PSR Annual Report 2005-2006

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Report on performance

Performance assessment

Table 1-Achievements at a glance
Target Outcome
Reviews 40 10
Committee reports issued 30 6
Final determinations issued 30 3
Effective final determinations issued 40 14

Reviews undertaken

Medicare Australia sent seven requests for review to PSR this year. The Director did not dismiss any cases following review. The Director negotiated eight agreements with practitioners where he was not satisfied a committee would not find the practitioner had engaged in inappropriate practice. Another two cases were sent to committees for further investigation and there were five cases under review at the end of the year (see Table 2).

Eight matters were the subject of applications in the Federal Court where consent orders were issued sending the cases back to newly constituted committees to be heard again.

In the opinion of the Director, none of the practitioners reviewed had caused, is causing or was likely to cause a significant threat to the life or health of patients. Consequently the Director did not initiate any referrals to a state or territory medical board.

Table 2-Reviews undertaken
2005-06 2004-05
Reviews completed 10 30
Reviews on hand 1 July 8 na
Requests received from Medicare Australia 7 9
Requests dismissed 0 15
Negotiated agreements 8 4
Requests withdrawn or lapsed 0 0
Committees established 2 11
Reviews on hand 30 June 5 8
Referrals to medical boards initiated by Director 0 1
Disqualifications from Medicare for failing to produce documents 0 0
Suspected fraud 0 0

It took an average of 208 days (313 days in 2004-05) to complete those eight cases leading to a negotiated agreement against a legislative timeframe of 13 months for completion.

Sanctions agreed as part of the negotiations were that:

There is a brief description of all eight cases involving a negotiated agreement later in this chapter.

Committee reports

The Director made two referrals to committees during the year (see Table 3). Six committees reported findings of inappropriate practice with all six going to the Determining Authority.

Table 3-Committee reporting
2005-06 2004-05
Committee reports issued 6 24
Referrals on hand 1 July 18 na
Referrals to committees
New referrals 2 11
New committees established following court orders 8 0
Referrals returned to existing committees to be heard again 7 0
Draft reports issued 5 6
Submissions received on draft reports 5 18
Final reports to person under review 6 24
Final reports to the Determining Authority 6 23
Referrals on hand 30 June 29 na
Adverse findings 6 23
Practitioner cleared 0 1
Investigation impossible 0 1
Committee sessions held 49 55
Referrals to medical boards initiated by committees 1 1
Disqualification from Medicare for failing to produce documents or attend hearings 0 0
Suspected fraud 0 0

There were 29 referrals in various stages of the process as at 30 June 2006.

With the exception of the prescribed pattern of services cases before committees during the year, most committees have used a sampling methodology to help quantify the levels of inappropriate practice and allow for extrapolation of repayment, should the Determining Authority choose this as a sanction.

One committee identified a practitioner for referral by the Director to the relevant state medical registration board because it formed the opinion the practitioner had caused, is causing or was likely to cause a significant threat to the life or health of patients.

The committee's particular concerns were that the practitioner may not have:

The average time taken for the six committees to report findings of inappropriate practice was 829 days (920 days in 2004-05).

Final determinations

Fourteen cases were sent to the Determining Authority this year. The eight negotiated agreements received were ratified (see Table 4).

Table 4-Final determinations
2005-06 2004-05
Effective final determinations 14 26
Final determinations issued from committee reports 6 26
Committee reports on hand 1 July 12 na
Committee reports received 6 23
Draft determinations issued 6 17
Submissions by person under review on draft determinations 5 15
Committee reports on hand 30 June 19 12
Negotiated agreements
Received 8 4
Ratified 8 11
Not ratified 0 0
Determining Authority meetings held 6 7
Referral to medical boards initiated by the Determining Authority 0 0

Six final determinations were issued from findings in committee reports. The Determining Authority had 19 cases under consideration at the end of June 2006, with almost all of these in the Federal Court (see Table 5).

