‘Nudge’ letters in spotlight amid GP push back on compliance campaign

Doug Hendrie

14/02/2020 2:42:46 PM

Concern over the Government approach has seen thousands join the backlash against the latest letter targeting mental and physical health co-claiming.

Dr Nespolon and the letter
RACGP President Dr Harry Nespolon has described the letter as an ‘intimidating and heavy-handed tactic designed to pick on a small group to affect the whole group’.

More than 4000 people have now signed Dr Gillian Riley’s petition, while Melbourne GP Dr Mariam Tokhi has called for an immediate end to the crackdown in The Guardian.
‘While the warnings are ostensibly aimed at GPs “rorting” the system, the effect is to frighten – and punish – family physicians providing whole-person care,’ Dr Tokhi writes.
RACGP President Dr Harry Nespolon has backed critics of the letter, describing it as an ‘intimidating and heavy-handed tactic designed to pick on a small group to affect the whole group’.
The Department of Health (DoH) has moved to address rising concerns, stating that there is ‘absolutely no suggestion that it is not appropriate to treat mental and physical conditions in the same consultation’.
The move is unlikely to mollify angry GPs.
The backlash to last week’s letter comes after the RACGP warned – in a submission to an audit of the DoH’s approach to health provider compliance – of a growing perception among GPs that ‘compliance activities are designed to monitor and target statistical outliers, as opposed to targeting fraudulent activity’.
Dr Michael Wright, Chair of the RACGP Expert Committee – Funding and Health Reform (REC–FHSR), told newsGP the letter has exposed issues regarding the use of algorithms to find outliers within the billing system.
‘Just because you’re a statistical outlier doesn’t mean you’re practising inappropriately,’ he said. ‘We’re trying to make this clear to Medicare.
‘This is the challenge of using algorithms which don’t take into account patient cohorts or practice circumstances.’
In a further sign of the rumbling dissent – made clear on social media and online discussion forums – GP Dr Rebecca Kerr has written an open letter to Federal Health Minister Greg Hunt.
‘I have grave concerns about the very real harm being done to GPs’ mental health and to the general public by the letters being sent to GPs by the government,’ Dr Kerr writes.
‘The level of distress I am seeing amongst GPs in the online community is real, high and appears dangerous. It is interfering with their ability to work and their ability to be with their family.’
Dr Kerr points out that previous DoH compliance letters have failed to take patient cohort and GP-specific circumstances into account.
After receiving a warning letter over her prescribing of the so-called chemical restraint risperidone for a single aged care patient, Dr Kerr decided to simply stop providing services to aged care homes.
‘I was seeing someone with a mental health indication for risperidone ... I got a letter,’ she writes.
‘It was already costing me money being away from the clinic to do this extra service, it was already hard work, with lots of extra phone calls. This letter was the straw that broke the camel’s back. I quit. I don’t provide this service.
‘What does the government see? Success. They ‘“fixed’’ my prescribing. What don’t they see? Reduction in services to the most vulnerable members of the community.’
Dr Kerr argues that the controversial opioid prescribing letter was similarly poorly targeted, and failed to consider GPs with a special interest in palliative care.
Dr Wright said the RACGP is working on the issue.
‘The RACGP is working hard to try and get clarity on these issues and to make sure the different arms of Medicare compliance are providing consistent and clear information for GPs,’ he said.
‘As GPs we treat the whole person. The issue now is that GPs might not deal with a physical problem when someone has a mental health condition, or vice versa, for fear of getting audited by Medicare.’
Dr Wright said the new compliance push will affect how he practices.
‘Frequently, I’ll have a patient for a mental health consultation who also has chronic physical conditions I manage. But I’m now cautious about billing patients for both because I’m concerned I might gain the attention of Medicare compliance.’
To stay safe, Dr Wright recommends ensuring the time and content of all MBS items is met.

