Our new Medicare Billing Compliance online learning module

Medicare billing errors and healthcare fraud are significant factors in the cost of the Australian health care system. Irrespective of different payment models, challenges exist at the interface of medical billing and medical practice across the system. Inappropriate Medicare billing resulted in $29 million of debts against doctors and healthcare providers last year, which led to reputation and legal penalties.

From 1 July 2018, the Professional Services Review Committee was empowered to make findings of inappropriate practice against persons or officers of body corporates who employ “or otherwise engage” doctors. This includes practice owners and officers of corporate practices. The consequences of a provider found guilty of inappropriate practices can lead to the repayment of the whole or part of the Medicare benefits paid for a service. Practices, hospitals and others with administrative responsibility for the submission of documents to Medicare should ensure documents are not inaccurate or misleading. Those with a responsibility for the direction of more junior providers such as supervisors, practice principals and senior hospital administrators should ensure their directions to junior providers are appropriate. Doctors are responsible for unsubstantiated claims regardless of who does the billing or receives the benefit.

Medical billing education is an effective measure to improve compliance, reduce incorrect claiming and improve programme integrity of health systems. doctorportal Learning has launched a new Medicare Billing Compliance accredited self-paced online learning module where you can gain critical insights on compliance regulations and legislation, procedures and record keeping obligations that helps you be responsible and remain compliant. Offered for free by the Australian Government Department of Health, there are six key topics addressing information on the role of compliance in the Medicare system, relevant regulations and legislation, obligations with regards to claiming under Medicare, and processes and procedures should payments be non-compliant after a compliance activity. CPD points are awarded following completion of the module. Click here and get started.

Your Learning is closer than you think! Sign-up or login now to view our latest learning opportunities and start your medical learning from anywhere, anytime. For more information please email our friendly member services team on: memberservices@ama.com.au

Be better prepared to respond to disclosures of intimate partner violence

BY VICTORIA COOK, VICE PRESIDENT, AUSTRALIAN MEDICAL STUDENTS’ ASSOCIATION

This year, like the ones before it, Australia has been shocked by stories of horrific violence against women reported in the media. Yet for every story that is reported, many go unmentioned. Women die by violence in Australia at a rate of more than one per week. The organisation Destroy the Joint which ‘counts dead women’ holds this year’s total at 47 women killed in Australia by September 14. There are another 13 weeks left in 2018, meaning we can expect that at least 13 more Australian women will be killed by the end of this year alone.

We know that healthcare professionals are often first responders in disclosures of domestic violence. Health professionals are the second most commonly sought source of support for women experiencing domestic violence, after family and friends. Of women experiencing domestic violence, 30 per cent will seek advice from a general practitioner and 20 per cent from another health professional. On average, eight women are hospitalised each day due to intimate partner violence, and the rate is rising. The person that a woman reaches out to, to disclose violence at home, will likely be one of us. Yet, medical students don’t feel as if medical school adequately prepares them to respond to disclosures of intimate partner violence.

Medical student representatives across Australia recently unanimously endorsed a position calling for improved access to education and training around intimate partner violence. In 2015, a study showed that the median time spent on intimate partner violence in Australian medical schools, across all years of the curriculum, was only two hours¹. One can only assume that access to education in this area after medical school is less again. Intimate partner violence is the greatest contributor to mortality and morbidity among women aged 18 to 44 in Australia. It outranks smoking, illicit drugs, and obesity. Yet the burden of illness is not reflected in the time dedicated in medical curricula or training.

Intimate partner violence is a complex and distressing topic, making it hard to teach but even more difficult for professionals to respond to without adequate training. Students must be taught to recognise intimate partner violence, assess risk, document disclosures, record evidence and understand legal implications. Medical practitioners are under-prepared to respond appropriately, which risks reinforcing women’s feelings of powerlessness and violation. This is a whole society issue, and action is needed not only from medical schools, but from medical training colleges, health services, Governments (Federal, State and Territory), and individual practitioners and students. When a woman reaches out she must find someone who is equipped to help. As future doctors we know we will be faced with disclosures, and when we are, we want to be prepared.

