22 January 2021

The great GP COVID vaccine swindle

Comment COVID-19 Government Pharmacy Political Vaccination





UDPATE: 10AM, January 23

This morning when the government opened registrations for GPs at 9am to do the COVID vaccine they announced at the same time that they would be creating item numbers for GP Covid vaccination of between $65 and $74.50 for each vaccinated patient. That makes the following comment piece out of date but maybe still an interesting read (there’s still a bit in there, like, is $65 enough given all the work for preparation). We had been asking both the DoH and the RACGP all week, including yesterday if and when there might be an item number to no avail. The full DoH announcement is HERE. The RACGP announcement, which appeared at 6am, is HERE. We won’t be changing any of the article below which we wrote yesterday afternoon believing at that stage that the government was moving on GP registration for COVID vaccines without first establishing any offer of funding. If any comment could be made at this stage on what happened here it might be: why did the DoH and the RACGP not let GPs know that some form of funding was definitely coming? Who knows. The other comment: is $65 to $75 per fully vaccinated patient enough to make it worthwhile financially still? At least practice managers can now start modelling that.

UPDATE: 1pm, January 23

Bad news travels fast. By 1pm today many of the GP social media and forum sites were going off with GPs upset with the level of the reimbursement being offered for the preparation work that is being indicated will be required in the government’s expression of interest document released this morning. When the government came out this morning with item numbers the initial reaction was relief, but that seems to be rapidly turning to anger among some GPs and practice managers. The items on offer (all 18 of them), don’t amount to much if you consider how much work practices will need to do to get set up and how much disruption setting up is likely to cause a practice. David Dahm, principal at leading GP accounting and advisory firm has already written an initial summary of the items vs what the government is asking GPs to do and he is offering anyone a $100 if they think they can make the new item numbers work financially. We have published his initial raw analysis HERE for you to check out. Dahm’s advice is do your homework and don’t scrimp on the detail. For one thing you won’t be able to charge above what the government is offering which is simplistically double the bulk billing rate for an A consult, or about $65 in the first consult and not quite double when your patient comes back, or about $55. Most mixed billing practices will immediately be aware that this effectively isn’t what they make on a A consult already so they will lose money from day 1. RACGP president Karen Price is hinting already that the items aren’t going to be enough by saying in the colleges PR news service newsGP this morning that

‘”Now we have this clarity, I know general practices right across the country will be doing the figures and working out whether they will be in a position to support this national health response.
 

“While it won’t be for every practice, I hope we’ll see enough taken up by general practice through the expression of interest program to get Australia vaccinated and back to some normality.

{Question?: is it really up to GPs to support vaccination if they are going to lose money doing it?}

By making the items so low and not allowing practices to add anything to the top the government is playing the middle with GPs. It looks like you might be able to break even or even make a little extra if you set yourself up well. That means the government has set the price at the lowest they can afford and a level which will offset most loss for any practices participating. The problem of course is, that during all the time and effort a practice goes to in setting up, and taking vaccine patients, they are not making money when they normally would be. Essentially the government has set the price at a point where GPs will now be torn between doing the right thing for their patients and the country, and making sure that their practice remains in reasonable financial shape in what are very uncertain times for most practices.

On spec you might say the government is saying to the GP fraternity here: ” OK, here’s some money to offset you for your trouble and to assure you that we are behind general practice. You won’t make any money here sure, you might even lose a bit, but hey…we’re all in this together right?.”

Before they were offering any incentive things were pretty clear for GPs. Now they’ve set in place these item numbers you could argue the government has made things more difficult in terms of planning and decision making for general practice. When the item numbers hit this morning I first thought that much of the article below was rendered irrelevant. But now Im not so sure. At this level of compensation all the problems that are alerted at the end of this article remain in play. The main one is that while GPs are going to struggle to set up to vaccinate based on these incentives, Chemists, backed by the big pharmacy chains will be champing at the bit to get involved. At that point the brand of GPs vs pharmacists in one of the biggest community based healthcare initiatives in the nations history will come into play. And pharmacists, backed by the capital, infrastucture and logistics capability of the big pharmacy chains will have gained an unfair upper hand. I’ve asked at the beginning of the article, prior to knowing that there was any new funding for vaccination if the government was naive and disorganised or cunning and cynical….it’s the latter. Read on.

