25 September 2017
Home doctor is the pink batts and school halls of medicine
Wash away all the emotion, the finger pointing, the twisted facts and figures, and most of all, the politicking, and the disaster that is after-hours home doctor servicing falls squarely at the feet of the federal government.
While some of us are sitting back celebrating, suggesting the greedy are getting their just desserts, the fallout feels significantly worse than just one more giant private equity play going down the drain.
The fallout is a lot of hardworking doctors, many of the them GPs, many others GPs in training, trying to make their way, who are being castigated and shamed, in what feels now like a witch-hunt calculated to distract people from the real story – which is the government has stuffed up big time and isn’t prepared to admit it.
That the government is prepared to sacrifice so many dedicated and hard-working doctors and GPs by putting them to the sword in Sydney’s Daily Telegraph newspaper is the real scandal.
It doesn’t seem likely we’ve even begun to see the human damage of the public humiliation that the Daily Telegraph dished out last week to the whole after-hours sector, including the specific targeting of many individual doctors using rehashed, and, at times, out-of-context, allegations that made the profession look very dirty.
Do we really think that this media hatchet job by the Daily Telegraph doesn’t affect the medical profession as a whole, most importantly the image general practice? Remember, GPs make up more than 30% of the after-hours workforce.
And does anyone think that the Telegraph’s special investigation was done in isolation from any goings on in Canberra? Many believe the story was leaked in order to prepare the ground for the findings of the Robinson enquiry, which will likely kill off the urgent items for the after-hours providers and restrict after-hours servicing to GPs only.
What is wrong with this picture?
From the perspective of primary-care funding, it’s hard to argue that shutting down the after-hours providers, or severely limiting their ongoing servicing remit, isn’t a reasonable thing to do in terms of return on investment for the community. The march of organisations such as the National Home Doctor Service into new communities certainly was costing us a lot, when we don’t have much to spare.
But let’s just put that aside for a second, and examine what actually happened here. Around 2004, the federal government promised access to 24-hour care to most of the community. And it set up the very system which is now claimed to be fraudulent and rorted.
The thing we hear most from non after-hours doctors, and from the AMA and the RACGP, is that the urgent items being claimed aren’t actually urgent. That, in essence, after-hours doctors are charging these items fraudulently. This is a pretty serious and damaging claim for all those doctors doing after-hours work.
No-one has done a thorough audit to determine where the line is on urgent and non urgent, and just how difficult that line becomes when you have a mum who is scared, but can’t or doesn’t want to go to ER.
But let’s take all those anecdotes we hear, and assume they do constitute good data and the urgents just aren’t urgent after all.
Do we now point the finger at these doctors?
The most common error in the whole home-doctor debacle is that the march of the private equity-led after-hours providers has massively increased the rate of urgent item charging and that is what has led to this mess.
Private equity figured out the following in making its plans:
· Most people didn’t have access to after hours, even if they wanted it
· Many more weren’t aware of the service
So what the providers did was increase access – massively.
They did this by taking the service to completely new geographies where it hadn’t existed before, and by increasing awareness in geographies where the service already existed. Those controversial TV and radio ads sparked a lot of anger among GPs.
But the actual rate of urgent-item charging has barely increased in the last eight years. The cake just got made much bigger. And that exposed a funding issue.
So if all those doctors who we are accusing of over-servicing today are bad eggs, then the truth looks like all doctors who ever used the urgent item in the last 10 years are bad eggs. That’s a lot of good doctors.
And the RACGP, the AMA, the government, and all those people who want to close down these services, are avoiding the inconvenient truth that the system was probably flawed from day one, given the limited funding regime that the government was going to apply to primary care in the same time frame it said it wanted all Australians to have access to 24-hour medical care.
What has actually happened is that the smart (not so smart, as it turns out) people in private equity did their sums and believed the government really wanted everyone to have access. Those sums just took the rate of urgent care billing and multiplied it by the amount they thought they could “expand” the market.
The private equity players also cop it here because the argument goes that they “stimulated” the market and caused the issue.
They were doing what the federal government had stated, as policy, what it wanted to occur. They were introducing the service into new regions where it didn’t exist, and they were making people aware of the service who weren’t previously aware of the service. They, technically, were doing nothing that the government hadn’t stipulated it wanted done.
The other argument goes that the urgent item over-servicing is revealed in the fact that hospital ED admissions have risen in the last few years, not dropped.
The most publicised research averaged ED admissions across 24 hours. They didn’t look at data in the hours which after hours operates. When you do that, admissions go down. But, all this data is fraught with methodology issues and probably can’t be trusted either.
There is currently work that suggests that probably there is a not much effect on ED admissions either way, as, quite simply, consumers do what they do best, consume. They fill up all available options to maximise their ease of healthcare service use.
The private equity people did not set out with a cynical view that they’d not affect ED presentations. They thought they would. They thought they’d even be liked, possibly.
But as things turn out, ED admissions aren’t affected to any meaningful degree. That didn’t help private equity. And it goes to an important point in this whole debate: after hours has turned out, in the context of our ever-tightening healthcare budget, to not be a great return on investment for the community.
The other argument made commonly is that when after-hours services were introduced, or pumped up in a region, the local GP practices suffered loss of income. There is no properly researched evidence for this claim. It looks largely based on assumption and fear, and lots of anecdotes.
The blame game we are playing here is unfair, and potentially very personally damaging. These organisations didn’t double the rate of fraud, they doubled the rate of people being seen. And the doctors in the service have not changed their practice in order to take more money. The rate of urgent hours servicing has been largely static.
If this were two commercial organisations, not the government and PE, and there was a contract involved, the PE firm would have a great legal case against the government.
What we have now is many well-meaning doctors, many of them GPs, being tarnished in what looks like a government effort to turn attention away from the fact that this whole mess was of its own making.
The private equity people were just doing what they do. The doctors delivering after hours were just doing what they’ve always done. What changed is that when after hours was pushed to more of the community, we all realised that urgent, wasn’t actually urgent, and that the drain in dollars could be applied better elsewhere. And urgent wasn’t urgent, all of a sudden, because of the context of a very tight funding regime. Not because people suddenly woke up to long term fraud.
We aren’t being honest about that. We are just seeking to blame people for greed and misdeeds.
The misdeed lies with the federal government.
And we now have a mess. Because the reality is that after hours is still an important service in many communities. And GPs largely don’t want to do after-hours these days.
So getting GPs to beyond 30% of the after-hours workforce is always going to be very difficult. Dictating that the service is mainly to be done by GPs is a decision with heavy implications for the community, for doctors training to be GPs, and for the income of student doctors.
After hours is a major training ground for doctors seeking to become a GP. And a major source of revenue for these doctors in training.
We need to pull back from the emotion, the Daily Telegraph tabloid horror stories and the blame game, and think much more carefully about what we are doing here.