‘For most mental health items there is a minimum of 20-minute consultation time. If you only have a 15-minute consultation, you can't be doing a mental health consult, let alone doing both a mental health and physical health item.’ 
The DoH has told newsGP that targeting holistic care was not the intention of the letter.  
‘[The DoH] taken steps to exclude consultations where there was evidence in claiming data that the provider may have been seeing the patient for both mental and physical conditions,’ a spokesperson said.
‘For example, exclusions included where the patient was referred for a pathology or diagnostic imaging service on the same day.
‘This activity is designed to ensure that where this occurs, doctors understand how to appropriately claim Medicare items [and] to provide guidance to GPs to ensure correct claiming of professional attendance items where a mental health treatment item has also been claimed.
‘Recipients have not been requested to provide any evidence to support their claiming; however, they have been advised of the appropriate steps they should take if they do self-identify any incorrect claiming that has occurred.’
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Dr Johanna Margaret Lynch   15/02/2020 6:35:42 AM

Oh my - a measure of whether we have cared for the body is whether they can see that we have prescribed or ordered pathology??? Really? Is this all that generalist physical care is- testing and prescribing ? What about prevention - for eg,. the smoking cessation conversation - how will they divide that work: physical or mental??
As a GP who has spent the last 4 years writing a PhD on whole person care I am appalled to hear of this reduction of our sophisticated, complex work into 'physical and mental'... where physical is measured by how many tests and drugs we use - it just shows the system does not understand how much we save them by not prescribing, not referring, not testing... because we have done the good quality work that means those interventions are not needed. As a GP who responded to the need in my community for trauma informed care, and has born the significant financial and emotional cost of long consultations for 15 years, this is just another disrespectful invalidation.

Dr Sean Kumar Das   15/02/2020 7:09:14 AM

I haven’t had the misfortune to receive one of these current letters, but did receive one a few months back regarding my supposed over requesting of musculoskeletal imaging. As a doctor practising almost 30 years, more than 20 of which in general practice, I found the letter insulting and a disgrace. Once again the faceless generals far behind the frontlines telling those of us who are there in the trenches doing our best under difficult circumstances how to do our job. Needless to say, if any of us end up in court as a result one of these letters, as a result of a patient suffering an adverse outcome from having changed our practice through fear, they will be nowhere to be seen and we will left dangling in the wind at the end of a short rope.

Dr Ash   15/02/2020 7:39:12 AM

In the last few years, we the frontline soldiers of the medical community have been treated shabbily and seen as scamsters rorting Medicare. Instead of words of praise or encouragement, Medicare is sadistic and punitive actions whether its freezing rebate, sending out covert threats to GPs in the form of Medicare item number compliance letters and be seen in the eyes of public as thugs, or compliance letters on prescribing by us showing us the inefficient professionals putting the public health and life at risk.

The numb Medicare is treating the doctors as guinea pigs by sending letters to tame the whole GP community to ensure that it can make us dance to their tunes and fall into their experimental and mathematical algorithms not realising that practice of Medicine is an Art and we (humans) are treating humans and it can't be one fit all situation.

Kudos to Harry for trying to make deaf Medicare hear the fear-filled cries of GPs and Govt will stop nailing in the coffin of GP profes

A.Prof Christopher David Hogan   15/02/2020 9:15:58 AM

It will be a great day when regulators make the effort to understand the complexity of General Practice & the massive contribution it makes to the health of Australia .
GPS are sick of the ignorant, disrespectful , heavy handed disdain with which they are bullied by a bureaucracy that sees them as a cost rather than an investment.
In their pathetic arrogance too many assume they not only know what a GP does but that they can do a better job.

When medical, nursing or allied students sat in with me for teaching I explained the complexity of the consultations. Almost universally they would express their surprise
- I thought Being a GP was easy
- It is so difficult
-You deal with so many issues
- There are so many things you need to check
-You make it look easy
-I’d prefer to be a ( non GP) specialist it is not as complicated

Dr Bahman Ranjbar   15/02/2020 1:28:52 PM

I work in a rural area and if a patient referred to psychologist it takes more than few months to be seen. Most of the time when they visit the psychologist due to out of pocket charge, which the psychologist will request, patients stop the follow up with psychologists. Most of my patients are pensioners who have several comorbidities and they cannot effort to pay out of pocket. Therefore, they come back to me to get help. They knew GPs will consider their condition and will do the bulk bill. Many of these patients also have chronic comorbidities and needs appropriate follow up. Due to waiting list timing, when they find a chance to come in, they request to manage their physical condition in addition to their mental health. They knew if they go out of room it takes more than 1 – 2 weeks to be able to have another appointment. I have been trained as a GP psychologist by RACGP and most of my patients prefer to follow up their mental health with me because I know them and their family.