UPDATE: 5.00pm January 23

If the government is going to deliver bad news or news they don’t really want analysed too well, usually the best time to deliver that is late friday afternoon. Even better as it turns out is 9am on Saturday. The day started with people wondering if the government would pitch in with funding for GPs to do COVID vaccination, and speculating, as we did, what might happen if they didn’t, and by 9am we knew the government was pitching in something. By 1pm it was pretty clear what they were pitching in wasn’t much, and the rules being set around becoming a GP vaccine clinic were going to be pretty restrictive. David Dahm pitched in with an article warning everyone to sit down and do the numbers and make room for error. It didn’t add up. The government, who had been telling GPs for two weeks, and the RACGP and the AMA, that GPs were the “cornerstone” of the upcoming vaccination program, had provided a level of funding and complexity to set up and run vaccinations which meant in fairly black and white terms that virtually no GP surgeries would end up signing up. Only very highly organised high throughput set ups stand a chance of making their money back. And there are a lot of ifs as to whether that’s a big risk as well. Given supply issues overseas, and cancellation problems in practices in the UK, even those signing on who are well funded and organised could expect a lot to go wrong. When news broke this morning that items were being funded we thought the article following was going to be fairly redundant. It isn’t. While there are items for vaccination being offered, they aren’t nearly enough to compensate GPs. And there are new issues, like why is the government mandating that if you use an item number to vaccinate, you can’t add anything on top? There’s a question already, as there was in COVID testing items, as to whether that is actually constitutional.

Minister Greg Hunt and crew have been taking GPs, the AMA and the RACGP and it’s executive for a ride for the last few weeks. GPs will not be the “cornerstone “of the upcoming vaccination program. They can’t afford to do that. The government might be able to turn around and say to the sector, “yes, but we are funding you, these are hard times for everyone and its a community effort…we’ve given you a good chunk in order for you to pitch in in if you want…” but the reality is times are tough enough and uncertain enough for most rational practice managers not to waste their time on trying. Yes, some will work out how to do it, and others, no doubt concerned for their patients and their practice branding will lose money doing it…so there will be some GP presence. But “cornerstone”?. The RACGP got back to us this afternoon and without saying as much admitted that it would really only be those practices which could organise for high throughput which would likely apply and it probably wouldn’t make sense for many to apply. In other words, GPs have pretty much side swiped (swindled perhaps even?). Why did the government pursue the cornerstone, front and centre line so prominently in the national press? It was never going to be that practical given the logistics in play – where fast high throughput could be achieved much better other ways – and the government is deep in debt and looking to optimise budgeting as far as possible now. It wasn’t necessary to get on national TV and promise the GP sector that they were going to be front and centre in the whole show. Now the very real issue is that other groups – hospitals, hospital hubs, private sector companies, and pharmacists, will be quite visible in the program and GPs won’t. The biggest national public health program in history. That’s unfortunate for the GP sector, as they are the real hub of community health. The government should have worked out a better way around this problem. GPs are too important to them and system efficiency moving forward to treat them so shabbily. This story went full circle in one day – from the government swindling GPs by not offering funding, to them offering funding, which turned out to be so poor, that we were back to GPs being swindled… or , at least at the butt end of a pretty cynical political three card trick. It should have been handled a lot better. Original article from yesterday is below. David Dahm’s article on what you’ll be up against and tips to work your position out is great and is HERE. The details on the funding are on the government’s website HERE. We will be back with more feedback and analysis on Monday.

