Report on performance
Negotiated agreements ratified by the Determining Authority
Dr A, General practitioner
Queensland
Medicare Australia referred Dr A because it was concerned that his rendering of management plans (MBS items 721 and 725[1]) might have constituted inappropriate practice. Medicare Australia was also concerned about Dr A’s daily servicing and the extent of his family servicing.
During the review period Dr A provided 13,087 MBS services, which placed him at the 98th percentile compared to all vocationally registered general practitioners in Australia. Additionally Dr A rendered GP management plan services above the 97th percentile.
Dr A’s clinical records were examined. It was considered that 80 per cent of Dr A’s GP management plans were inappropriate. It appeared that the entries in the data fields of the plans were populated by Dr A’s software, and that these entries were identical in many instances. There did not appear to be any clinical judgement applied to many management plans, as they were not individualised for a particular patient’s conditions. Many of the plans appeared to have been for relatively minor conditions. All of Dr A’s management plan reviews were considered inappropriate. There was no attempt to evaluate the care given over the preceding six months and there was no comment on the progress toward treatment goals or changes to the management plan. Dr A’s management plans would not have contributed to an improvement in his patients’ health.
Dr A was visited in his surgery and the Director’s concerns were discussed. Dr A had started to change his practice to satisfy Medicare Australia’s concerns. As it appeared that Dr A was making a genuine effort to change his practice profile a negotiated agreement was signed. Dr A acknowledged that he had practiced inappropriately and he agreed to repay $35,000 and be disqualified from the provision of MBS items 721 and 725 for a period of six months.
Dr A’s case highlights the fact that GP management plans are designed to improve the quality of patient care and need to be done thoughtfully with adequate clinical input that seeks to improve a patient’s health outcome.
Dr B, General practitioner
Victoria
Medicare Australia was concerned that Dr B’s level C consultations[2] and her initiation of pathology may have been inappropriate. Medicare Australia had first identified Dr B in 2003.
Dr B rendered 2313 level C consultations and only 926 level B consultations[3] in the 12 months July 2004 to June 2005. This is a very unusual pattern for a general practitioner. Dr B’s ratio of level B to level C consultations was 1:2.49 for the review period compared to that rendered by general practitioners nationally on average being 7:1.1. Dr B’s total rendering of level C consultations was above the 99th percentile.
Medicare Australia’s other concern was in relation to her ordering of pathology. During the review period Dr B’s ordering of hormone assays and homocysteine was significantly above the 99th percentile. Dr B’s total patient numbers were on the 32nd percentile.
Dr B was visited in her practice and a sample of her clinical records was examined. Dr B appeared to have a ‘niche’ practice where she treats patients with obesity, hormone imbalances, and osteoporosis and to whom she offers lifestyle counselling. There is a DEXA bone density scanner in her rooms.
Dr B’s records were handwritten, disorganised and barely legible. Dr B’s use of abbreviations and idiosyncratic symbols was confusing and would preclude another doctor effectively continuing the care of her patients using her clinical records.
Dr B’s records did not support the level C consultations she had claimed. There was no evidence of a detailed history or the recording of an extensive physical examination. It appeared that a level C consultation was billed on a time basis only, without regard to the content requirement of the item descriptor.
It became apparent from the records that nearly every patient had a significant number of pathology tests requested. Justification for these investigations was rarely found in the notes. It was also clear that the majority of tests would have had little contribution to patient management. Dr B appeared to order a battery of similar tests for each patient without regard to the clinical situation.
A further concern was her extensive use of DEXA scanning for bone mineral density estimation. A consultant endocrinologist reviewed the clinical notes of patients who had undergone a DEXA scan and, in his opinion, these scans were being ordered unnecessarily and without justifiable medical indications. In addition, he was concerned that many young women whom Dr B had labelled as having a ‘hormone imbalance’ were being scanned. The Director formed the opinion that Dr B had failed to comply with professional standards in her use of DEXA scanning and she was referred to the Medical Board of Victoria.
Dr B acknowledged that she had engaged in inappropriate practice in relation to MBS level C consultations and her ordering of pathology tests. The Director considered that her inappropriate conduct could be satisfactorily addressed by a negotiated agreement. She agreed to repay $70,000 in Medicare benefits.
Practitioners should always be thoughtful in their ordering of pathology and limit any investigations to those required by the clinical situation. It is unwise and not good practice to have a ‘standard’ list of tests for every patient.
Dr C, General practitioner
Western Australia
Medicare Australia referred Dr C because it was concerned about his level of initiation of both diagnostic imaging and pathology. Dr C had first come to the attention of Medicare Australia in 1995. Following Medicare Australia’s intervention at that time he had modified his pathology and radiology ordering practices. However a similarly concerning pattern of behaviour had reappeared in 2001 and 2004.