The eight negotiated agreements were ratified in an average of 22 days (13 days in 2004-05) against a legislated timeframe of one month. A failure by the Determining Authority to ratify an agreement within the one-month limit means the agreement is taken to have been ratified.

The Determining Authority took an average of 195 days (144 days in 2004-05) to issue six draft determinations and another 158 days (186 days in 2004-05) to issue the three final determinations. This is against a legislated timeframe of one month for a draft determination and 28 days for a final determination (including 14 days for the practitioner to make submissions). The time necessarily taken to properly re-appoint and appoint members to the Determining Authority resulted in additional time taken by the Authority to make draft determinations when compared with the previous year. All time limits on the Determining Authority have an exemption clause.

During the year 14 final determinations became effective. Eight of these were negotiated agreements and the other six were as a result of committee findings of inappropriate practice.

The sanctions imposed on these six effective final determinations included:

When a practitioner has had two effective final determinations the Director must provide a written notice to the Medicare Participation Review Committee (MPRC). The MPRC has a discretionary range of options available from taking no further action against the practitioner to counselling and reprimand and full or partial disqualification from participation in the Medicare benefits arrangements for up to five years. As required under the Act, the practitioner was notified of the correspondence to the MPRC.

The Director informed the MPRC of a second effective final determination against Dr Tisdall in March 2006 pursuant to section 106X of the Act. The first effective final determination against Dr Tisdall came into effect in December 2005.1 There is a description of both these cases later in this chapter.

Court challenges

This year, the dominating cases have been those involving challenges against the prescribed pattern of services-the so-called '80/20' cases. It was always expected that practitioners would challenge findings where committees decided there were no exceptional circumstances to warrant the practitioner exceeding 80 or more attendances on 20 or more days in the specified period. This has been the case this year with the Federal Court handing down six decisions in 80/20 cases. Two judges handed down four separate decisions in favour of practitioners (Oreb, Hatcher and two in Lee2) indicating that the various committees had applied the wrong test when making findings about what constituted exceptional circumstances.

Table 5-Court actions
2005-06 2004-05
Court applications
Review 0 0
Committees 4 11
Determining Authority 5 6
Professional Services Review Tribunal 1 1
Federal and Full Federal Court hearings held 19 17
Federal and Full Federal Court decisions handed down in favour of the person under review 17a 5
Federal Court decisions handed down in favour of PSR 6 8b
High Court applications 2 0
High Court decisions in favour of PSR 1 0
  1. 12 by consent remitted back to a PSR committee to be heard again.
  2. Four applications to the Federal Court by practitioners were settled with the applications being dismissed by consent. In addition, there were two other preliminary decisions in one case where, firstly, the group of practitioners failed in an attempt to obtain an order for discovery and, secondly, it was ordered that an appeal on non-constitutional grounds proceed rather than be delayed as sought by the practitioner.

It is interesting to note that, in the next decision handed down (Tisdall), Gray J totally disagreed with the reasoning of his fellow judges in the earlier decisions, indicating that, in his opinion, their 'reasoning … was fundamentally wrong' in relation to their approach to the issue of exceptional circumstances. All these cases are now the subject of appeal in the Full Federal Court. A number have had hearings and decisions reserved. Most should have been decided for next year's report.

At 30 June 2005, 27 cases were outstanding in the Federal and Full Federal Court. (These are listed at the end of this chapter under 'Decisions of the Federal Court and Full Federal Court'.)

Re-referrals

In 2005-06 there was one request for review of a practitioner whom Medicare Australia had previously sent for review.

In June 1999 Medicare Australia referred this practitioner to the Director for consideration. Medicare Australia was concerned about the practitioner's high number of services per patient-6.87, which was above the 98th percentile at the time-and the practitioner's high rate of prescribing certain pharmaceuticals. The practice was semi isolated just outside a metropolitan area and consisted mainly of aged and retired patients. Weekends and holiday periods brought an influx of visitors. The practitioner also held an authority to dispense because of the practice location.

