12 February 2018
After hours companies are crooked, so banning their advertising is obvious, right?
The news that home doctor groups, through their Approved Medical Deputising Service (AMDS) assets, can’t advertise in any way, shape or form directly to the public, is a fascinating development in the decades-long saga that is the relationship between the government and after hours or home doctor services.
Whenever the government starts regulating things such as advertising, or re-regulating, as in this case, there is generally something very wrong. And not always with the entity being regulated.
What exactly are we trying to achieve by stopping these groups advertising, and is there a more sensible way to do it?
Ostensibly, the regulators want to stop them creating demand that they do not think exists. The regulators have looked for some time at the quite significant advertising and marketing of some of the major players with messages which they think aren’t clear to patients.
The regulators would say, and most would probably agree, that a key theme in this advertising has been that after hours is a “free” and “convenient” alternative to daytime GP services, whether this theme was intended or not.
That creates a range of issues, particularly because every after-hours consultation item, even the most basic ones, are significantly more expensive than the daytime GP ones. This is quite apart from the issue of the potential such a message might have to drain business from daytime GP services, for no good reason.
Whatever reason, it is all at significant additional expense to the public purse.
OK, we get it. But when you ban advertising entirely, what else happens?
A few important things.
For starters, patients who weren’t aware of this service and genuinely have a need have significantly less access to it, whatever their local GP might do to advertise it themselves.
What those patients then do is go to the local hospital ED, or, in some cases, make a dangerous decision to last the night out. After hours does a lot of triage, remember. They take a lot of calls which they refer immediately on to emergency services, or they tell the patient to get themselves to hospital quick smart.
Who replaces this part of what after hours does if patients just don’t know it is there?
In regions where the service is new and needed, it has virtually no chance of being used by patients because now, especially, they have no way of knowing that the service exists or has been introduced, except if the local GP wants to advertise the service themselves.
There can be a big problem with that. This was demonstrated to some extent by the introduction of after-hours services into the Canberra region in the last two years. The local GPs saw those services as a direct threat to their daytime business and so they mostly did not engage with the service at all.
There is a lot of debate over whether the National Home Doctor Service actually cannibalised local GP practices in Canberra. If it did, that is not good. But even if it did, does that mean that after hour doctor services are just not needed in the Canberra region? That is very difficult to believe. How could a region such as Canberra have no use for such services, when so many other urban and regional parts of Australia with a similar demographic do?
Surely, if they are introduced in the manner that is appropriately dovetailed to daytime services and local hospital EDs, then they are going to help the system, as they are intended to do. And it’s hard to see any circumstance that you can do that without allowing them to advertise to the public directly in some manner. Not, of course, in the manner some have in the past.
This view is reinforced somewhat by an outcry from some major hospital groups and patient advocacy groups last week soon after these new guidelines became apparent. And by the odd GP lobby group as well.
These groups aren’t saying that some of the home doctor groups didn’t go too far and create some need for more specific guidelines and regulation. But they are saying that the advertising ban is badly thought through when all the aims of such services are taken into account.
One of those aims is very clearly to serve regional centres much better. No home doctor service is going to expand any further without the ability to market themselves in any way.
There are other very messy issues associated with the ad ban, which the government does not seem to have considered.
If you trawl the existing rules and regulations on “advertising of regulated medical services” on AHPRA, you can only come up with a lot of “grey”. It explains probably why we got so many commercial organisations testing boundaries. If you’re commercial you tend to do that.
The following sentences from the AHPRA guidelines probably sum up what regulators were referring to when they told the home doctor companies in the lead up to the guidelines that they were looking at aligning their advertising with those guidelines.
- Advertising that contains false and misleading information may compromise health care choices and is not in the public interest
- The unnecessary and indiscriminate use of regulated health services is not in the public interest and may lead to the public purchasing or undergoing a regulated health service that they do not need or require
The regulators would argue probably that home-doctor advertising breached these guidelines by not being in the public interest and probably by promoting “unnecessary and/or indiscriminate use”. I think the problem is they sat back and watched it for a couple of years and said nothing about it, until it was pretty clear that the cost of home-doctor servicing was starting to rocket. They then had to react. And they knew they could probably get them on these clauses.
But how responsible is that really? Should they have not been on them immediately they saw those TV ads spruiking the service as free and convenient a little to openly? Why did they wait so long, and when they acted, why ban all advertising full stop. Surely they just needed to bring them into line with some more detailed definitions of what is wrong and maybe introduce a new and stern fine regime. This is how a lot of other sectors which involve consumer protection operate already.
The other thing people should consider, but don’t like to because it’s an inconvenient truth about the home doctor debacle, is that it is generally put out that the these services started to overcharge and fraudulently charge, especially for urgent services and this is what drove the massive growth.
The truth of the massive expansion of these services is that almost all of the new money came as a result of expansion geographically and from increasing‘awareness of an existing service in an existing region. The actual rate at which these services charged their items, including the urgent items as a ratio of charging per patient to area population, has remained steady for over 10 years.