UPDATE: 2pm Sunday January 24

Things continue to move fast among various GP groups. The latest assessment HERE by David Dahm is that the decision by the government to effectively make COVID vaccinations by GPs bulk billed, albeit at a special new item rate of on average $66 per patient visit for one complete vaccination, is that it is going lead to the majority of GP practices not participating on the grounds that it simply doesn’t make financial sense. Dahm quite correctly points out that the government could have easily allowed private billing in the equation with a little forethought and good communication and made sure that a lot more GP practices were involved. This would have been better for the whole program overall – more patients would be handled by GPs so less for other vaccination hubs – better for patients – who could choose their own doctor if they wanted to pay extra, and of course much better for brand GP. As things stand, the current offer of MBS items is probably just a mess for the GP sector. One the one hand they can’t really afford to take part, but on the other the government has been spruiking for the last few weeks that GPs are the “cornerstone” of their program. Many GPs will feel compelled by civic duty, and for their patients to participate still. They will likely lose money. But most probably won’t. And the GP sector will be largely invisible in the largest community health initiative in the history of the country. One where hospitals, pharmacists and nurses will be front and centre. The government didn’t think this out very carefully. Or they are that cynical. Maybe the college, having had the time to assess the situation carefully over the weekend will come out fighting here. They probably need to. Original story from Saturday below.

5pm : Friday January 22, ORIGINAL ARTICLE FROM YESTERDAY STARTS HERE

The federal government is either truly naïve and disorganised or seriously cynical and cunning.

It’s most likely the latter based on what we know so far about the role of GPs in the COVID-19 vaccination rollout and indeed the reasonably competent performance we’ve already seen from the DoH in the whole COVID disaster.

On the one hand it has made sure that GPs feature front and centre in most of the glitter and glam of national press conferences and intermittent press releases on the topic (here’s a big one from yesterday ) and on the other has chosen to ignore the fact that for any GP practice to actually participate in the process the costs almost certainly will create significant financial hardship without some additional funding.

It looks like a classic set up. Perhaps one that is the first in a series where the government attempts to claw back money from its COVID largesse on other GP-related health matters, most notably, telehealth.

The build-up featured the RACGP president Dr Karen Price hand in hand with the Health Minister at national press conferences (one here), assuring the public that general practice would be at the heart of the vaccine rollout and that our GPs were an essential part of our system of defence against such national health disasters.

On Thursday Hunt’s website featured an update on the vaccination workforce which had a few ominous signs about just how important GPs would actually be in the rollout.

Hunt announced here that the DoH had appointed four private sector healthcare companies “to provide a vaccine workforce to supplement the existing immunisation workforce for specific populations”.

The providers are Aspen Medical, Healthcare Australia, International SOS, and Sonic Clinical Services.

These groups will likely be targeting high-risk communities such as aged care and Aboriginal and Torres Strait Islanders, but potentially also immune-compromised groups and the like.

Nominally, there will 500 staff used from these providers but in a press conference yesterday Hunt said that the number is actually uncapped.

When asked how much the use of these companies would cost, Hunt deferred the question saying it would follow normal DoH contracting procedures. But it’s going to be a lot.

It’s not a stupid idea to appoint private sector groups like this for a program like the COVID vaccine rollout. It wouldn’t be stupid either for the government to ramp up significantly its hospital hub and spoke presence to get scale and throughput, which it looks likely they will do. And it wouldn’t be stupid to get the big pharmacy chains to organise using nursing staff to provide a lot more capability.

All of it makes sense.

It just doesn’t align at all with the rhetoric so far on the role of GPs being the “cornerstone” of the vaccine roll out.

Another pointer to GPs playing a lesser role than the government is spruiking is that the Australian College of Nursing (ACN) rather than any GP peak body has been charged with the role of developing and preparing the training materials which will cover the handling and administration of COVID-19 vaccines.

Again, it’s not illogical that the ACN is involved in the COVID-19 vaccination program in this manner. It points to the most economic and practical route in vaccine application being mostly by nurses, not GPs.

Unfortunately, eventually, a lot of those nurses are likely going to be stationed at big pharmacy chains.

Yesterday the DoH released this press release and followed it up with a national press conference from Hunt. No less than four times during that press conference did Hunt refer to GPs as “the cornerstone of the distribution rollout”.

The press release is headed: GPs’ key role in COVID-19 vaccination rollout. Among other thing it is announcing that from 9am today, GPs can apply at health.gov.au to register to become a vaccination provider.

“General practices are the core of our health system and those involved in supporting the vaccine rollout will include GPs and primary health care nurses, as well as their support staff, including practice managers, receptionists, cleaners, and IT support,” says the release.

We will bring you the detail of that application process on Monday, but even if it’s a simple registration to start with, you’d imagine for nearly every GP practice in the country, any time spent applying to do COVID-19 vaccinations is time better spent doing something else for now.