In the wake of the tragic death of Eurydice Dixon, students and young women reckoned with an awful paradox; despite entreaties to be safe and stay home, they often aren’t safer at home at all. One medical student told me she began university in Melbourne when Jill Meagher was murdered, and is graduating as Eurydice Dixon was killed. These seemingly random acts of violence remind us to fear what we do not know, whilst distracting us from the facts we do; most women who die by violence will be killed by a man that they know. Our medical education must prepare us to help prevent that.

References

Valpied J, Aprico K, Clewett J, Hegarty K. Are future doctors taught to respond to intimate partner violence? A study of Australian medical schools. Journal of interpersonal violence. 2017;32(16):2419-32.

Study suggests ways to cut bowel cancer numbers

Healthier lifestyles could reduce the incidence of bowel cancer in Australia by 45,000 over the next decade.

Newly published research that pooled data from seven cohort Australian studies, involving almost 370,000 people aged 18 and over, has found that a large portion of bowel cancers are preventable through the adoption better lifestyle choice.

The study by researchers from UNSW’s Centre for Big Data Research in Health has found that current rates of smoking, obesity and excessive alcohol consumption could lead to 45,000 cases of bowel cancer over the next 10 years.

The results, first published in JNCI Cancer Spectrum, have implications for public health education, promotion and policy.

UNSW Associate Professor Claire Vajdic said the researchers examined the factors causally associated with developing bowel cancer and their current distribution in the Australian population.

They found that 11 per cent of the future bowel cancer burden can be attributed to ever-smoking, and four per cent to current smoking.

Overweight or obesity was responsible for 11 per cent of cases, and excessive alcohol consumption contributed six per cent of the burden.

“We then explored what this means for the future bowel cancer burden in Australia, and where we should be targeting our health promotion efforts,” Prof Vajdic said.

“Combined, these factors will be responsible for one in four future bowel cancers – even more so for men – 37 per cent of bowel cancers – than women – 13 per cent.

“If people changed their behaviours accordingly, a large proportion of this future burden could be avoided.”

The study is the first to identify subgroups within the population with the highest burden.

The patterns were due to differences in both the prevalence of these lifestyles – both factors are more common in men – and the strength of the association between the lifestyle factors and bowel cancer risk.

“We found that more bowel cancers were caused by overweight or obesity and excessive alcohol consumption in men than in women,” Prof Vajdic said.

“Hormones and differences in body fat distribution, particularly excessive fat around the stomach, likely contribute to the higher body fatness-related risk in men. We also know that men drink more alcohol than women, which increases their bowel cancer risk.”

The researchers also found an interesting interplay between smoking and alcohol: the bowel cancer burden attributable to smoking was significantly exacerbated by excessive alcohol consumption, and vice-versa.

This means that the future bowel cancer burden would be markedly lower if current and former smokers did not drink excessive alcohol. The study results have important public health implications.

The findings can inform both general and targeted education, public policy, health literacy and health promotion campaigns aimed at reducing cancer incidence and maximising early detection.

Prof Vajdic said the results suggest education efforts may need to be especially directed towards current and former smokers, given their increased burden.

The results can also be translated into a number of health recommendations.

“We know that smokers are less likely to participate in our National Bowel Cancer Screening Program, so they are a particularly vulnerable group,” she said.

“Our findings make a case to support everybody – but men in particular – to achieve and maintain a healthy weight to prevent bowel cancer.”

The current Australian recommendations for healthy living are to not smoke, to do at least 150 minutes of moderate or 75 minutes of vigorous physical exercise per week, to maintain a healthy weight (BMI 18.5 – 25 kg/m2), to drink fewer than two alcoholic drinks per day, to not eat more than 65 grams of red meat per day, and to keep processed meat consumption to a minimum.

Research collaborator and Cancer Voices South Australia representative, Julie Marker, has survived bowel cancer three times over the past 17 years.

“Any action you can take to prevent or detect bowel cancer early might save you from the battle I’ve had,” she says.