Following visits to the practitioner by the Director and later by a consultant on his behalf, the Director formed the view that there would be insufficient grounds on which a committee could reasonably find the practitioner had engaged in inappropriate practice in connection with the referred services. Consequently the referral was dismissed in June 2000.

The request for review in March 2006 contained exactly the same concerns as those raised in 1999-high number of services per patient and high rate of prescribing, particularly COX-2 and potential drugs of dependence. The Director is currently reviewing the matter.

Description of negotiated agreements

A brief description of the eight negotiated agreements that came into effect is given below.

Dr A, General Practitioner Adelaide SA

Medicare Australia requested a review of the provision of services by Dr A because it detected a very high level of total services (15 018 at a cost to Medicare of $479 305) that was above the 99th percentile. In addition to Medicare Australia's concern about total services, Dr A was providing a range of other services above the 99th percentile. This included MBS items 601 (after hours), 2521 (diabetes), 2552 (asthma 3+), 30006 (extensive burns), 30192 (premalignant skin lesions), 42644 (removal from cornea), 50124 (aspiration/injection joint) and 41500 (removal from ear). Medicare Australia also requested the Director to review Dr A's prescribing. During the 12-month review period Dr A had prescribed 27 051 items subsidised by the PBS at a cost of $814 299.

Medicare Australia had previously counselled Dr A in 1995 about high daily servicing and in 1999 about high pathology generation and high services per patient.

The Director reviewed Dr A's medical records. Dr A's records were seen as wholly inadequate; they did not contain sufficient clinical information to adequately inform another practitioner taking over the care of a patient. It also appeared that some consultations had been 'up-coded', where a straightforward condition was billed as a complex consultation. There was evidence of a large number of pathology tests being ordered for inadequate clinical indications. Of more concern, was the fact that the majority of Dr A's elderly patients were taking large numbers of medications with little or no evidence in the medical record for a sound clinical indication. For several of Dr A's billed consultations and procedures, there was no clinical record at all.

Following examination of Dr A's records there was sufficient evidence to conclude that a committee of Dr A's peers would find the conduct in relation to rendering of the items examined, to be unacceptable to the general body of general practitioners.

The Director met with Dr A who accepted having practiced inappropriately by not keeping adequate records that would support the services provided and the benefits claimed. Dr A agreed to be reprimanded by the Director and to repay the Commonwealth $55 000 in Medicare benefits.

Dr B, General Practitioner Perth WA

Medicare Australia sent Dr B to PSR because it detected a very high number of services, (18 203 services for a total benefit of $532 666). In addition, Medicare Australia was concerned that Dr B prescribed 25 251 items under the PBS for a total cost of $572 431. In particular Dr B's prescribing of drugs of dependence was higher than most general practitioners in Australia. On 132 occasions Dr B issued more than one original prescription for the same drug of dependence to the same patient on the same day. Many of the patients had received the same drug of dependence from other providers.

Medicare Australia had counselled Dr B in 2002 over similar concerns.

Dr B's medical records were reviewed and the rendering of MBS item 23 was examined. Dr B's records lacked meaningful history or recording of physical examination; indeed 47.5 per cent of the records were found to be inappropriate. It was noted that many of Dr B's patients had a serious drug dependency problem. There was considerable doubt as to whether these patients were attending for Dr B's expertise in treating drug dependence or for preparedness to issue narcotic prescriptions. Seventy five per cent of Dr B's long consultations (MBS item 36) were considered inappropriate. One alarming record was that of a 16-year-old girl who, despite several claims by her of 'tabs stolen, bag stolen, or scripts stolen', appeared to have easy access to prescriptions for drugs of dependence.

When confronted with the fact that a committee was likely to find Dr B had practiced inappropriately, Dr B sought the opportunity to enter into a negotiated agreement. Dr B acknowledged having not kept adequate and contemporaneous records and to having practiced inappropriately.

