How concerned should GPs be about proposed PSR changes?

Last week, the Health Legislation Amendment (Medicare Compliance and Other Measures) Bill 2022 was reintroduced into the Senate.
 
Originally introduced in October last year, the proposed legislation was allowed to lapse in the wake of the election being called in April.
 
According to Labor Senator Katy Gallagher, who tabled the Bill, its ‘primary intent’ is to strengthen the compliance powers of the Professional Services Review (PSR) and to add a degree of flexibility to the regulator’s ability to address the inappropriate practice of corporations.
 
‘Australian Government expenditure on the MBS, PBS and CDBS [Child Dental Benefits Scheme] is projected to be nearly $44 billion in 2021–22,’ she told the Senate.
 
‘As stewards of this investment in the health of Australians, the Government is committed to protecting the integrity and financial viability of Medicare, ensuring that Australians may continue to have access to our world-class health system.
 
‘While the vast majority of healthcare providers do the right thing when claiming Medicare benefits, there is unfortunately a small number that do not.
 
‘In most cases, these are a result of mistakes and administrative errors, but in some cases, it is as a result of incorrect or inappropriate claiming and, at worst, fraud.’
 
Senator Gallagher went on to say that ensuring ‘rigorous, effective health practitioner compliance’ and identifying healthcare practitioners who are not doing the right thing is ‘vital’ to protecting the integrity of Medicare.
 
‘Historically, compliance activities have concentrated on the behaviour of individual practitioners, on the principle that practitioners are ultimately responsible for what is billed under their Medicare provider numbers,’ she said.
 
‘While this principle remains critical, the Government needs to adapt its compliance arrangements to an environment where corporations are employing or otherwise engaging practitioners, and are increasingly involved in, and influencing the provision of, healthcare services.’
 
An inquiry into the legislation led by the Senate Community Affairs Legislation Committee elicited a number of submissions, including from the Department of Health, PSR, and medical colleges. While most are broadly supportive of the intent of the legislation, some potential issues have also been flagged.
 
The RACGP submission, sent in February 2022, provides ‘in principle’ support for measures aimed at preserving the integrity of Medicare and use of health resources by preventing wrongful claiming, but also asked that the Committee consider the impact on the broader profession.
 
‘It is reasonable to have aligned accountabilities and regulations for individual practitioners and corporate entities; however, the potential for unintended consequences needs to be further explored,’ the submission states.
 
‘We acknowledge the elements of the Bill that aim to protect individual practitioners from being prejudiced or penalised should their employer come under scrutiny [but] the RACGP recommends clarifying the role and obligations of individual practitioners during an investigation with dual lines of inquiry to avoid confusion and concerns regarding culpability
 
‘[Additionally], the increase in sanctions and broader debt-collecting powers suggest a focus on cost recovery and punitive approaches to compliance, rather than an educative focus that supports practitioners to bill correctly.’
 
But despite the reservations of the college, and other organisations such as medical indemnity insurer MIGA, the Bill has been tabled by the Committee without amendment.
 
RACGP Expert Committee – Funding and Health System Reform (REC–FHSR) member Dr Emil Djakic believes the Bill in its current form is unlikely to impact the vast majority of GPs practising in Australia – but he is also sceptical of its benefits.
 
‘It’s basically allowing them to go after corporates, instead of just individuals … [but] this doesn’t particularly strengthen Medicare – that’s just a political slogan,’ he told newsGP.
 
‘If anything, it just consolidates further regulation of a system that’s already broken.’
 
Instead, Dr Djakic says widespread reform and simplification of Medicare, combined with a greater emphasis on education and support, is needed to improve compliance and ensure better utilisation of finite medical resources.
 
‘I always get worried that we spend so much time focusing on the PSR compliance argument, which is really the very much smaller end of the argument, versus the great amount of other work we should be undertaking,’ he said.
 
‘This is focusing on the pointy end of the pyramid which is really very important, but … we would rather be working with the [Department of Health] in a collaborative way to help bring education and clarity to our GP population.
 
‘The fact that so many people drift into problematic usage of Medicare is because it’s become completely unusable, and therefore open to misinterpretation.
 
‘The base of the pyramid is where the work really needs to be done.’
 
To support his position, Dr Djakic pointed to team care arrangements.
 
‘[These] have now been in place for 15 years and we’re still talking about the interpretation of the wording,’ he said.
 
‘There’s got to be a problem here if we’re still seeking clarification from Medicare and getting confusing answers. Our members regularly report that they’ve made an inquiry and gotten two different answers, and so they don’t know where they stand.’
 
He also likened the focus on punitive compliance to treating diabetes once it has gotten out of control, rather than managing the condition early or instituting lifestyle changes to prevent it from developing in the first place.
 
‘Clearly, educate is a better return than just growing more Star Chambers. [At the moment] it’s not treating the “disease”, it’s treating the end result,’ Dr Djakic said.
 
‘You don’t start diabetes treatment diabetes by amputating limbs. You do the preventive work, educate and help them to realise there’s things that they can do, and need to do.’
 
However, he also warned that GPs need to be vigilant in ensuring that they are doing their best to bill correctly and maintain sufficient evidence should they come under investigation, including those working for practices that have taken a more active role in assuming control of billing processes.
 
‘The majority of this … [relates to] the change in the industry, the change in the business model, and realising that there are corporate bodies that can sometimes be behaving badly without the doctor realising it,’ he said.
 
‘[But] we need to be educating to make sure those members are aware that if they were in that situation, they are still obliged to have a good handle on what’s been billed … they need to be checking their day sheets and getting an idea of what’s actually been handed over.
 
‘Ignorance isn’t acceptable.’
 
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