Strong backlash to Medicare mental health compliance push

Doug Hendrie

12/02/2020 4:51:04 PM

Hundreds of angry GPs have signed a petition calling for an end to the latest Medicare compliance campaign.

Dr Harry Nespolon
RACGP President Dr Harry Nespolon said separating mental and physical treatments ‘seems entirely counterproductive’.

More than 700 people have now signed Dr Gillian Riley’s petition to stop the compliance push, which many GPs fear will stop them from treating a patient holistically.
RACGP President Dr Harry Nespolon has criticised the compliance push, backed by many of Australia’s vocal and high-profile GPs.
‘Requiring GPs to see patients for a mental health issue one day and their physical health issue the next day seems entirely counterproductive,’ he told newsGP.
‘Many patients have both physical and mental medical concerns and it’s entirely within the scope of general practice to treat the whole person.’
The issue stems from the Department of Health’s (DoH) latest ‘nudge’ letter, sent last week to 341 GPs who the DoH believes have been overbilling mental health items alongside normal GP consultation items.
Under Medicare Benefit Schedule (MBS) rules, GPs should not claim normal consultation items if a patient has initially attended for a mental health item, unless it is ‘clinically indicated that a separate problem must be treated immediately’.
That, many believe, acts as a disincentive to whole-of-person treatment, and may make it harder for vulnerable people to access care.  
According to Dr Riley’s petition, the flow-on effect will be to ‘reduce the number of GPs who feel safe to look after people with complex mental and physical health conditions’.
‘This specifically discourages the [holistic] care of patients with mental health concerns … It’s ridiculous to think that mental health issues present in isolation,’ the petition states.
‘In fact, we know that the burden of physical illness in this group is higher and yet we are asked to deal with the mental and physical aspects of their health on separate days.’
Many GPs and health policy experts have spoken out about the letter in recent days.

GP and ANU Associate Professor Louise Stone told newsGP that the DoH is undermining best practice by targeting GPs treating mental and physical conditions together.
‘Treating mental and physical illness together is best practice,’ she said. ‘People with mental illness die up to 20 years earlier than others – and due to physical ill health. The comorbidity of mental and physical health is extremely high.’
Associate Professor Stone said that earlier ‘nudge’ letters targeting opioid and antibiotic overprescribing had been trying to identify poor medical practice.
‘This letter doesn’t make any clinical sense. Patients shouldn’t have to send their head into the doctor one day and their body another,’ she said.
‘This is clinically incredibly unhelpful. Identifying [GPs] by what they bill isn’t going to help identify problem people. You’re just picking up high users [of MBS items].’
Associate Professor Stone said MBS rules are often vague.
‘If you go to the mental health item listings, you see that you can only bill if it’s clinically indicated for immediate treatment. What’s “immediate”?’ she said.
‘If I’m rural and a patient with schizophrenia comes in who may have trouble making an appointment, it makes sense to do their blood pressure. How is it saving money?
‘They’re targeting us for not being able to interpret a very unclear message.’
Associate Professor Stone predicted younger GPs will respond by effectively volunteering their time and not claiming for items to which they would be entitled.
‘It’s manipulating people into charging Medicare less,’ she said.
Brisbane GP Dr Wendy Burton told newsGP this compliance letter has ‘hit a raw nerve’ and described it as ‘bureaucratic bullying’.
‘I’m mad as hell about this. It’s a bridge too far,’ she said. ‘GPs are losing sleep over the fear factor and intimidation, the suggestion that we’ve done something wrong.
‘This is Australia in 2020, with drought, bushfires, coronavirus and flooding rains. We are a traumatised nation. And then they’ve dropped this on us. The timing is rubbish.
‘The campaign engenders fear.
‘People with chronic and complex mental health issues, childhood trauma survivors, and people with PTSD – we need to be keeping an eye on them regularly and along the way, dealing with their physical health issues.’
Dr Burton said that if she followed the letter of the law, she would have to ask people presenting with a mental health issue to come back another day to treat their physical issues.
The DoH was approached for comment. 
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Dr Gihad Chabbou   12/02/2020 8:37:43 PM

It is disgusting as I do work in Cobram rural Victoria and my special interest is mental health dealing with lot of stressful farmed and high unemployment rates I received a letter from Doh to audit me about my voluminous people I see. How demoralising is that and supportive in our future management of our distressed patients.
This is appalling and creating anxiety and fears in continuing treating the patients. We in my region struggling to find counsellors and mental health services.
Dr Chabbou

Tos   13/02/2020 7:13:43 AM

GPs need to be united to end this threat to patient care and outright intimidation. The seperate billing of mental health and physical conditions is ridiculous and shameful

Dr Rohit   13/02/2020 8:20:59 AM

DOH should realise people living in low socioeconomic conditions likely to have more Mental health issues. Separating body n mind doesn't sound justified.
Some client’s are just on feet.
Everyone knows people have other priorities as well and calling tham back involves logistics n neglect towards other commitments.
We talk about holistic approach and DOH is forcing doctors to move away from it.
DOH should rethink this decision.

Dr Rita Liana Ponce   13/02/2020 8:22:04 AM

I believe that as long as your records indicate that 1. the patient came for a medical consult, PE is done and management was in place then 2. says "and also, I think I need to see a counsellor..." the billing should be allowed. Patients usually says one problem before stating what they really came for.. and that is usually for their mental wellbeing.
It seems like they test the waters and gather courage first before they mention the mental health problem... Why do they crucify GPs for doing their job properly?
Anyone out there?