Dr B agreed to repay the Commonwealth $30 000 and be reprimanded by the Director. Dr B accepted disqualification from the Medicare arrangements for three years.

Dr C, General Practitioner Sydney NSW

Dr C, a vocationally registered general practitioner, worked almost exclusively in a skin cancer clinic. Medicare Australia requested a review of the provision of services by Dr C for several reasons. Dr C rendered 6 300 services to 1 826 patients for $304 586 in Medicare benefits; 69 per cent (4 371) of the total services were to 863 patients, rendered where each patient received a consultation on the same day as one or more procedures. Medicare Australia was also concerned about Dr C's use of flap repairs; Dr C rendered 225 single stage flap services to 111 patients for repair of a small defect (item 45200). This is significantly more than all other medical practitioners in Australia where the 99th percentile for this procedure commences at three services.

A PSR consultant reviewed Dr C's clinical notes. Dr C's use of a consultation item in association with a procedure was found to be inappropriate. The consultant was particularly critical of Dr C's use of cryotherapy for premalignant lesions, without histological confirmation. Dr C's use of flaps drew the following comment from the consultant: 'what is clear from [Dr C's] correspondence is that he has no proper surgical training and no concept of the appropriate choice of closure'. The report concluded '… all of [Medicare Australia's] concerns are justified'.

The Director met with Dr C and put to him that a committee was very likely to find that Dr C had engaged in inappropriate practice. Dr C sought a negotiated agreement. Dr C agreed to having practiced inappropriately in the following areas:

Dr C agreed to repay $80 000 and to be disqualified from provision of MBS items 45200, 45206 (both skin flaps) and items 31200 to 31335 (surgical excisions) inclusive for a period of 12 months. The Director formally reprimanded Dr C.

Dr D, General Practitioner Melbourne Vic.

Dr D rendered 16 564 services to 4 853 patients during the review period for a total benefit of $438 947 which was well above the 99th percentile (14 208 services) for all other active general practitioners in Australia. Dr D rendered 1 238 level C (MBS item 36) consultations during the review period. Medicare Australia was concerned that Dr D had provided services on 278 instances to three or more family members on the same day.

The Director examined Dr D's medical records and concluded that Dr D did not keep adequate and contemporaneous records that would justify the MBS item 36 claimed. In particular, the majority of records were found to be brief and lacking clinical detail. There was little evidence recorded of clinical complexity, detailed history or an examination of multiple systems. It was considered that Dr D may have based the consultations on time rather than on complexity, as is required by the Medicare Benefits Schedule.

Dr D met with the Director and, following a discussion of the issues, entered into an agreement. Dr D acknowledged having engaged in inappropriate practice by not keeping adequate and contemporaneous records that justified the MBS item 36 services claimed. Dr D agreed to repay $19 984 in Medicare benefits and to be reprimanded by the Director.

Dr E, General Practitioner Sydney NSW

Dr E practiced in a large medical clinic as a general practitioner. Medicare Australia was concerned that, because Dr E had provided 28 102 services to 10 660 patients for a total benefit of $830 208 and may not have had the time to provide appropriate services to all patients. Dr E had provided services at almost twice the number of other practitioners at the 99th percentile. Dr E was in fact the busiest general practitioner in Australia at the time. In addition, Dr E had breached the prescribed pattern of services provision of the Act (the 80/20 rule). Dr E had seen 80 or more patients on 32 days during the review period. Medicare Australia was also concerned that Dr E had provided 1 046 care plans (MBS item 720) and 702 review of care plans (MBS item 724). Dr E's rendering of items 720 and 724 was above the 99th percentile in both instances.

An extensive number of Dr E's medical records were reviewed. Of Dr E's item 23 consultations, 28 per cent were found to be inappropriate, as were 100 per cent of care plans, 100 per cent of reviews of care plans, 90 per cent of exercise electrocardiograms, 100 per cent of respiratory function tests, and 100 per cent of the removal of in-growing toenail.