“I’d encourage men and women – but especially men – to adopt a healthy lifestyle and participate in bowel cancer screening to reduce their risk. GPs and other health professionals should target prevention and screening advice to their patients, using insights from this research.”

Inquiry into sleep health awareness

The House of Representatives Standing Committee on Health, Aged Care and Sport has commenced an Inquiry into Sleep Health Awareness in Australia.

It has been estimated that about 7.4 million Australians do not get enough sleep.

Inadequate sleep can impact on a person’s health and wellbeing, and may also lead to a loss of workforce productivity. Deloitte Access Economics assessed the health system costs associated with inadequate sleep to be about $1.8 billion in 2016-17.

Committee chair Trent Zimmerman MP said: “The Committee will examine the causes, economic and social costs, and treatment of inadequate sleep and sleep disorders – in addition to education and training available to medical professionals regarding sleep health issues, and current research into sleep health.

“The Committee will also consider workplace awareness of inadequate sleep and sleep disorders, particularly for shift workers.”

Submissions from interested individuals and organisations are invited by Thursday October 18, 2018. The preferred method of receiving submissions is by electronic format lodged online at the My Parliament website.

Further information about the Committee’s inquiry, including the full terms of reference and details on how to lodge a submission are available on the Committee’s website https://www.aph.gov.au/SleepHealth.

Learn about the 1 July 2018 MBS changes

INFORMATION FOR MEMBERS

The AMA has added the July 1 Medicare Benefits Schedule (MBS) changes to its health professional education resources.

We have updated our Indigenous and MBS eLearning and education guides with the July 1 MBS changes. These education resources help you work out claiming and billing MBS item numbers.

We also have education resources about:

the Australian Immunisation Register
the Child Dental Benefits Schedule
the Department of Veterans’ Affairs
incentives programs
digital claiming
PRODA (Provider Digital Access)
HPOS (Health Professional Online Services)
Pharmaceutical Benefits Scheme (PBS)

Our eLearning programs are comprehensive, using case studies to show you how to apply the information. Check out the changes and updated education resources (humanservices.gov.au/organisations/health-professionals/subjects/education-services-health-professionals) today.

Next steps

Explore the education services for health professionals (humanservices.gov.au/organisations/health-professionals/subjects/education-services-health-professionals)
Read more News for health professionals (humanservices.gov.au/organisations/health-professionals/news/all)
Subscribe to News for health professionals (humanservices.gov.au/organisations/health-professionals/news/all) and get regular updates directly to your inbox.

The profession must help solve the egregious fees problem

BY AMA VICE PRESIDENT DR CHRIS ZAPPALA

This issue will not go away.

The shrill voices of opposition and those zealously defending their own turf (by blaming doctors) will only get more stentorian and insistent. The health funds, all hatching plans for managed care, are desperately trying to preserve their $1.8 billion profit. The politicians want to claim victory in increasing bulk billing rates without having to pay as much as they should either. The Government must be delighted with the emerging public expectation that bulk billing is a fair price for medical care – it is lamentable that we have not been more effective at changing this view. Our medico-political strategy perhaps needs to change here…

Dr Linda Swan, Chief Medical Officer for Medibank, recently made the point in The Australian that cost is not an indicator of quality (in health care). This is not true though, is it? While high fees might not always correlate with high quality (but absolutely can correlate), you can be fairly certain that low cost will always put quality in jeopardy. The saying ‘cheap and nasty’ has real meaning. If Government designs a budget, no frills, ‘free’ healthcare system it will necessarily produce a budget health outcome – as occurs in everything else in life. We have no problem generally accepting this truth and moreover, paying for quality when we perceive it elsewhere – the same should also apply for health care.

The extension of this observation is that we should not be ashamed to value ourselves properly. We work long hours, get woken in the middle of the night to come into work, accept significant responsibility and continuing education (which is costly), and so on… While in theory we can charge whatever we want – as can any other professional, business, sole proprietor etc – it does not mean we can obfuscate when it comes to explaining our fees. Patients should always have a choice not to proceed and an appropriate ability to ask questions. Regretfully, this does not always occur and I do not think anyone really regards this as appropriate.

