The Victorian Coroner has called for specific Medicare items to encourage more GP reporting, but the RACGP and GPs disagree.
Creating domestic violence-specific MBS items would be a safety issue, would not solve the problem and would create a hierarchy of suffering, says prominent GP and mental health advocate Dr Louise Stone.
A Victorian coroner reporting on the death of a domestic abuse victim has recommended the introduction of domestic violence-specific MBS items to “support the identification and management of family violence by GPs”.
The coroner, Paul Lawrie, led the investigation into the death of a 75-year-old Loris O’Meara, who was found deceased in her apartment in November 2019.
Ms O’Meara was under the care of her husband, who she had repeatedly told her GP was emotionally and physically abusive.
The report quoted coroner Judge Cain, ruling in another case, who said several previous investigations showed “a continued lack of occupation-specific understanding of family violence … among GPs treating the general public”.
The report suggested specific MBS items might help account for billing of extra time doctors spend “collaborating with other services, exploring referral pathways and sharing information”, which often goes unpaid as it is outside of consultation time.
The judge recommended that CPD requirements for GPs include a specific domestic violence portion. The Prime Minister and Minister for Health and Aged Care supported exploration of this suggestion.
In their testimony to the court, the RACGP said that although domestic violence specific training is not compulsory, “competencies required to respond to family violence form a part of the core skills taught to GPs as part of the standard curriculum”. Due to the complexity of family violence the RACGP did not support one-off mandatory training.
Speaking to TMR, Dr Louise Stone, Associate Professor at ANU’s College of Health and Medicine, concurred that it was “very important that we educate, but how many hours do you want us to educate for?”
“Our job doesn’t pay for our education … We can be ready and willing, but we are still not able.”
Dr Stone emphasised the importance of privacy for the safety of patients experiencing domestic violence.
“It’s very common for my patients who experienced domestic violence to pay me in cash so that their partners don’t track their Medicare accounts. [The abuser] owns their phones, they track them.
“If their doctor charges an item number without considering that, that’s a big issue.”
Dr Stone added that specific MBS items “allow complexity in the Medicare schedule to increase the risk of unintentional error, interpreted as fraud”, and said data could be weaponised to reduce Medicare costs.
She was also concerned that individualised MBS items, and therefore variations in reimbursement, could be seen to rank categories of suffering.
“It’s creating hierarchies of suffering and these hierarchies are determined by the ability to lobby.
“A child who has been abused by the neighbour, does that make them less worthy than the child has been abused by their father? Because it’s not domestic? It’s a minefield.
“I don’t think someone should get less services because they are a survivor.”
Dr Stone said another limitation was the availability of services for victims of domestic violence.
“If you can’t get a women into a shelter and she can’t survive on Centrelink, if she’s going to be taken to the Family Court and told she’s mad because she’s been gaslit and he’s going to get the children, she will stay.
“People think that if we detect [victims of domestic abuse] there’ll be some sort of magic and we’ll be able to transport them to a safe world where this all goes away. I don’t often say this, but I’m just a GP. I can’t take them home. I can’t keep them safe. I can’t protect the kids.
“Everybody deserves the same care. You shouldn’t get less resources just because your problem is mental or because you’re pregnant.
“If the children are at risk … of course I mandatorily report it. But it doesn’t stop the abuse.”
Despite all states requiring abuse or neglect of children to be reported by health professional, there is no requirement to report domestic violence for adult patients unless there are directly life-threating concerns.
RACGP President Dr Nicole Higgins told TMR expanding criteria for general practitioner management plans (GPMPs) might be the answer.
“Giving patients and GPs this option will help GPs to help patients in these situations while minimising the risk to patients,” she said.
Dr Higgins said the RACGP hoped a GP consultation item that accounted for consultations over an hour may help address this complex issue.
“An adequately funded Level E consultation item would support the provision of care for people with chronic and complex conditions, allowing patients time to discuss their care needs and further develop trusted relationships. This allows patients and GPs to work in partnership and fosters patient-centred care.”