The Director met with Dr E on several occasions to discuss rendering of MBS items. Dr E acknowledged conduct during the review period constituted inappropriate practice and expressed an intention to significantly change the mode of practice. Dr E claimed to have been encouraged and reassured by more senior staff at the medical centre that Dr E's work was appropriate. Dr E's case illustrates the effect poor mentoring can have on doctors early in their career.

Dr E signed a negotiated agreement in which Dr E admitted to having engaged in inappropriate practice and agreed to repay the Commonwealth $115 000 and be fully disqualified from Medicare for six weeks. The Director formally reprimanded Dr E.

Dr F, General Practitioner Outer Melbourne Vic.

Medicare Australia referred Dr F because it was concerned that the rendering of 18 174 services for a total Medicare benefit of $497 599 may have involved inappropriate practice. Dr F's level of service provision was well above the 99th percentile. Dr F's Medicare data showed that, if the claimed items were provided in the minimum time possible, it would have required Dr F to work up to 36 hours on some days without a break.

The Director examined Dr F's medical records; many did not include a history or details of examination, and the clinical content in the claimed long consultations-MBS item 36 (level C)-was inadequate and did not fulfil the item descriptor. Dr F had claimed many laceration repairs involved deeper structures and thus attracted a higher fee-there was no supporting evidence for this claim in the records. Practitioners should be aware that the MBS item for a deep laceration refers to repair of structures that lie deep to the superficial fat layers of the skin and not to use of absorbable sutures within the fat layer. Dr F was also found to have claimed for a larger skin excision item than was supported by the histological evidence.

Dr F met with the Director and after a discussion of the Director's findings was willing to enter into a negotiated agreement.

Dr F conceded inappropriate practice and having kept records that were inadequate. Dr F agreed to repay $100 000 in Medicare benefits and to be disqualified from providing MBS items 31200 to 31335 inclusive (skin excision items) for a period of six months. Dr F agreed to be reprimanded by the Director.

Dr G, General Practitioner Brisbane Qld

Medicare Australia requested the Director to review Dr G's provision of services for four reasons:

Services per patient had placed Dr G on the 97th percentile in comparison to all other active general practitioners in Australia. The proportion of Dr G's level C and level D consultations in relation to level B (MBS item 23) was substantially higher than Dr G's peers. Dr G's most commonly initiated pathology tests were for serum B12, folate and iron studies. Medicare Australia was concerned that these investigations may not have been medically necessary. Oxazepam and diazepam were ranked as Dr G's first and second most commonly prescribed drugs. Medicare Australia was concerned that these potential drugs of dependence had been prescribed for purposes that may not have been clinically relevant.

A Medicare Australia medical adviser had counselled Dr G in 1998 following a Medical Services Committee of Inquiry finding of over‑servicing. Dr G had also come to the attention of Medicare Australia in 2001 as possibly having a practice profile significantly different to Dr G's peers.

The Director reviewed Dr G's medical records. There was no recorded evidence of a medical summary, family history, drug lists, past or current medications or allergies. Dr G's records demonstrated poor management of everyday medical conditions. There was an excessive reliance on the use of benzodiazepines. The Director found Dr G had inadequate management of patients' psychological problems, mostly recorded as 'listen and talk'. There was evidence that Dr G did not modify treatment for one patient when this was clearly indicated; Dr G failed to reduce the dose of thyroxine despite the patient being demonstrably thyrotoxic, and another patient was given a further prescription for the same antibiotic despite clear evidence that it was not working.

After a discussion of the Director's findings, Dr G sought a negotiated agreement. Dr G acknowledged engaging in inappropriate practice by a failure to maintain adequate and contemporaneous records to support the consultations claimed for the MBS items 23, 36 and 44. Dr G further agreed to repay $80 000 in Medicare benefits and to be reprimanded by the Director.

Dr H, General Practitioner Sydney NSW

Medicare Australia requested a PSR review of Dr H due to a detected high volume of services and a high level of prescribing COX-2 anti-inflammatory medication to patients under 40 years of age. Dr H had provided 13 857 services to 4 095 patients during the review period for a total benefit of $424 325 (above the 99th percentile).

