Director’s report
This year has been one of considerable importance for Professional Services Review (PSR) and the future regulation of the Medicare Benefits Schedule (MBS) and the Pharmaceutical Benefits Scheme (PBS).
The Department of Health and Ageing completed its Review of the Professional Services Review Scheme during the year, and the Minister, the Hon. Tony Abbott, agreed to the recommendations in July 2007. The central purpose of the Review was to examine the effectiveness of the Scheme and to develop recommendations to address the challenges envisaged for the future. The Review had broad terms of reference and included analysis of Medicare Australia’s initial detection, monitoring and referral to PSR, the review by the Director, the PSR Committee investigative process, and the activities of the Determining Authority.
The Steering Committee for the Review comprised senior representation from the Department of Health and Ageing, Medicare Australia and the Australian Medical Association; I was a co-opted member.
Early in the Review the length of time a practitioner is involved in the investigative process was recognised as an obstacle to an efficient scheme. Medicare Australia moved quickly to adjust its internal processes to address this issue. As a result, the flow of referrals from Medicare Australia to PSR increased to 27 in 2006–07 compared to seven in 2005–06. It is anticipated that the number of referrals will continue to increase.
PSR also moved quickly to improve its internal processes. This has resulted in a reduction in the time taken for my initial investigation from an average of seven and a half months to three months.
The Review’s recommendations endorsed peer review as a key mechanism for regulating quality and fiscal outlays for the Medicare and pharmaceutical benefits programs. Health professions should not underestimate the importance of this mechanism. The professions’ continuing support of the PSR Scheme will ensure peer review remains at the heart of Commonwealth health regulation.
The Review made recommendations concerning emerging areas of practice where Medicare Australia and PSR will require additional flexibility and legislative change to respond effectively. The increasing trend for large corporate entities to employ health practitioners as contractors in multidisciplinary clinics was one such area. Currently there is limited ability to apply sanctions to corporations if their behaviour has influenced a practitioner to practice inappropriately.
Further, the appearance of niche clinics including skin cancer, impotence, cardiac disease and anti-ageing requires a flexible and timely response by PSR to protect the public from possible inappropriate practice. These trends are not confined to general practice. Many specialities have now formed large groups, including ophthalmologists, radiologists, orthopaedic surgeons and radiotherapists.
The success of the government’s introduction of the new mental health items into the MBS coupled with general practitioners’ ability to refer patients to allied health practitioners has expanded the numbers and types of health professionals now able to access the Medicare scheme. The Review recognised the need to develop appropriate regulatory mechanisms to keep pace with these changes.
During 2006–07 there were six Federal Court challenges and one challenge before the Administrative Appeals Tribunal. These are detailed in the body of this Annual Report. Importantly for PSR, the Federal Court confirmed in Phan that PSR’s processes do provide a practitioner with adequate procedural fairness. Phan also resolved the frequently challenged issue of the statistical sampling methodology. At the time of writing we are awaiting the Full Federal Court’s judgement in the Constitutional challenge to the validity of the PSR Scheme. Fourteen cases are awaiting this judgement for resolution.
Increasingly practitioners are legally represented at an early stage in the PSR process. I regard this as a positive development. Appropriate and early legal advice can guide and support a person under review, and prevent any misunderstanding of the operation of the Scheme.
The range of inappropriate practice seen this year covers a number of MBS items and PBS drugs. General practitioner (GP) management plans and long and prolonged GP consultation items have been consistently inappropriately used. These are high value items in the MBS and practitioners should take care to abide by the relevant criteria before claiming.
Medicare Australia asked PSR to review several practitioners for their use of narcotics and benzodiazepine medications. In all cases reviewed, Medicare Australia’s concerns were confirmed.
In addition to repaying benefits, a number of practitioners were referred to their state medical board as their conduct was considered to be a threat to the health or life of a patient.
This year Health Insurance Act Regulations were amended to allow referral to a number of practitioner organisations, colleges, associations and accreditation bodies for failure to comply with professional standards. During the year I referred two such matters to the relevant body.
A negotiated agreement is an alternative to a committee referral. This involves the practitioner acknowledging that he or she has engaged in inappropriate practice. An increasing number of practitioners are entering into negotiated agreements as they offer a speedy resolution to the process. One such agreement resulted in repayment of $400,000 and partial disqualification from the Medicare scheme for three years.
In the coming year PSR will be actively working with the Department of Health and Ageing to implement the recommendations of the Review. In addition we will be expanding and strengthening our relationships with Medicare Australia and other health regulators around Australia. I anticipate a continued growth in referrals from Medicare Australia as we evolve to meet new challenges as they emerge.
Tony Webber
Director