SD   13/02/2020 10:12:10 AM

It is extremely frustrating to work in the constant fear of paybacks. Instead of finding fraud, they are now finding small clinical errors in genuine consultations and make it look like fraud for example things like prescribing Augmentin instead of Amoxycillin and fining in hundreds of thousands of dollars. GP’s are soft and easy targets. In a 15 minute consult, nothing is perfect and it is easy to evaluate someone else’s notes and find errors. They shouldn’t be allowed to intimidate and denigrate GP profession like this.

Dr Christine Mary Ahern   13/02/2020 10:36:15 AM

The issue here is that the DoH think people fit into neat little compartmentalised boxes of mental or physical health. As others have said more eloquently, this is absolutely not so. I do not relish the idea of triaging a person’s mental health needs against their physical needs even more that I already do, to see which comes up trumps.
Secondly they seem to think it’s easy for patients and their doctors to find and arrange another early appointment for the unexpected new, or exacerbation of an existing problem, identified either by me or the practice nurse. This also is not so. Not for the practice where I work, or any, I suspect, in the rural area where I work.
And finally, just a reminder to the DoH, that all medical students transit through general practice as part of their training. They have eyes and ears and I doubt they are ‘feeling the love’ about general practice, and particularly it’s relationship with the DoH, at the moment.

Dr David Monash   13/02/2020 12:24:49 PM

As a doctor who was present when the mental health items were developed and applied by Medicare I can categorically state that there was no such restriction intended or applied to these items.

Item 2713 was developed as a "procedural item" with the stated intention it would be used in conjunction with normal consultation items - this was agreed by department officials at the time of its development and implementation. In the real world physical and mental health should always be reviewed together it is the bonus GP's have over other specialities.

I Quote:
"The GP Mental Health Treatment Plan, Review and Consultation items cover the consultations at which the relevant items are undertaken, noting that:
· if a GP Mental Health Treatment item is undertaken or initiated during the course of a consultation for another purpose, the GP Mental Health Treatment Plan, Review or Consultation item and the relevant item for the other consultation may both be claimed;
202003 – MBS Page 105"

Dr Irene Rosul   13/02/2020 12:55:45 PM

Its really so many strange systems in this country. If we need to get an authority script-A GP need to get the permission/ authority script number from just a telephone operator! Non medical persons sitting an calculating how the GP'S should claim their Billing, its only because GOVT is paying indirectly( its all of our money via tax) paying for the bulk billing !! A patient rarely comes only for mental health problem, due to traffic, their own work, transport , parking every pt's come with at least a few propblems. If you work as a GP we know what happens if we say I wound be able to help to do your mental health plan/ ref today you need to come another day, I am sure everyone knows the answer or we see it in review, she rushed me -she didnt wantys to hear my problems!!! Its really getting very difficult ....!!!!

Dr Irene Rosul   13/02/2020 2:47:04 PM

A lady saw me today-Initial booking was for PAP smear.
then HPV-Vaccinations inquiry.
lastly-she opened up and asking help for her anxiewty.
She had counselling before with 2 different psychologist with no help!
Then she had Medications didnt help her.
then she took prn valium for panic attack.
now not sure what will help her.
I couldnt tell her about the GOVT Rules of Mental health consult is not applicable with normal consult!

Dr Aletia Vivienne Johnson   15/02/2020 9:14:38 AM

Thank you for coming to see me about your depression, Mrs Jones. As you can see, we have spent 23 minutes talking about it. As per medicare rules, I will charge a 2713. What, it is worth less than a standard 36? Yes, that is because your mind isn’t worth as much as the rest of you. Oh, you have developed crushing central chest pain now and it radiates down your left arm? I’m terribly sorry, but medicare says I am not allowed to treat that at the same consultation. Please come back tomorrow if you are not dead.

Dr Susan Elizabeth Tyler-Freer   16/02/2020 11:48:41 AM

Before this nudge campaign I received a “please explain” phone call about the same issue, telling me I was outside the norm of co-claimed mental/physical health numbers and that I was going to be monitored to ensure that I improved my proportion of consult numbers billed without a co-claimed mental health number.

My entire practice was 45-60 minute appointments with patients with PTSD, complex PTSD, other serious mental health struggles, and drug and alcohol issues. My other practice is almost entirely palliative care, again with 60-90 minute appointments where physical and mental health issues are inextricably linked.

I was so disheartened after that phone call that I gave up practice. It broke my heart.

I now work only out of hospital, plus a small handful of home visit only patients where I go out twice as often as I would normally and struggle to keep everything to 40 minutes so that I can just bill a 44 and not end up working for free.

I loathe this situation.

Dr KLD   22/02/2020 10:09:26 PM

I've spent three years gaining a postgraduate qualification in family and systemic therapy, to complement training in interpersonal therapy and a previous honours degree in psychology, to facilitate working in rural and remote areas with vulnerable populations and news about the department's lack of support and "guilty until proven innocent" stance has made me rethink that entirely. colleagues that work in other specialties have mostly chosen those specialties because they could not carry the strain of working in the role that we GP's do... Dealing with complex biopsychosocial and chronic is probably not the case but I feel that we are one of the most targeted groups, poorly reimbursed for throwing our lives into the profession, and you're expected to go on every day as if these attacks are water off a ducks back.