The Director examined Dr H's rendering of MBS item 23 (level B) and item 36 (level C) consultations, prescribing of COX-2 inhibitor drugs and prescribing of alendronate. Following examination of the medical records, it appeared that 60 per cent of Dr H's prescribing of alendronate did not follow the requirements as set out in the Pharmaceutical Benefits Schedule. Although there was evidence in records of osteoporosis on bone density scans, there was no evidence the patient had had a fracture. Dr H seems to have prescribed alendronate on the basis of a diagnosis of osteoporosis alone without any evidence of a fracture to satisfy the PBS requirements. Similarly, when Dr H's pattern of prescribing COX-2 drugs was examined it was found that many of the patients who had been prescribed these drugs did not fulfil the requirements of the PBS. These two examples highlight the need for doctors to be mindful of the PBS requirements when prescribing for patients.

On examination of Dr H's medical records, 80 per cent of the level C consultations were considered inappropriate. Dr H seems to have charged a level C consultation when Dr H dealt with multiple problems, despite the fact that these problems were all minor and could have been adequately covered by charging a level B consultation. Most records examined lacked essential details of history, examination and a management plan and most encounters should have taken less than 20 minutes to complete. There were many records in which nothing at all was recorded.

Dr H met with the Director and following a discussion of the results of the Director's review agreed to enter into a negotiated agreement, admitting to having engaged in inappropriate practice in that Dr H had:

Dr H also agree to repay to the Commonwealth $30 000 in Medicare benefits and to be reprimanded by the Director.

Description of effective final determinations

As the Director is able to publish certain information on practitioners where a final determination comes into effect, details of those, in date of effect order, are given below.

Dr Peter Thomas Tisdall (Case 106) General Practitioner, Kyabram Vic.

See summary under 'Decisions of the Federal Court and Full Federal Court' later in this chapter.

Dr Anthony Joseph Medical Practitioner, Lithgow NSW

See summary under 'Decisions of the Federal Court and Full Federal Court' later in this chapter.

Dr John Warren Piesse General Practitioner, Kew Vic.

See summary under 'Decisions of the Federal Court and Full Federal Court' later in this chapter.

Dr Clarence Charles Dietman General Practitioner, Elanora and Surfers Paradise Qld

On 7 December 2000 Medicare Australia sent Dr Dietman to the Director PSR for investigation because it was concerned about his prescribing under the PBS. During 1999 Dr Dietman provided 11 563 services to 4507 patients at a total Medicare benefit of $288 766 and he prescribed 12 470 items under the PBS at a net cost of $265 171 (including 2320 scripts for narcotics and benzodiazepines). Following an investigation, the Director referred Dr Dietman to a PSR committee on 10 September 2001.

The committee did not use sampling, but instead examined 17 MBS item 23 services drawn from a list of the top 30 patients to whom Dr Dietman prescribed morphine, pethidine, and/or benzodiazepines during the referral period. The committee reported on 5 October 2004 that Dr Dietman had engaged in inappropriate practice in connection with his rendering of some of the services examined because he prescribed pethidine other than in accordance with the listed restrictions in the PBS and/or prescribed narcotics and benzodiazepines where they were not clinically appropriate.

Regarding the latter, the committee found that Dr Dietman often failed to take an adequate history and/or make an adequate examination of patients, provided insufficient clinical input, did not formulate an adequate management plan, did not manage apparent drug dependence acceptably, did not monitor the quantities of drugs patients were using, failed to monitor the health effects of these drugs in patients, and/or kept deficient medical records.

For example, at four of the services examined, Dr Dietman prescribed pethidine for lumbar and cervical pain that was 'persistent' and 'constant'. He asserted the pain was an acute exacerbation thereby meeting the PBS restrictions. The committee did not accept this explanation as the PBS clearly stated pethidine was for the short-term treatment of acute pain and the pain experienced by the patient was neither short-term nor acute.

