After-Hours: Urgent or Free-for-All?
Written by Jan Hallam
Wednesday, 31 May 2017
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31052017 GP after hours visitsLast month’s budget may not have addressed the blow-out of the MBS urgent after-hours item numbers – to the tune of $250m in the past year – but that probably shouldn’t be read as a victory for providers because Minister Greg Hunt has flagged his intention to take action.

It’s is believed he is in receipt of the taskforce report initiated by Sussan Ley last year, and will make public the recommendations. Whatever they may be, it has been enough for the peak deputising body National Association for Medical Deputising Services (NAMDS) to launch a campaign appealing direct to the public for support. Its Protect Home Visits website, with a logo looking suspiciously like the Medicare Logo, has had 59,839 registrations of support at the time of going to press.

However, the campaign has anything but the support from key deputising services which have been in the business a long time – Western Australian-based WADMS also known as Doctor Home Visits, the Sydney Medical Service Cooperative, the Canberra After Hours Locum Service (CALMS) and DoctorDoctor (formerly ALMS). These organisations were so concerned about the Protect Home Visits campaign that they split from NAMDS in December last year and have formed their own industry group, the GP Deputising Association.

Galloping forces

The direction of NAMDS appears to have changed over the past few years. What was once an association working for the good of all medical deputising services, regardless of their business model, NAMDS seems to have encouraged a more ‘free market’ position among its members if some of the vigorous marketing campaigns direct to the public are any indication.

Convenience and accessibility for the consumer, regardless of the medical issue being treated, is being promoted rather than the primary role of a deputising service, which is to attend the patient on behalf of the their regular GP.

Concerns have been raised by the RACGP and independent GPs for months now questioning whether all of the players in the crowded after-hours market are true deputising services for daytime GPs or they’re simply running their own race.

Medical Forum spoke to Tanya Steele Business Development Manager from the not-for-profit Doctor Home Visits (WADMS) about the unrest that led to the formation of new group.

“NAMDS was formed as an industry body to represent the interest of the Medical Deputising industry and of its individual members’ services, regardless of their business models. Unfortunately with private equity companies acquiring a majority of MDS service members, the focus of NAMDS changed dramatically. The true definitions of a deputising service to work for and on behalf of GP general practice was basically taken off the table, corporates adopting a direct-to-patient market focus. WADMS guiding principle for the past 40 years has been to act for and on behalf of GPs first and foremost. The changes the corporates were implementing is not a true reflection of what MDS services should be,” she said.

Scare campaign last straw

 “The clincher for us was the Protect Home Visits campaign and the sensationalism in the message the corporates were inciting. It was a scare campaign that was indicating to the public that changes to the MBS would make home visits a thing of the past. This is not the case for genuine deputising service providers. When no resolution to this difference of opinion in regards to the direction the campaign, WADMS’ view was that the interests of our GP members were best served outside of NAMDS.”

The result of this free market behaviour in the controlled environment of the MBS has seen a staggering blowout of the use of Item 597 for urgent home visits. With a rebate of $129.80 (sociable after-hours) compared to rebates for non-urgent numbers ($29 [short] to $117.75 [extended]) claims for Item 597 have grown from just over one million claims in 2014 to 1.5 million in 2016.

The Minister Greg Hunt in a television interview, and reported in The Medical Republic, said that doctors were claiming to be giving urgent services when they were simply providing repeat scripts or “other things”.

The Professional Services Review in 2016 found through an examination of clinical records that some practitioners “have billed these items for medical conditions such as an uncomplicated rash, reissuing prescriptions for patients’ regular medication and for routine completion of medication charts in residential aged care facilities”.

Minister points the finger

The Minister also put the onus on “junior doctors and corporate firms” for claiming ‘urgent’ items that were not really urgent and that was costing the system $246m.

The RACGP has expressed concern that some after-hours companies using junior doctors were putting patients’ safety at risk but has not linked their hiring with the Item 597 blowout.

