Doctors are waiving fees for assisted dying

But altruism can only get you so far, a VAD researcher suggests.

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Many doctors providing voluntary assisted dying services are doing so pro bono, prompting Queensland doctors to push for Medicare reform.

Voluntary assisted dying is now a legal option for competent, terminally ill adults in five states, with NSW to join as the sixth state towards the end of the year.

But a lack of Medicare subsidies have led a group of doctors from Queensland to propose a standardised billing system as they call for urgent MBS reform.

Currently, to receive remuneration for most VAD-related services, doctors must privately bill.

Casey Haining, a research fellow at the Australian Centre for Health Law at Queensland University of Technology and first author of paper in the MJA on remuneration for VAD, told The Medical Republic that “a lot of doctors who are doing this are doing this pro bono … They’re going above and beyond.

“[Doctors] are doing this outside of their usual work hours. For a general practitioner there are some MBS items that they can claim but this is limited to end of life planning,” she said.

“It certainly doesn’t recognise the time commitment that would be required by a practitioner.”

VAD in Australia is highly regulated. Eligibility approval requires assessment and approval from two medical practitioners, each of whom must complete an estimated six hours of training before they are accredited.

Doctors often travel to patients who are too ill to travel, provide support and information to families and complete a host of additional administration, most of which is unremunerated, according to medical practitioners.

Although “euthanasia and any service directly related to the procedure” are not remunerated under the MBS, associated counselling may be subsidised.

According to Ms Haining and her colleagues, it is left to doctors to decipher what part of the VAD process can and can’t be billed.

“No guidance is given by Medicare about what such services may be and which MBS items may be available for medical practitioners to claim in relation to them,” the paper says. “As a result, individual medical practitioners must use their discretion to claim the appropriate MBS item(s), if any, based on the clinical circumstances of the services rendered.”

Ms Haining said while many practitioners are providing the service altruistically because “they’re in it to help their patients”, this might not be a sustainable model.

“We have to recognise it’s a systemic issue. We ultimately have a deficit of providers.”

In response to the lack of remuneration, the Queensland Voluntary Assisted Dying Working Group has proposed a guide for billing for Queensland providers that would involve an out-of-pocket cost of $860 for assessment of eligibility and self-administered euthanasia.

The proposal would involve an estimated minimum of five hours of a doctor’s time.

“This guide has been formulated based on the current MBS service fees, average hourly rate and time required in providing VAD services for a general practitioner in Queensland,” the proposal said.

The group maintained that it should ultimately be at the discretion of doctors to charge as they see fit.

Although not endorsed by Health Queensland or the Queensland Voluntary Assisted Dying Support and Pharmacy Service, it was written to encourage important discussion around remuneration, according to The Guardian.

The RACGP’s president Dr Nicole Higgins concurred that as things stand, Medicare rebates for VAD don’t equate to GP time spent. She looked to the federal government to decide whether VAD should be Medicare-subsidised.

“Existing Medicare rebates are not reflective of the amount of work involved, which would be a barrier to GP involvement. The RACGP is generally not in favour of disease or condition-specific item numbers; however, we would consider all options in designing a mechanism to make voluntary assisted dying sustainable and affordable,” Dr Nicole Higgins told TMR.

Dr Higgins also touched on how telehealth barriers to VAD may be disadvantaging some terminally ill patients.

“The current laws [around telehealth], which leave GPs vulnerable to legal action, are particularly disadvantageous for terminally ill patients in remote, rural, and regional areas.

“Telehealth has become a fundamental component of general practice and is playing a vital role in reducing barriers to access and facilitating ongoing and comprehensive high-quality care.

Dr Higgins said the RACGP would need to further assess the evidence and consult with its members over whether VAD services should be available over telehealth.

“Any changes to these laws would, however, have to be very carefully crafted,” she said.

Dr Higgins reiterated the college’s position on VAD: that where they are legally available, patients looking to access the services should be met with “a respectful and compassionate response”.

“As things stand, patients face out-of-pocket costs for the voluntary assisted dying schemes across Australia, and this does create a barrier for people seeking access.”