During the review period Dr C provided 5715 services (63rd percentile) to 1332 patients (41st percentile). However Dr C was at the 98th percentile for initiation of diagnostic imaging compared to all other general practitioners. Similarly Dr C was initiating pathology at the 97th percentile. Dr C’s practice demographics did not account for this discrepancy.
Samples of Dr C’s records were examined. His records in relation to provision of level C consultations did not justify the item claimed. Specifically it appeared that when he had treated a number of minor conditions at the same time, he had billed for a level C consultation. These consultations did not contain the level of complexity the item descriptor requires. In addition, there was evidence of frequent pathology and radiology initiation without adequate clinical justification.
The Director met with Dr C and the findings were discussed. Dr C explained that he had a large Southern European patient base, and that his patients expected frequent investigations. The Director pointed out that it is the treating doctor’s responsibility to determine any investigations, based on clinical need. Dr C was also made aware that his peers would not consider it appropriate to acquiesce to patient demands or expectations for unnecessary investigations.
Dr C demonstrated that he had considerable insight into his inappropriate pathology and radiology ordering. The Director considered that Dr C’s matter could be the subject of a negotiated agreement. Dr C acknowledged that he had practiced inappropriately and agreed to repay $14,887.
Many practitioners who come before PSR find themselves in difficulty when they practice medicine dictated by their patients’ request for either investigations or drug treatment without a sound clinical basis for these decisions.
Dr D, General practitioner
Queensland
Dr D worked in a Queensland skin clinic; Medicare Australia referred him over several concerns. During the review period Dr D received $765,101.85 in Medicare benefits, which is at the 100th percentile. Medicare data demonstrated that Dr D was the second highest renderer of items 30192 and 30213.[4] Lesions treated under MBS item 30213 must be visible from four meters. Given the volume of these services Dr D rendered, his peers may consider it unlikely that so many patients with these lesions would present to one practitioner.
Medicare Australia was also concerned by the high number of skin flap items Dr D had claimed as being needed for wound closure. During the review period Dr D was above the 99th percentile for his rendering of skin flap services. Medicare Australia was concerned that many of his skin excision items may have been billed at a higher level of benefit than was warranted by the size of the lesion.
A large number of Dr D’s records were examined. It was considered that Dr D had claimed skin flap items for closure of wounds in which the histopathology revealed the original lesion to be very small. In one instance Dr D had claimed that two skin flaps were needed to close a wound following excision of a two millimetre lesion from the back of a hand. The Director was of the view that Dr D’s peers would consider this an inappropriate use of skin flap items.
Dr D appeared to have claimed for malignant lesion removal where the histopathology revealed that the lesions were benign and therefore did not justify the benefit claimed. The difference between the benefit for a benign lesion and a malignant one can be more than $60. The impression gained, from examination of Dr D’s medical records, was that his patients received inappropriate and unnecessary treatments. It also appeared that in some instances Dr D ‘up-coded’ the MBS item to obtain a higher benefit.
When confronted with the Director’s findings Dr D acknowledged that he had practiced inappropriately. He agreed to repay $400,000 in Medicare benefits and to be disqualified from using MBS items related to skin cancer medicine for three years.
Dr D’s conduct should remind practitioners that it is essential to pay scrupulous attention to the requirement of the MBS descriptor and to practice in an appropriate manner when billing for skin cancer services.
Dr E, General practitioner
New South Wales
Dr E was referred to PSR as Medicare Australia was concerned that her prescribing of Cox-2 drugs and narcotics may have been inappropriate. In addition they were concerned that the level of services to patients may also have been inappropriate. Dr E’s individual patient numbers (1420) was on the 45th percentile, however her level of services per patient was on the 92nd percentile.
Dr E issued 731 prescriptions for celecoxib and 434 prescriptions for meloxicam, a combined volume of 1165 prescriptions, 838 of which were for patients under the age of 50. The requirements of the PBS Schedule state that these drugs are not to be used for acute pain, soft tissue injury or arthrosis without an inflammatory component. Medicare Australia was concerned that Dr E’s prescribing may have been outside the PBS guidelines.
During the review period Dr E issued 919 prescriptions for opium alkaloids and 625 prescriptions for benzodiazepine derivatives. Medicare Australia was concerned that this level of prescribing may not have been clinically appropriate.
The Director met with Dr E in her surgery and examined a sample of her records. Dr E practiced in an isolated region as a solo general practitioner. She had also been granted dispensing rights, as there was a considerable distance to the nearest pharmacy.