There are three points that need to be underlined in this discussion and that we must find a way to have Government and our patients clearly understand.

If we keep wanting a bargain basement health service (i.e. bulk billing) we must expect quality cannot be achieved in all circumstances.
Bulk billing and health insurance rebates are not designed with the true costs of medicine – rather, funders wish to pay the least they can to preserve profits or for Government to spend money on something else (it really would be refreshing if Government and the health funds cracked open the AMA fees list and took heed).
You get what you pay (or don’t pay) for.

Having said all of this, there are some doctors’ fees that do seem excessive, i.e. many times above the AMA fees (which have kept pace with inflation over time and better represent fair value and the cost of practice). Quite clearly, we need to be honest with patients about the full costs of their care before it happens when they still have time to opt out and ask questions. The huge majority of the profession agree that booking/administrative fees are not appropriate. Even if we were wavering on this issue, we must realise that patients (plus Government and funders) are going to be increasingly derisive of this practice. Let’s please deal with all of this now in our own way rather than have to endure an imposed solution from one of the funders who remain conflicted by their desire to pay as little as possible.

There are four initial solutions that we, the profession, should consider implementing immediately.

Administrative/booking fees must go. Bill honestly and up front.
Obtain informed and signed financial consent from all patients (if you cannot give an exact price give a reasonable range and stick to it).
Allow an appropriate ‘cooling off’ period for the patient to consider options and opt out if they desire.
Let’s develop a definition of what is unequivocally ‘egregious’ billing and develop a credible strategy of how we deal with this.

Health funds and Government are going to define their own version of what is appropriate or not, so the profession should take the lead. We must preserve a system that rewards increased effort or superior skill, otherwise everyone just regresses to the mean where there is no incentive to do anything other than the bare minimum. We cannot strike this happy medium that preserves ‘fee for service’ medicine if the few outliers do not realise the harm they are doing to us all.

Collaboration, not competition

BY DR RICHARD KIDD, CHAIR, AMA COUNCIL OF GENERAL PRACTICE

Team work in providing comprehensive and quality patient care is not a new concept. Within the medical profession, we recognise our professional limitations and operate only within our scope of practice. When needed, we seek the opinion, or skills and expertise of other colleagues.

With an aging population and the rising incidence of chronic disease adding to the complexity of patient care, there is an enhanced focus on the role and importance of well-coordinated multidisciplinary health care teams. However, it is critical that these teams work effectively. Mutual respect for the skills and expertise of team members is fundamental, with each making their contribution within their scope of practice to meet the health care needs of the patient.

We all know the dangers to our patients of poorly coordinated, fragmented care. We also know that best practice care starts with the right assessment and diagnosis by a medical practitioner and, in the case of general practice, a longitudinal relationship with the patient. Despite this, we see ceaseless ambition of some pharmacist groups for prescribing rights and a greater role in the provision of health services, such as preventative health, disease screening and detection and chronic disease management.

For a GP, the community pharmacist, who is responsible for the dispensing and supply of medications, provides an important and complementary role in the delivery of quality patient care. Pharmacists are vital to the safe provision and use of medicines. They provide assurance that correct dosages are dispensed and that patients understand when and how to take their medications.

The AMA places a high value on the professional role of pharmacists working with medical practitioners and patients to: ensure medication adherence; improve medication management; and provide education about patient safety.

The AMA fully supports pharmacists undertaking roles within their scope of practices to support patient health care. But the community needs a clear understanding of how the core education and training differentiates medical practitioner and pharmacist scopes of practice.

Taking comprehensive histories, undertaking examinations, determining appropriate diagnostic investigations, making a diagnosis, and managing and treating a patient are the domain of the medical profession because that is what we, not pharmacists, are trained to do.