Without any commitment from the government to fund the process, there’s almost no use in GPs even starting to prepare. Without any idea of what the funding might be, or if there is going to be any funding, no practice could sensibly model the impact on their business of taking on COVID-19 vaccinations.

They can model cost to some degree of course. And we know it’s going to be significant because its going to need to include registration, education, training, indemnity insurance, practice set up, disruption to normal business as patients stay longer and are counselled in consent and follow up, and some degree of likely disruption around continuity of vaccine supply.

A week ago RACGP president Dr Price reported that there were “whispers” of the DoH working out an item number which would sufficiently compensate GP practices to go to the enormous effort of setting themselves up to do COVID-19 vaccinations.

Then this week AMA president Dr Omar Khorshid told TMR that “the government is considering a new MBS item number and that the AMA and the RACGP are talking to the government about it.

“We don’t want general practices to decline to be involved, because it’s just too hard or it’s going to cost them money to do it,” he said.

So the AMA and RACGP are pretty much on the hook here to deliver an item number for their constituents. It’s central to what they both want and think is right in having GPs be broadly involved in the program.

But given the government has already established application procedures for GPs, is busy preparing education and training, via the ACN, not the peak GP organisations, has contracted four outside private organisations at significant cost, and we have not even a whisper of an item number, or something equivalent, you’d have to think that the RACGP and the AMA are now in a very awkward corner.

David Dahm, lead at Health and Life, of one of the country’s largest GP accounting and advisory firms, tells TMR that without reasonable compensation via MBS item number(s), taking on COVID-19 vaccinations might not only be “financial suicide” but it might also represent significant legal risks given the speed and complexity of the rollout and the lack of information available to practices so far.

“Practices will be expected to make it free,” Dahm warns.

“Additional safety measures, secure and reliable delivery costs are of concern.

“These additional risks are higher than delivering a traditional vaccination clinic, e.g. new systems, staff training, refrigeration and building capacity.

“Overseas experience is that an unreliable supply chain has caused significant clinic cancellations,” he says, adding that practices will need to factor in disruption into services.

Dahm believes that any practice taking on COVID-19 vaccinations will have to build and keep staffing capacity resulting in significant systems and staff overhead increases.

“Since COVID-19 we have seen average wages costs go up by up to 10% per annum due to additional work.

“Some MDOs and Workcover will not insure or provide limited insurance for COVID-19 risk. This is still a moving target.”

Not withstanding, Dahm suggests it’s OK at this stage for a practice to put in an expression of interest.

“Then do your numbers and weigh up the risks with a good contingency plan should things go wrong,” he says.

“Tread carefully and do not assume it is a financial boon or something you have to do.”

Even without funding in the form of an item number for GPs, general practice isn’t by any measure so far “the cornerstone” of the government’s impending COVID vaccine program.

At best it’s wishful thinking on everyone’s part. At worst it’s debilitating government propaganda.

Something to soothe the profession and keep it at bay.

If the government really was on the GPs’ side there would have been an announcement on funding and an item number at least a week ago, to give practices assurance of backing and the ability to at least model if they could afford to take on COVID vaccinations.

Why the sham?

Obviously it’s better for the government to have all parties onside. To present a united healthcare community front.

But by putting GPs up as being the “cornerstone” the government might also be putting the GP sector in a corner.

We can’t afford to pay you properly, or at all, sorry, but can you afford not to do vaccinations anyway?

One huge issue for the college, for GPs in general, and maybe even for the government, is the potential of vaccine rollout to significantly shift the brand of chemists as healthcare providers upstream further into where GPs live as a brand.

That will likely come about because when pharmacists get involved, which they are slated to do in the phase after GPs, they will get involved in a big and systematic way, via funding from the large chains.

You can imagine a scenario where the government doesn’t fund GPs, or doesn’t fund them enough, most GPs choose wisely to stay away on financial grounds, and there is a large vacuum created which pharmacists will dearly love to fill.

The government won’t be needing to pay the big chains anything to take up vaccinations because the commercial upside of doing it, even if they do lose a lot of money in the process, is so big and strategic long term.