Dr Bahman Ranjbar   15/02/2020 1:29:33 PM

Most of them believes and would like to manage their conditions with one person. We as doctors know that most of the physical comorbidities strongly related to patient mental health and needs to be managed appropriately to have a better outcome for patients and community.
Now my question is how can I ask the patient to leave the room and come back another day to manage his chronic physical condition? When a patients comes to me and starting to cry due to mental tension how can I ask the patient to leave the room in 20 minutes or after managing his mental condition tell the patient because his physical condition is not an emergency he has to come back another 1 – 2 weeks or goes to emergency department for proper management? Isn’t it increasing the working load on the emergency departments in hospitals?
What should we do as a general practitioner who feels responsible for the patients and his family wellbeing?

Dr Bahman Ranjbar   15/02/2020 1:29:51 PM

Why DoH does not talk to patients to find out if they are happy with their Gp or not, instead of creating tension to general practitioners.
Who is responsible for the tension we as general practitioners will received by such these letters which will affect our confidence to deal with day to day mental and physical condition of the patients?
It will be highly appreciated if anyone could answer to my questions.

SD   15/02/2020 3:30:47 PM

This whole thing will result in saving few millions to government in the short run by overall reduced claiming and PBS prescriptions by GP’s due to fears and intimidation of heavy fines. This success is not compared to poor patient care and reduced access to GP’s. I feel that work environment of GP’s is shifting unnecessarily from patient care to actually satisfying lines in MBS items descriptors. It is becoming increasingly stressful for things GP’s shouldn’t be worried about at all. My UK colleague who moved to Australia said that NHS look a better system than Medicare now.

Dr John Joseph Scally   15/02/2020 4:58:09 PM

Apart from the unwarranted pressure and anxiety that this letter causes conscientious GPs who are just trying to help their patient,I would like to know why we even have to do a Mental Health Plan.
We are able to refer to specialists with a referral letter so why can't the same process be used to refer to clinical psychologists.
I feel the whole thing is a clumsy bureaucratic hurdle whose only purpose is to raise an item number that triggers a medicare rebate for the psychologist visit.

Dr Peter James Strickland   16/02/2020 11:32:43 AM

The best thing here is to totally reject the letters as being pragmatically accurate, and continue to practice as you see as ethical and in the interest of your patients. It must be remembered that these public servants have little or no experience in pragmatic community medicine. My colleague who was a GP for 40 years was "counselled" for too many home visits; what he was doing was visiting his now very elderly patients to help them from having to come in for monitoring their health problems, delivering their scripts to the pharmacy etc. --totally ethical practitioner. I gave the DoH a big 'rocket' for their total ignorance and arrogance! Don't worry about these public servants ---just send back a short letter and tell them you won't be changing your practice on false assessment of one's practice by a computer program, AND you insist the Health Minister visit your practice, AND there is an insistence that there be a Ministerial into the practice of these public servants letters.

Dr Greg Saville   16/02/2020 12:56:23 PM

Please don’t call these letters “nudge” letters. This shows an ignorance of what behavioural insights team do. Read Thaler and Sunstein’s “Nudge” or David Halpern’s “Inside the Nudge Unit” for a better understanding of nudge campaigns.
This government campaign is more sinister and is reminiscent of the Centrelink Robodebt debacle. This latest letter writing campaign relies on FUD (fear, uncertainty and doubt) in attempt to increase government revenue. You all know what to do at the next election...

Dr Peter JD Spafford   16/02/2020 1:58:35 PM

My father always said any system that makes and honest man dishonest, is a bad system. Annual membership fees are too expensive and difficult to manage, so we are now doing daily membership fees of $30 (and $20 for concession card holders) for access to the clinic facilities and bulk billed services on the day. It is working well and the patients love it. Suggest others do the same.

Dr Eric John Drinkwater   18/02/2020 12:24:05 PM

is this gaslighting? it is NOT illegal to co-bill, just a cloudy set of rules need to be followed. The usual bizarre indicator of top percentage of activity is being presumed to be rorting. This ain't a nudge, its another shove because the profession has not pushed back strong enough against previous shoves ... where do we make our stand and fight? Is now the time we all stand and shove back?

Bizarrely there are GPs finding out they are under billing ... with better understanding of the rules (medical problem first THEN mental health problem) there is going to be more 23/2713 co-billing, not less. The best "up yours" the profession can offer is exactly this ... more correct itemisation not less.