Certainly, the AMA recognises the benefits of integrating non-dispensing pharmacists into general practice to provide enhanced patient care. That is why we worked with the Pharmaceutical Society of Australia in developing such a plan that now, through the incoming Workforce Incentive Program, will see GPs and pharmacists supported to work even more collaboratively in the best interest of patients. With medical oversight, the current role of pharmacists may well expand to support a greater role in the provision of more holistic patient care. Patient wellbeing, after all, is a fundamental tenet of both our professions’ codes of ethics.

What we don’t want to see is patient care further fragmented, services duplicated, and access to the right care delayed. This simply causes undue costs to the health system and poor health outcomes for patients. What GPs and pharmacists should do is continue to work together respectfully, acknowledging the different skills and expertise we bring to the team for the patient. Our patients deserve collaboration, not competition, and policy makers must continue to avoid simplistic ideas that are driven by commercial needs and not good patient care.

Increasing the length of internship – what will we actually achieve?

BY DR CHRIS WILSON, CO-DEPUTY CHAIR AMA COUNCIL OF DOCTORS IN TRAINING

In 2015, a COAG review of Australian Medical Intern Training was completed. The intent of the review was to look at the internship model and assess if internship was producing “fit for purpose” clinicians. As part of the review, four models for change were proposed. Model A, the least revolutionary with no significant change to the structure but increased access to non-traditional settings including general practice, was the most preferred by doctors in training. Model B proposed shifting from a time-based internship to one focussed on specific mandatory skills and exposure to the “patient journey” and “different care contexts”. Models C and D were more revolutionary, with a proposed two year program either starting in the final university year or covering the first two postgraduate years.

As mentioned, the opinion of the AMA CDT and DiTs across the country at the time of the review was that, while there is always room for improvement, internship is not broken. Despite this, after the release of a COAG Health Council response to the review in July this year, we look to be pressing towards the two year model.

In a postgraduate world, internship commencing during university would be unworkable for obvious reasons, so the current preferred model is an internship covering PGY1 and 2.

While on the surface this looks like significant change, what does the second year actually achieve? There is agreement that general registration should be granted after successfully completing the first year, as it is now, so no change on the registration front. If it comes with increased opportunities for exposure to patients across the health spectrum and more structured learning, this will be to the advantage of doctors in training, the healthcare system and in the long run, our patients. It’s not clear though how this would be distinguishable from the current roles undertaken by PGY2 doctors. Changing the role title to ‘intern’ does not automatically reduce the service requirements and increase the educational value of rotations – someone still has to write the discharge summaries.

One potential benefit would be an expectation that all rotations are accredited as suitable training environments by a Medical Board delegate (like the Post Graduate Medical Councils). Thankfully, this already happens in most jurisdictions, however, there is a danger that without additional resources, regions where it is not standard to accredit beyond PGY1 could see their accreditation processes watered down to meet demand. Currently, the federal body responsible for the coordination of State/Territory-based accreditation bodies, the Confederation of Postgraduate Medical Education Councils, remains unfunded. It seems absurd for the Government to push for change in the makeup of internship yet not fund the body responsible for enacting it.

Should we move to a two year model, we would also expect doctors in training be able to obtain job surety over the period of internship in the form of a minimum two year contract. This would be a sign of good faith from employing health services that they intend to train and support their doctors in training during this transition period.

AMA CDT’s position in 2015 was that internship is not broken and that position remains unchanged. Without tackling the creep of increasing service need forcing education and training to become ancillary components of internship, it’s hard to see a second year bringing with it much improvement.

Summit emphasises need for national medical workforce strategy

By AMA VICE PRESIDENT DR CHRIS ZAPPALA

The Medical Workforce and Training Summit convened by the AMA in March, the first since 2010, is notable. The Summit drove home the importance of ending the expansion of medical schools, finding strategies to address workforce maldistribution and ending the poor coordination between the Commonwealth and State governments when it comes to workforce planning and training. If we are to preserve the public-private balance in medicine with a focus on quality, then we need to help Government solve this problem. It’s vital that the Summit’s call for a national medical workforce strategy overseen by the nation’s health ministers will be heeded.