The move of private equity companies into the after-hours landscape, however, has been considered a game changer by some, including evidently, the Minister.

One of the most influential players in NAMDS is the largest after-hours provider in the country, National Home Doctor Service, which is owned by Sydney-based equity firm, Crescent Capital.

Dr Spiro Doukakis is NAMDS president and also general manager of clinical governance at National Home Doctor in South Australia. This intimate relationship between NAMDS and National Home Doctor is not a new one. Last year CEO of National Home Doctor Ben Keneally was also president of NAMDS before he resigned from both posts in September.

GPs protest loudly

Then, a controversy with National Home Doctor activities in the Gold Coast was called out by local GPs who collected evidence that suggested the service was claiming ‘urgent’ items that were not, after-hours antibiotic prescribing had gone through the roof, and that ED presentations had not decreased as claimed.

The WA market has been saturated with an influx of new MDSs. WADMS Doctor Home Visits is the only not-for-profit, 24-hours deputising service operating in WA. The for-profits include National Home Doctor Service, which has been buying up smaller operations in other states, DoctorDoctor (ALMS), Perth After Hours Medical Services, Dial-A-Doctor; Doctor2U, Doctor on Wheels and a range of telephone and video services.

All operators have clinical oversight but the market is highly competitive and the concerns of some in the sector is that some operators are going outside of RACGP and AMA guidelines especially when it comes to marketing to consumers, focusing strongly on engaging patients directly to their services.

Convenient emergency

Then there is the question of consumer demand. Understandably, having a doctor come to you at any hour between 6pm and 8am and have that service bulk-billed is an attractive proposition and consumers have responded to advertising campaigns which have at various times been published on social media, TV, in cinemas, radio and newspapers.

Tanya Steele told Medical Forum that even though the code of conduct for deputisers banned advertising of after-hours medical services for convenience purposes, many of the corporate equity backed companies disregarded this guideline. It would be easy for the Department of Health to change those guidelines to align with the (RACGP) position paper which called for the prohibition of mass-media advertising.

“What is clearly emerging in the after-hours space is on-demand healthcare for people who are reacting to the mass media advertising and not booking into GP Practice but want to utilise at home visit for routine care. You would be amazed at the number calls we get from people asking for an after-hours doctor to visit to write them a script or a referral.”

“As all reputable deputising services should, our answer is, ‘sorry no, you need to ring your regular GP and make an appointment’. We’re here for an unexpected illness, and not to replace your regular GP. WADMS role is to support GPs in practice, we are in essence doctors working for doctors.”

Wise heads lead change

The new GP Deputising Assocation board certainly has serious experience in its ranks.

The make-up of GPDA is Chair, Melbourne GP Dr Nathan Pinskier (from Doctor Doctor), Nic Richardson (General Manager of Doctor Doctor, formerly ALMS, which has been established nearly 50 years), Ms Tanya Steele (WADMS, which is celebrating 40 years) Mr Adel Badawy (CEO of the oldest deputising service in Sydney since 1966), Dr Ian Brown and Mr Graeme Sellar (from CAHMS, which is also about 40 years old).

Tanya said the GPDA was in active discussion with other entities regarding membership to the association. It had, she said been received positively by other healthcare stakeholders.

“The GPDA will seek an inclusive membership base not only limited to six Medical Deputising Services to enhance the efficacy of the association. We will work together with other stakeholders like the RACGP, GPs and other primary health care providers to promote innovative and ethical models of after-hours healthcare delivery focused on safety, quality improvement and the appropriate use of healthcare resources,” she said.

“We do see the need for the public to understand what deputising really is and how important it is to have a GP for continuity of care it is important for us to work with GPs in educating patients of when to utilise the after hours services.”

The next few weeks will be crucial to the after-hours landscape. Government action to tighten up the guidelines which would see the use of Item 597 restricted may throw some business models a curved ball and irritate consumers, but it will benefit everyone in the long run, not least the taxpayers who have had to foot the bill of this after-hours free-for-all.