So even though you might still argue the advertising was stretching the AHPRA interpretations by emphasising “free” and “convenience”, and therefore encouraging “non-discriminate use”, the reality is that all these services did was find new patients who didn’t know about the service, or previously did not have the service in their region. They mostly made no changes to how they assessed their items.
The inconvenient part of this truth by the way is that what is rated as fraudulent today, wasn’t 10 years back. And the people who copped it on the head were the GPs and registrars who were doing what had been done forever. The reason that it suddenly got rated as fraudulent was essentially because we can’t afford it anymore. The reason we can’t afford it is because these companies took their service out to far more people in the community.
If you think that’s the bad bit you had better consider that this was pretty much the initial objective of the Howard government back in 2004-5 when they first changed the rules that set the industry on this current path of expansion. The government wanted after hours to be available to significantly more of the population.
I don’t think there is any question that what occurred is that commercial entities took the Howard government at its word, pushed the system outwards on the basis of new relaxed rules and the governments loose mandate, and what we found was that when stretched, the whole thing did not add up. After hours services being supplied in the manner we had for many years, but made accessible to so many more people was quite simply not a sensible spend of taxpayers money in the health system. Especially given how much strain we were placing directly on GPs via policies such as the MBS freeze.
The whole thing had to blow up. But we tend to point the finger mainly at the home doctor providers, not the government, when at so many points of this mess, they could have stepped in and smoothed out what was going on.
I suspect that if this wasn’t the government involved and the healthcare sector this would have been in court a long time ago, and the government would have found itself on the end of some very serious damage actions, based on where they have led these companies. But fortunately, such an action by any of these companies would send their popularity ratings so far below their already benthic deep sea depths, they would never try it.
Unhappily, the potential for more mess is emerging in this ad ban. One of those messes is the internet and what actually constitutes direct advertising on the internet. The other is whether they actually should advertise to the public for better ED and public purse efficiency anyway.
If you take the time to read the new guidelines on advertising for the home doctor groups who use the Approved Medical Deputising Service program (which is all of them do because registrars and the like make up nearly 60% of their workforces) you can find loopholes everywhere. You also find that if applied to normal GP practices and other regulated medical services, there are giant breaches of the basics around these guidelines now.
As a quick example, what constitutes advertising directly to the public in terms of a health directory listing on the internet? What if you’re home doctor group is being listed by a third party provider, or shared on face book massively by a mums group, and in those listings you are described as convenient and free? Social media is not an animal that is easily contained. And the origins of certain widespread facebook listed information can’t easily be tracked. The point is, this ban can be gamed, just as the old grey guidelines were. They need something that is more broadly clear about their intent, not so prescriptive. If you read the actual list of banned methods, I think they forgot only to include skywriting.
If you look at GP surgeries they appear everywhere in ratings services, and a lot of breaches now exist against the strict guidelines that the department of health (DoH) is seeking to push in the name of “regulated medical services”. For one thing, most include forms of testimonials which are strictly forbidden, even according to AHPRA.
By clamping down on home-doctor groups, are we opening a can of worms in the whole regulated medical service advertising market? Is that what we need right now?
Another probable issue is how grey these new guidelines are with respect to the actual websites of these home doctor providers. DoH says that the providers aren’t prohibited from maintaining a website, but such a site should be focussed marketing to GP practices seeking to engage a deputising service. But then it goes on to say they can outline the scope of their services and contact numbers et cetera.
In the world of the internet, this means they can actually advertise directly to the public quite widely via leveraging search engine and social media listings.
Currently all the major home-doctor players have a number for patients to call directly and book directly on their websites. Some are singularly directed at the public rather than at GP surgeries (see NHDS home page inserted). Will DoH require them to get rid of these elements of their site based on their guidelines?
If they do, what does a patient do to book a home doctor if they don’t have a regular GP, and have no idea how to contact them outside of this quite restricted avenue? Unless every GP surgery in the country has got its act together, has employed a deputising service, and can 100% guarantee that their patients have the number, which isn’t ever going to happen, then significant numbers of patients now won’t be able to access an after hours service when they are in need.
So back to the question at hand. Why stop them advertising entirely to the public? Why not just be sensible and give them some better guidelines for advertising, and if you feel it necessary a fine regime for flaunting the new rules? They do it in every other advertising market that needs consumer protection. Why not this one?
You suspect it’s because we are playing the game here. The game that attempts to position these after-hours companies, or some of them as uncontrolled crooks who took advantage of us all so they are getting what they deserve. But what about the patients and their doctors getting what they deserve?
The Medical Republic does not have any sponsorship or advertising contracts with any home-doctor group. We last accepted money from such a group for advertising to recruit GPs almost 18 months ago. Since then, we suspect they’ve not had the budgets to ask for any more advertising.The author used to work for a private equity firm. He isn’t a fan.