Director’s Report
In 2008–09 Professional Services Review received 136 requests from Medicare Australia to review a practitioner’s behaviour. This represented a 172 per cent increase on the number of requests we received in 2007–08 and consequently required a 20 per cent increase in staff numbers, establishment of more PSR Committees, and a considerable increase in travel for our operational staff. Despite these challenges, I am pleased to report that some of our timeframes for completion of cases have been further reduced this year. The current caseload will ensure the panel of practitioners that sits on PSR peer review committees will be fully engaged over the next 12 months.
The diversity of issues Medicare Australia referred this year has demonstrated the confusion that still exists among some practitioners concerning their obligations and the expectations of their peers when using the Medicare Benefits Schedule and the Pharmaceutical Benefits Scheme. This year PSR implemented its Communication, Education and Media Strategy that sought to alert practitioners to their obligations and to illustrate areas where their colleagues had been found to have practiced inappropriately. I am particularly keen to engage isolated practitioners who do not have regular contact with peers. Many areas of poor clinical practice and the inappropriate use of the Medicare Benefits Schedule and Pharmaceutical Benefits Scheme could be addressed with targeted education. I intend to expand PSR’s communication with the professions in the future. The Australian Medical Association, various professional associations, colleges and the medical media have been valuable allies in this endeavour.
This year PSR has been actively engaged in providing feedback to its portfolio department, the Australian Government Department of Health and Ageing. Last year PSR reviewed over 14,000 medical records from general practitioners, medical specialists and optometrists. PSR therefore has a unique vantage point from which to assess the way practitioners use the Medicare Benefits Schedule and Pharmaceutical Benefits Scheme. PSR has held discussions with the Department of Health and Ageing about general practitioners’ use of consultation and chronic disease management items.
The Health Insurance Act 1973obliges me to refer a practitioner to a state medical board if I find evidence of behaviour that could pose a significant threat to the life or health of a patient. I made seven such referrals last year and was very concerned that six of these were for inappropriate prescribing of narcotics and benzodiazepine drugs. The practitioners concerned had prescribed large quantities of these drugs to their patients, well in excess of what would reasonably be needed for their care. Most alarming was the amount of alprazolam prescribed without clinical indication. Some people within the illicit drug-using community crush this drug for intravenous injection. It was apparent, from some of the medical records I saw, that these drugs may have been diverted for sale on the street. Tighter restrictions on and surveillance of these drugs may be needed, as the evidence suggests PSR’s cases are not isolated examples.
The other significant case I referred to the New South Wales Medical Board was a skin clinic practitioner whose skin cancer excision technique put many patients at risk of a recurrence, including recurrence of melanoma. This doctor was also referred to NSW Health, which was obliged to contact more than 9000 of his patients for recall.
During this year the High Court heard the long-running constitutional challenge to the validity of the PSR Scheme and Medicare more generally. As 13 doctors had tied their cases to Drs Wong and Selim’s challenge, resolution of these cases had effectively been stalled for many years. The court found that Part VAA of the Health Insurance Act 1973did not amount to ‘civil conscription’ within the meaning of section 51(xxiiiA) of the Constitution and therefore resolved the matter in the Commonwealth’s favour. Following this welcome decision PSR fast-tracked all the stalled cases towards final determinations.
General practitioners have been critical of the PSR Scheme in the past, as it appears to focus on general practitioners, despite approximately 40 per cent of medical practitioners working as specialists. Last year Medicare Australia referred 13 medical specialists. Medicare Australia also sent four optometrists to PSR for review. All the optometrists referred have been investigated for their use of computerised perimetry. Optometrists are reminded that specific indications need to be present for this item to be claimed under Medicare.
Of the many issues PSR investigated during the year, I would like to discuss three here.
Patients and allied health professionals, including dentists, have increasingly been putting pressure on general practitioners to provide a Team Care Arrangement (MBS item 723) to enable patients to claim a Medicare benefit when accessing allied health services. In many of the cases PSR examined, the patient’s condition did not warrant use of this item. Some allied health practitioners have told patients to see their doctor to ‘get the paper work done’ to be able to claim a Medicare benefit. This puts general practitioners in a difficult situation; if a doctor accedes to a patient request for an unjustified Team Care Arrangement the doctor may be required to repay any benefit paid for that item.
Medicare Australia has paid increasing attention to the excessive use of diagnostic imaging; particularly computerised tomography (CT) scans. PSR has found a number of general practitioners who order excessive numbers of CT scans without clinical indications. While these investigations do give valuable clinical information in the right context they also expose patients to much more ionising radiation than a conventional x-ray. I am concerned that some general practitioners have used CT scans as a screening tool in simple back strain. This is of particular concern in younger women in their reproductive years. Inappropriate use of CT scans is not without risk and may result in referral of the practitioner to a medical board for unprofessional behaviour.
The increasing popularity of alternative medicine and natural remedies has created a large herbal medicine and alternative therapy industry. Practitioners from many different backgrounds are now offering such services. Medical practitioners are also now including these therapies when treating patients. PSR Committees have found practitioners to have practiced inappropriately if their use of these therapies is well outside what the general body of their peers would consider appropriate. Practitioners who order excessive and unusual pathology, or who render Medicare consultation items during which they provide unconventional and unusual treatmentsmay put themselves at risk. Medicare benefits are not payable for treatment considered inappropriate by the general body of the practitioner’s peers. Doctors who use these therapies should satisfy themselves there is an evidence base supporting their use and that their peers would agree with the treatment plan they are proposing. Many herbal medicines are pharmacologically active and their use is not without risk.
During 2008–09 PSR redeveloped its risk management and governance plans, including the Protective Security Plan, Privacy Policy and the Intellectual Property Plan. Despite the increased caseload, updating our corporate policies proceeded as planned. I would like to thank the Audit Committee and the Management Committee for the many hours and solid work they contributed to PSR’s corporate governance.
I would also like to thank all my staff for their work during this busy year, and the members of the Determining Authority and PSR’s panel members around Australia who generously gave their valuable time to participate in PSR’s work.
PSR continues to be committed to protecting the public from the adverse outcomes of inappropriate practice and, together with Medicare Australia, to ensuring the integrity of the Medicare Benefits Schedule and Pharmaceutical Benefits Scheme.
Tony Webber
Director