On another occasion, Dr Dietman failed to examine a new patient stating 'there was no point. She'd been examined so many times in the past [by other practitioners], she said, and nobody could find anything wrong with her'.3 Despite this, Dr Dietman continued to prescribe alprazolam along with other medications. He also failed to confirm the patient's information with her previous medical practitioners.

The Determining Authority directed on 30 November 2005 that Dr Dietman be reprimanded, counselled, repay Medicare benefits of $283, and be fully disqualified for three years. The Final Determination took effect on 9 January 2006.

The committee also reported on 17 February 2004 to the Director, pursuant to section 106XA of the Act, that Dr Dietman's conduct during 1999 was a significant threat to the life or health of the patients under his care (through his clinical management of patients dependent on narcotics and benzodiazepines). The Director informed the Medical Board of Queensland of these issues. On 7 December 2004, the Queensland Health Practitioner's Tribunal ordered that Dr Dietman's registration and licence be cancelled, and that the Board never reregister him.

Dr Bao-Quy Nguyen-Phuoc General Practitioner, Greystanes and Merrylands NSW

Medicare Australia referred Dr Nguyen-Phuoc to the Director of PSR on 9 September 2002 because it was concerned about his numbers of services, services per patient, initiation of pathology and prescribing under the PBS. During 2001 Dr Nguyen-Phuoc rendered 13 429 services (including 2018 level C consultations) to 1332 patients at a total Medicare benefit of $365 005 and provided 60 or more services per day on 45 days in the referral period. His total services exceeded the 97th percentile for all active general practitioners in Australia. He also rendered an average of 10.8 services per patient, which was above the 99th percentile.

During 2001 Dr Nguyen-Phuoc initiated 4 392 pathology services (above the 99th percentile) to 809 of his patients (almost 61 per cent of patients, which was above the 98th percentile). His average of pathology services per patient was 3.30, which was above the 96th percentile.

Dr Nguyen-Phuoc also prescribed 6130 PBS items at a net benefit of $189 307 including 305 prescriptions for hydroxocobalamin (vitamin B12) injections (which was above the 99th percentile).

Medicare Australia did note that the demographics of Dr Nguyen-Phuoc's practice (high concession cardholders and pensioners) might have elevated his statistics compared with other practitioners. Nevertheless, Dr Nguyen‑Phuoc's response to counselling did not allay Medicare Australia's concerns.

The Director established a committee on 23 May 2003. Following investigations using sampling methodology, it reported that 48 per cent of Dr Nguyen-Phuoc's MBS item 23 services and 69 per cent of his item 36 services involved conduct which would be unacceptable to the general body of general practitioners.

For both item 23 and item 36 services, the committee's reasons for finding inappropriate practice included initiating unnecessary pathology, insufficient clinical input (for example, failing to perform appropriate examinations to investigate possibly serious causes of symptoms, to follow up abnormal pathology results, or to implement appropriate management plans), failing to satisfy requirements of the MBS (not taking selective histories or not performing examinations), and keeping deficient clinical records (lacking essential information and inadequate to enable another practitioner to care for the patient).

The committee reported on 23 December 2003 to the Director of PSR pursuant to section 106XA of the Act that Dr Nguyen-Phuoc's conduct during 2001 was a significant threat to the life or health of the patients under his care (particularly his poor management of some patients). As required by the Act, the Director informed the New South Wales Medical Board. On 22 August 2005, the Board advised that conditions aimed at improving certain areas of Dr Nguyen-Phuoc's practice had been placed on his registration.

The Determining Authority directed on 8 February 2006 that Dr Nguyen-Phuoc be reprimanded, counselled, repay Medicare benefits of $105 816, and be fully disqualified for six months from all group A1 services (items 1-51, those items available to vocationally registered general practitioners). The Final Determination took effect on 17 March 2006.