Providing vaccinations on scale for a chain like Chemist Warehouse will be seen by their management as a  seminal customer acquisition and branding exercise first.

The big chains have the capital, scale, facilities and wherewithal to slam dunk such an opportunity.

It would be a perfect brand tactic to prepare politicians for the sort of skulduggery that the Pharmaceutical Society of Australia has proposed this week in their 2021-22 pre budget submission where they suggest that community pharmacy could manage “non-urgent” emergency department presentations.

Individual GP practices, even some of the larger ones, aren’t able to compete with this commercial dynamic. There’s a big structural issue in play for healthcare and the country.

The market is wholly lopsided in favour of the big pharmacy chains that have the money, the processes (warehousing, bulk handling and distribution), and, of course,  the will to invest in such an important branding venture.

This puts even more pressure on the AMA and the RACGP in their conversations with the government about GP funding.

So far, there’s no indication from those two bodies that they’re kicking up a fuss about remuneration.

As things stand, it looks like the government is playing off all sides in a game where in the end, as nearly always, you need to follow the money.

Given the state of the budget, and the amount paid out on COVID telehealth consults, a lot of the GP money has maybe already been spent.

So far we haven’t heard even that whisper of whether the government is going to spend more on GPs via an item number to seriously involve them in the COVID vaccination program.

Yet they are already spending big on private health providers, hospitals and even the nursing fraternity in the preparation for the program. If you follow that money so far, then GPs aren’t going to get much to do COVID vaccinations.

If you keep following the money, then using pharmacists to massively boost your vaccination capacity without having to spend a red cent, makes a lot of sense (cents too) for a government increasingly looking to a COVID safe future which is also trying to pay back the now massive deficit.

Saying  that GPs are the “cornerstone” of your vaccination program, even saying it a lot, doesn’t make them the “cornerstone”. If you don’t pay them, or pay them late, or pay them confusingly, or not enough, they simply can’t participate.

And if they can’t or don’t participate, and pharmacists do at scale, which feels almost inevitable, the damage to the brand of GPs as the hub of preventative and community medicine will take one of the largest hits it has in some time.

Lots for the government – and the RACGP and the AMA – to think about here.

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4 Comments on "The great GP COVID vaccine swindle"

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Lou Lewis
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Lou Lewis
7 months 23 days ago
Early this morning I was rummaging through some old stuff I had at home and I found what I thought it was a crystal ball. However this ball was more than a crystal ball in that it showed me glimpses of the past few weeks as well as the future . A few weeks ago the health minister rang up the respective presidents of the AMA and the RACGP ,and he said to them “ hey ,new presidents , I am Greg Hunt and I am personally going to meet with you so that we can discuss the future roll… Read more »
Lou Lewis
Member
Lou Lewis
7 months 26 days ago
Jeremy, I didn’t read the whole article because, as you rightly point out. things are changing by the hour. However, I will reference 2 quote: 1. ” OK, here’s some money to offset you for your trouble and to assure you that we are behind general practice.” This is the same bullshit we have been fed for years. 2: “Minister Greg Hunt and crew have been taking GPs, the AMA and the RACGP and it’s executive for a ride for the last few weeks.” When Oh When are are so-called GP leaders going to realise the the Govt doesn’t give… Read more »
Raymond Yeow
Member
Raymond Yeow
7 months 26 days ago
Jeremy 1. best reportage on the CV19 vaccination rollout by a country mile …well done and much appreciated 2 also thank you for working on the weekend 3. RACGP and AMA played by the govt [again]. When will Drs ever learn the proverb “…fool me once, shame on you; fool me twice, shame on me…” 4 Pharmacy is running rings around the RACGP & AMA (again)…..when will we ever play hard ball as a profession ? That’s a rhetorical question – umm…never it looks like 5. David Dham’s article linked above is a must read for the finance part of… Read more »
Sobhy KHALIL
Guest
Sobhy KHALIL
7 months 27 days ago

As soon as I read the offer to participate and the strings attached to it, I said to my wife and practice manager, I better attend my patients with day to day medical needs.
To participate with the set conditions is non rewarding and for an active practice, one has to abandon those in need for treatment to see those who want the vaccine and are quite well.
Government should set instructions to vaccinate the 20 millions with facilities set for the requirements.

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