Australia is now becoming saturated with doctors, as emphasised by recent workforce data. AIHW projects that there will be an oversupply of at least 5,000 doctors in 2020 (I suspect this is under-estimated). The prospect of organising vocational training for all these graduates is daunting and as we are currently finding, not really feasible. Some Colleges are training record numbers of trainees with, it appears, no real sense of what all of these specialists are going to do.

Everyone must make a living somehow, so this is when we see fringe medical practices emerge and the enervating effects of bulkbilling become prominent. The obstetricians provide a worsening example of this problem. Ultimately high quality, ‘fee-for-service’ medicine is in jeopardy and we set the stage for an indentured medical workforce trapped in managed care practices without independent decision-making, public practice (which will always be underfunded) or doing something else.

A 2015 OECD study showed that Australia has the highest medical graduate rate per capita with 3.4 per 1000, compared to New Zealand and the United Kingdom (2.8 per 1000) and the United States and Canada (2.6 per 1000), with Australian medical graduate numbers more than doubling in the past decade. We will graduate just under 4,000 new doctors in 2018 and this number will increase as Curtin and Macquarie Universities come online with increased Commonwealth places over the next couple of years. Unemployment looms……

It is estimated there will be 118,803 doctors registered in Australia in 2019. This compares to 79,653 employed in medicine in 2012. Health Workforce Australia estimated our doctor to patient ratio has increased to 3.6/1,000 which is well above the OECD average of 3.2/1,000 and well above the UK (2.8/1,000) and USA (2.5/1,000).

The universities like the thought of their graduates getting jobs but this is unashamedly not their primary concern. They are not concerned at the prospect of their graduates obtaining vocational training. They are not concerned about the profession’s ability to mentor and train the extra junior doctors as residents. All the university wants to do is fill seats. They’re not worried about doctors or the profession – this is our concern. I accept this is how universities operate – they are a business selling education. Therefore, we definitely should not let them (or Government) dictate workforce outcomes for the profession.

The high graduating workforce numbers adds to the pressure on the growing cohort of vulnerable doctors in training. They should be assured of transparent and fair selection and examination processes with open knowledge of workforce trends. The AMA has a clear need to strengthen relationships with the Colleges and move us collectively in this direction.

Post-graduate training opportunities have grown by 2.5 times in the last 15 years or so, but there remain real challenges in resourcing vocational training opportunities for registrars such that this will remain a bottleneck that will only become more problematic as graduating numbers increase. In this environment it is clearly imperative that medical student and vocational training numbers should reflect credible workforce data and not be driven by political/institutional desires or parochial interests.

It is important to acknowledge the strides being made to meet the health needs of our rural communities with the design of the National Rural Generalist Pathway now underway; nevertheless, as a physician who practises in both metropolitan and regional Queensland, I am keenly aware of the shortages of specialists and sub-specialists in the regions and outer-metropolitan areas. It’s perhaps forgotten sometimes that regional centres servicing large geographical areas also need specialists and sub-specialists. Innovative solutions that will not cost much are part of the solution e.g. combined public-private jobs that capture the principles of easy entry-gracious exit as espoused by the AMA, with industrial recognition of the difficulties faced by regional/rural doctors.

As well as moderating the size of the workforce which requires urgent attention, an important area of work for the MWC will therefore be advocating for the colleges and jurisdictions to increase specialty training positions in areas of unmet community need, based on the advice of the National Medical Training Advisory Network.

[Correspondence] Evidence-based psychological therapies for insomnia

We read with interest Kimberly Whitehead and Matthew Beaumont’s Perspective1 (June 16, p 2408). As clinicians and researchers working on insomnia over the past three decades, we can only agree that the cultural and historical conditions under which insomnia occurs indeed shape the condition. However, we would like to stress that today’s psychological therapies for insomnia2 go far beyond sleep hygiene as stated in the perspective. Cognitive behavioural treatment for insomnia (CBT-I) has evolved as a mainstay of modern insomnia treatment, encompassing sleep hygiene; education about sleep; relaxation techniques; behavioural techniques, such as stimulus control and sleep restriction; and cognitive techniques to reduce nocturnal ruminations.