Medicare integrity ‘more than just compliance’

New legislation giving the Professional Services Review (PSR) greater capacity to target wrongful Medicare claiming by corporations rather than single practitioners has now passed Parliament.
 
With bipartisan support, the Health Legislation Amendment (Medicare Compliance and Other Measures) Bill 2022 went through the House of Representatives on Monday.
 
As well as delivering new authority to the PSR to include corporates in their compliance activities, the legislative changes also aim to improve debt recovery processes.
 
Dr Edwin Kruys, a member of the RACGP Expert Committee – Funding and Health System Reform, said the college backs actions to counter Medicare misuse.
 
‘The RACGP supports measures aimed at preventing wrongful claiming and it is reasonable to have aligned accountabilities and regulations for individual practitioners and corporate entities,’ he told newsGP.
 
However, he said the new laws will do little to tackle underlying systemic issues.
 
‘If you place this legislative change in a bigger picture something is wrong,’ he said.
 
‘Health providers are tired of hearing decisionmakers state that we need to protect Medicare’s “integrity” through introducing tougher compliance measures.’
 
Dr Kruys describes compliance as ‘part of the picture, but … a very small piece of the puzzle’.
 
‘Legislation such as this does not address the real issues Australia is facing, such as the waste that occurs through Australia’s disconnected and fragmented healthcare systems, the administrative burden Medicare’s confusing complexity places on health providers and the relentless and demoralising focus on a punitive compliance approach, giving the false impression Medicare just needs to be protected from the health professionals working in it,’ he said.
 
For Dr Kruys, the priority should be to simplify Medicare rules and introduce item numbers that respond to contemporary challenges such as the increased level of chronic disease.
 
‘Integrity means acting swiftly in response to the requests from the profession to, for example, introduce MBS item numbers that allow them to spend more time with patients who need it most – not continue to support a system that encourages high throughput,’ he said.
 
A number of parliamentarians, including those with extensive medical backgrounds, also raised broader issues about Medicare when speaking during the Bill’s second reading this week.
 
Dr Michael Freelander, a paediatrician turned politician now representing the NSW electorate of Macarthur, said he may have been the only member of the House of Representatives who had once relied entirely on Medicare repayments.
 
Noting the recent media attention on compliance, Dr Freelander outlined his belief that the broader issues are systemic.
 
‘This is actually a system problem that relates to the history of the development of health services in Australia and the changes that have occurred in the last several decades,’ he said.
 
‘Essentially, we are using the same system now that was developed in Australia in the 1960s.’
 
He said the changes to illness patterns, bulk-billing rates, and rebates make the system ‘much less equitable’.
 
‘The system is not designed to deal with the current age of chronic illness and an ageing population, so people are forced into non-compliance,’ he said.
 
He also acknowledged that fraud does occur.
 
‘This is a $50 billion scheme and some people will not do the right thing,’ he said. ‘But those numbers are very small.
 
‘Practitioners are almost forced into non-compliance with a scheme that doesn’t deal with chronic illness, doesn’t deal with patients with multiple system disorders, doesn’t deal with the time it takes to deal with the social determinants of health – things like housing, medication costs, family issues, education.
 
‘The medical system is not designed to deal with all these issues.’
 
Subsequently, the Member for Kooyong, Professor Monique Ryan – who formerly worked as a paediatric neurologist – referenced the repeated use of legislation in Parliament focused on inappropriate billing. In her speech, she cited amendments to health legislation in 2018 and 2019, as well as the Health Insurance Amendment (Administration) Bill 2020 as examples.
 
While she commended this latest Bill, Professor Ryan also warned of a potential to compromise care.
 
‘This government needs to have different regulatory expectations of corporate entities of varying sizes and resources as compared to smaller individual practices,’ she told Parliament.
 
‘There is with this bill a real risk of increased compliance burden on smaller practices, particularly in rural areas, which could reduce the capacity for those doctors to provide high-quality care to patients while their practices are under investigation.’

The Member for Kooyong also noted the increased penalties in this bill for the refusal or failure to produce documents or information. According to Professor Ryan, that approach ‘suggests a focus on cost recovery and punitive approaches to compliance, which may exacerbate existing concerns in the profession about the intent of compliance activities’.
 
The RACGP submission about the legislation earlier this year supported it in principle but raised concerns about the PSR’s transparency and procedural process.
 
The college also described legislation allowing the publication of details of a person who has not fulfilled their obligations under a section 92 agreement as ‘an unreasonable breach of privacy’.
 
‘We recommend a supportive and educative approach to ensuring individuals meet their requirements under a section 92 agreement,’ the submission stated.
 
The legislation was originally introduced to Parliament under the Coalition in October last year, but the process lapsed when the Federal Election was called.
 
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