Dr E’s records relating to her level B consultations were brief and poorly documented with minimal or no written histories or details of examination findings. Similarly many of her level C services lacked the clinical complexity to justify the item claimed. The records related to Medicare Australia’s prescribing concerns were also poorly documented. There was little evidence that the PBS guidelines for prescribing Cox-2 drugs had been followed. Contrary to the requirements of the PBS Schedule, the records showed that Dr E had prescribed Cox-2 drugs for soft tissue injury and lower back pain without evidence of inflammation.
Dr E’s prescribing of narcotics in many instances was also considered inappropriate. She paid little attention to drug interactions and did not record accepted pain management principles. It appeared that Dr E allowed her patients to dictate treatment beyond what her peers would consider reasonable. Several records suggested that her patients were addicted to the medication being prescribed.
During the Director’s visit to her surgery, additional causes for concern were found. Dr E had made inadequate provision for vaccines and had no proper cold chain for either storage or transportation. Concerns were also held for Dr E’s stock control. The dispensary was housed in the staff kitchen and was easily accessible to patients. There did not appear to be any security measures in place to prevent theft.
After a further meeting with Dr E she acknowledged that she had practiced inappropriately. She stated that she felt isolated and found many of the patients’ demands for medication intimidating. She felt an obligation to the community; however, she did acknowledge that in some instances her drug dependant patients were manipulating her.
She agreed to repay $60,000 in Medicare benefits, be fully suspended from prescribing narcotic medications for nine weeks, and that her authority to dispense pharmaceutical benefits be suspended for three years. As a result of these sanctions, Dr E moved her practice to an area where she would gain peer support and would not require dispensing rights.
Dr F, General practitioner
Western Australia
Medicare Australia referred Dr F as it was concerned that his level of ordering of cerebral perfusion studies, also known as SPECT scanning (MBS item 61402), may have been in excess of clinical requirements. SPECT scanning is an item predominantly used clinically by psychiatrists and neurologists. In addition, Medicare Australia was concerned with Dr F’s itemisation of level C consultations.
Dr F, a vocationally registered general practitioner, saw only 470 individual patients during the review period, (7th percentile). However, he ordered 117 item 61402 perfusion studies. Dr F was above the 99th percentile for his initiation of this item when compared to all active general practitioners and all active psychiatrists in Australia during the review period.
Dr F rendered 41 per cent of his consultations as level C and 40 per cent as level B. Medicare Australia was concerned that Dr F’s rendering of level C consultations may not have fulfilled the MBS descriptor on each occasion or may not have been clinically relevant.
Dr F’s records were examined in relation to MBS item 36 and 44[5] services. Dr F’s records revealed that he had recorded exhaustive histories, detailed notes, management plans and counselling notes. It appeared that Dr F would have spent the time with the patients as required by the MBS item descriptor. However, following examination of his records, a new concern emerged. The records examined showed a referral pattern of Dr F’s patients to a psychiatrist who issued a prescription of dexamphetamine and authorised Dr F to be a ‘co-prescriber’ of the medication. In many records examined there was little evidence that dexamphetamine was the best first treatment option.
The records examined in relation to SPECT scanning revealed no evidence that this test was a useful discriminatory diagnostic tool for diagnosing Dr F’s patients. SPECT scanning has a limited role in other neurological and psychiatric conditions and it appeared that these tests may have been undertaken to justify the prescriptions issued for dexamphetamine. Current mainstream medical opinion contends that SPECT scanning has a small and defined use in neurosurgery, neurology and psychiatry. The majority of Australian practitioners would view Dr F’s use of SPECT scanning as experimental and without scientifically validated data to support its use.
The Director met with Dr F to discuss these issues. Dr F acknowledged that he had practiced inappropriately and agreed to repay $15,000 and be disqualified from using item 61402 for 18 months.
- [1] MBS item 721 is a GP management plan, item 725 is a review of a GP management plan.
- [2] Level C consultations are defined as involving a ‘detailed history, an examination of multiple systems, arranging any necessary investigations and implementing a management plan…lasting at least 20 minutes’.
- [3] A Level B consultation is defined as ‘involving taking a selective history, examination of the patient with implementation of a management plan in relation to one or more problems, OR a professional attendance of less than 20 minutes’.
- [4] MBS item 30192 is removal of pre-malignant skin lesions and MBS item 30213 is removal of telangiectases
- [5] Level D consultations (item 44) are defined as ‘an exhaustive history, a comprehensive examination of multiple systems, arranging any necessary investigations…to one or more complex problems and lasting at least 40 minutes’.