonable remuneration seems completely unreasonable.”

Caitlin Wright is a Sydney-based freelance journalist and 2022 Copywriter of the Year who writes for communities and organisations that care for others.

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