Money Matters Medical Markets The Obstetric Fees Debate
The Obstetric Fees Debate
Friday, 01 May 2009
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"Shared care" by Dave Freeman

When it comes to fees, there are inevitable turf wars between factions within the profession, and as raised by Dr Olga Ward's April guest column, the current practice of private obstetricians triggering the Medicare safety net with a hefty fee for pregnancy planning - sometimes to the GP's detriment - is a slippery slope.

Based on 2007 figures, obstetric services account for around $99m (31%) of the $319m Medicare safety net. The safety net presently covers 80% of out-of-pocket costs incurred outside hospital once families or individuals spend $1111 on medical expenses in a calendar year ($555.70 for low-income families).

As Medical Forum went to press, an independent review of the Medicare safety net - and the hefty impact of obstetric fees - was in progress.

Shared care and staking claims

Dr Ward's column (Antenatal Care: When is a pregnant patient allowed to be ‘normal'? April edition) raised a situation the GP faced when a private obstetrician had asked her to rescind her fee for pregnancy planning and management beyond 20 weeks (Medicare item number 16590, a ~$100 rebate) as they, in turn, needed to use the rebate to trigger the safety net for their own considerably larger fee.

So who is in the right? GPs often see their patients during pregnancy and help with planning, but many private obstetricians like Dr Vincent Lee feel claiming fees for pregnancy planning beyond 20 weeks is solely their domain.

"I strongly believe the pregnancy planning and management fee (PMF) should only be charged by the delivering doctor. That's where the greatest risk lies," he said.

"I had a patient whose GP obstetrician charged her the PMF at 20 weeks. When she came to see me for delivery, I had to give her a discount on my PMF as she could no longer claim it from Medicare. So rather than have her argue with her GP to rescind the fee at 20 weeks, I reduced my PMF so she wouldn't stress out."

"There are undoubtedly a number of players in a women's antenatal care, but in its current format with the delivering obstetrician taking overall responsibility for the medical management of the pregnancy, I think it is not unreasonable for the obstetrician to trigger the PMF," private obstetrician Dr Cliff Neppe agreed.

Dr Louise Farrell, also a private obstetrician, felt this item number was a difficult issue.

"It is an item number that covers planning and management of a pregnancy that has progressed beyond 20 weeks. Obstetricians regard it as their payment for being available or organising cover for availability 24 hours a day, 7 days a week. It is the obstetrician that has to manage all the obstetric issues in a pregnancy after 20 weeks. Dr Ward may well dismiss those "few frantic hours", but unfortunately, they are the crux of the matter," she said.

"The 16590 is an avenue for obstetricians to make up for the woeful scheduled fees in a manner that allows the patient to recoup these costs. Obstetrics is becoming increasingly complex with more routine testing and issues to discuss and resolve."

Obstetrician and gynaecologist Dr Michael Gannon does not see a reason for a GP/specialist turf war over the PMF.

"There is little genuine appetite for shared care in my private patients, even from that not insignificant part of my practice from rural areas. Private obstetric care consistently rates highest in any measures of patient satisfaction. The antenatal visit constitutes far more than an opportunity for screening for pre-eclampsia. It is also about building trust and a therapeutic relationship for that time on the labour ward where decisions need to be taken in minutes, rather than hours," he said.

On the other hand, Dr John Overton, currently at KEMH and previously a private obstetrician for 25 years, said, "I feel sorry for GPs. This is all about acting with common sense and GPs need to do what they feel is right."

GP obstetrician Dr David Van Der Moezel has had the opposite experience to Dr Ward.

"I have never been asked by any obstetrician to rescind my fees. In fact, I have been reminded by private obstetricians to be sure to claim item 16590," he said.

How much is too much?

Allegations of private obstetricians charging up to $9000 has been levelled by the media recently, but Drs Farrell and Gannon believed this was most likely in Sydney's affluent eastern suburbs, not in WA. But what of the flipside? Dr Gannon said the PMF was former Federal Health Minister Tony Abbott's recognition of the historic underfunding of obstetrics. Are we now seeing the other extreme end of the pendulum swing?

"I believe that the schedule obstetric fees have been ridiculously low for a considerable period of time and quite out of context with other specialty remuneration. The safety net provided a means where obstetrics was more recently seen as an attractive medical specialty, after many years of dramatically falling interest due to high litigation indemnity costs, unfavourable work hours, and poor remuneration. The ability to charge reasonable fees that were not entirely borne by the patient was seized upon by the obstetric fraternity. Unfortunately, too enthusiastically by some," Dr Farrell said.

Dr Lee does not see a problem with the current level of fees.

"In private practice, you can charge anything, as long as the patient is willing to pay. I won't say [$9,000] is too high," he said.

But Dr Overton can see a correction on the cards. "Like the case with high executive wages, [if high obstetrics fees are made public] there will be very little public support and some doctors may be shamed," he said.

The impact of lowering the safety net

It has been suggested by some obstetricians and gynaecologists that the safety net rebate could be reduced from 80% to 66 %. According to figures in the Herald Sun, this would reduce rebates on current charges from an average of about $4,000 to $3,300.

But will a reduction in the rebate lead to a reduction in fees charged by private obstetricians?

"Any changes to the safety net might see some sort of reduction in obstetric fees, but more importantly, there would be a reduction in patient rebates, something that the AMA, if not NASOG, opposes," Dr Gannon said.

Dr Neppe suspects fees would remain unchanged.

"Some obstetricians may reconsider what they charge, although most, I suspect, charge what they consider reasonable. I don't believe a reduction in the Medicare safety net will have a great impact on the private health system. I believe most people choose private health insurance to have greater choice and autonomy in their own health care," he said.

Conversely, Dr Farrell believed the rebate reduction would see small obstetric fees.

"It is a natural marketplace response to transfer costs to the patient. It is likely that the private health system will still continue to be strong as there is overload on the public system and little ability to absorb extra patients. There is likely to be a period of readjustment while the fees and what the marketplace can afford equilibrate," she said.

The way forward?

What is the future of shared care in pregnancy planning? For a start, Dr Anne Karczub, KEMH Medical Director, Obstetrics, felt that "all models of care should involve the GP to a greater or lesser degree, as ultimately, the woman and her baby will come back to the GP for ongoing care."

Dr Van Der Moezel said that when a pregnancy being cared for by a GP develops into a high risk case, the GP quite rightly wants to bill for the planning up to that point, before handing over to the obstetrician.

"Under these circumstances, both the GP and obstetrician should be able to claim 16590 as the circumstances warrant a new plan, so why not allow a new 16590? An even more radical idea would be to allow either the GP or the obstetrician to claim a new 16590 for major changes in the previous plan," he said.

Dr Neppe agreed with this logic, saying, "A share care arrangement involves a close and mutually respectful working relationship between all concerned in the patient's antenatal care. The notion of a specific item number for pregnancy and planning as well as planning for labour is interesting and I would support further consideration."