Dr Peter Thomas Tisdall (Case 420) General Practitioner, Kyabram Vic.

Medicare Australia referred Dr Tisdall on 21 November 2003 because it was concerned about his numbers of services and his prescribing under the PBS.

During 2002 Dr Tisdall rendered 21 242 services to 4032 patients at a total Medicare benefit of $532 200 with an average of 5.27 services per patient. His total services exceeded the 99th percentile for all active general practitioners in Australia. He rendered large numbers of services per day on many occasions: 80-89 services on 66 occasions, 90-99 services on 24 occasions, and 100 or more on two occasions.

During 2002 Dr Tisdall prescribed 36 039 PBS items at a net benefit of $826 763, including several drugs (rofecoxib, amoxycillin, codeine compounds, diazepam fluoxetine, simvastatin, atenolol, and omeprazole) at very high percentiles compared with other practitioners. Three patients received between 200 and 400 prescriptions in the referral period.

A committee was established on 30 June 2004. Following investigations using sampling methodology it reported on 31 March 2005 that 69 per cent of Dr Tisdall's MBS item 23 services involved conduct which would be unacceptable to the general body of general practitioners, because he failed to satisfy requirements of the MBS item descriptor, provided services that were not medically necessary, failed to provide appropriate levels of clinical input, failed to satisfy PBS requirements, prescribed drugs despite the lack of clinical indication and/or kept inadequate medical records of the services.

For example, Dr Tisdall's notes failed to document crucial conditions and he did not know whether his patients were diabetic, hypertensive, asthmatic, had chronic conditions or suffered allergies to medications.

Dr Tisdall only dealt with the problems patients presented. Management plans in relation to ongoing health problems, such as diabetes, asthma and cardiac conditions, were either nonexistent or inadequate. As a result patients remained on prescription drugs for long periods of time without proper review.

Dr Tisdall generally took minimal histories and examinations were cursory. Commonly, Dr Tisdall recorded 'signs in the chest' for all patients who presented with a cough or bronchitis and he could not see the necessity to establish whether patients smoked if they presented with asthma, bronchitis or a cough; nor did he find it necessary to take temperatures in febrile patients, including children.

Most pulse rates for patients were recorded as '84 and regular' (or occasionally 64 or 74), which the committee believed was not possible. For example, Dr Tisdall recorded the pulse rate of a patient with a mitral valve replacement taking Lanoxin as 'regular' on 17 out of 19 services rendered during 2000, but a colleague noted that patient to be in atrial fibrillation on one occasion during that period.

When patients' blood pressure was measured, Dr Tisdall usually documented 'no chest pain or shortness of breath' in identical form. The committee was concerned Dr Tisdall had simply replicated his notes from previous services.

Dr Tisdall prescribed a variety of drugs, such as multiple anti-inflammatories, analgesics and antibiotics to elderly patients without any instruction on their use. During the committee hearing Dr Tisdall appeared, at times, to be confused and unsure as to why he had prescribed certain drugs to particular patients. Large dosages of habit-forming drugs were prescribed in an ad hoc manner without any clinical indication. Dosage reviews were mostly non-existent.

On 8 February 2006 the Determining Authority directed that Dr Tisdall be reprimanded, counselled, repay Medicare benefits of $286 461 and be fully disqualified for 12 months. The Final Determination took effect on 17 March 2006.

On 21 March 2006, pursuant to section 106X of the Act, the Director informed the Chair of Medicare Participation Review Committees that this was the second effective final determination against Dr Tisdall under the PSR scheme.4

  1. On 4 August 2006, the Medicare Participation Review Committee fully disqualified Dr Tisdall from participating in the Medicare benefit arrangements until 17 March 2008 inclusive.
  2. A full report is given on all these cases later in this chapter.
  3. Transcript dated 25 November 2003, p.76.
  4. On 4 August 2006, the Medicare Participation Review Committee fully disqualified Dr Tisdall from participating in the Medicare benefit arrangements until 17 March 2008 inclusive.

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