PCs a cause of Medi­care abuse

The watch­dog that hunts down abuses of Medi­care is find­ing new tech­nol­ogy can hin­der doc­tors as well as help them. Health ed­i­tor Adam Cress­well re­ports

The Weekend Australian - Travel - - Health -

COM­PUT­ER­I­SA­TION of med­i­cal records is a won­der­ful thing, re­duc­ing er­rors, speed­ing up com­mu­ni­ca­tion and — in the­ory, at least — en­sur­ing the pa­tient’s his­tory is ap­par­ent to the treat­ing doc­tor, whether the pa­tient is in their home­town or on hol­i­day.

But just as sen­si­ble use of tech­nol­ogy can im­prove pa­tient care, the latest re­port from Medi­care’s of­fi­cial watch­dog, the Pro­fes­sional Ser­vices Re­view, makes clear that it can also al­low the lazy or in­com­pe­tent doc­tor to achieve ex­actly the op­po­site by cut­ting cor­ners.

Take one Queens­land GP, who be­came so fond of the lu­cra­tive man­age­ment plans funded by Medi­care that in 2005-06 his use of them placed him in the top 3 per cent of GPs in terms of the num­ber of th­ese ser­vices that he claimed.

As the man­age­ment plans were then rel­a­tively new and still lit­tle used, the num­bers them­selves were not enor­mous: the doc­tor pro­vided 125 GP man­age­ment plans (Medi­care item 721), in that year worth $122.40 each. He also pro­vided 52 re­views of ex­ist­ing man­age­ment plans (item 725), then worth $61.20 (a rate that put him in the top 1 per cent of GPs).

Though small, th­ese num­bers were still large enough to ring alarm bells at Medi­care Aus­tralia, which re­ferred ‘‘ Dr A’’ to the Pro­fes­sional Ser­vices Re­view, which in­ves­ti­gates cases of sus­pected in­ap­pro­pri­ate prac­tice.

The PSR found much more to be con­cerned about, as it dis­closed in the agency’s Re­portto the Pro­fes­sions, pub­lished this week.

The PSR looked into Dr A— who pro­tected his iden­tity by agree­ing to a deal un­der which he ad­mit­ted wrong­do­ing — and found 80 per cent of his man­age­ment plans were in­ap­pro­pri­ate. Not only that, but com­put­erised soft­ware was a large part of the prob­lem.

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,’’ the re­port said.

There did not ap­pear to be any clin­i­cal judg­ment ap­plied to many man­age­ment plans, as they were not in­di­vid­u­alised for a par­tic­u­lar pa­tient’s con­di­tions.’’

As for his ‘‘ re­views’’ of pre­vi­ous plans, ev­ery sin­gle one of them was 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,’’ it con­cluded.

The re­port in­cluded a spe­cific warn­ing about com­put­ers, which it noted GPs had ‘‘ en­thu­si­as­ti­cally em­braced’’ but which could lead to lower stan­dards if GPs did not have the skills to use them prop­erly.

Many doc­tors were ‘‘ still at the ‘ hunt and peck’ two-fin­ger level of typ­ing’’, the re­port said, which ‘‘ has im­pli­ca­tions for the qual­ity of the med­i­cal record pro­duced’’.

‘‘ Doc­tors who once wrote com­pre­hen­sive notes in long­hand are now some­times re­duced to a few lines of tor­tured text... Doc­tors need to en­sure their key­board skills are suf­fi­cient for the task be­fore adopt­ing the new tech­nol­ogy.’’

The re­port re­pro­duced one doc­tor’s notes for one pa­tient, which was en­tirely blank ex­cept for six date stamps down the left-hand side, dated from 27 July 2005 to 23 June 2006. The doc­tor told in­ves­ti­ga­tors he had started us­ing a com­puter to write pre­scrip­tions in 2005, and af­ter that did not take any clin­i­cal notes about his pa­tients. ‘‘ He stated that he did not have time to do both,’’ the re­port said.

This year’s re­port, which will be sent to about 55,000 health care work­ers in Aus­tralia as a de­ter­rent to abus­ing the sys­tem, names and shames eight health care prac­ti­tion­ers, com­pris­ing six GPs, one psy­chi­a­trist and one chi­ro­prac­tor. The re­port also de­tails the fail­ings of a fur­ther six GPs, who ad­mit­ted their wrong­do­ing and en­sured their names were not re­leased.

The 48-page re­port paints a pic­ture of a sig­nif­i­cantly more ac­tivist watch­dog, which has seen a near four­fold surge in re­fer­rals from Medi­care Aus­tralia, from seven in 2005-06 to 27 in 2006-07. Re­fer­rals are ex­pected to soar again, to 50 or 60, this year.

But also the PSR it­self is be­com­ing more ac­tivist. In the latest re­port, seven doc­tors were re­ferred to med­i­cal boards — up from zero the pre­vi­ous year — af­ter in­ves­ti­ga­tors feared the health and safety of the prac­ti­tion­ers’ pa­tients could be in jeop­ardy.

It is also ad­dress­ing a past crit­i­cism that the PSR has fo­cused ex­clu­sively on GPs, by in­clud­ing a chi­ro­prac­tor and psy­chi­a­trist in this re­port.

PSR di­rec­tor Tony Web­ber, him­self a GP, says more spe­cial­ists, in­clud­ing sur­geons, are now be­ing in­ves­ti­gated, and may ap­pear in fu­ture re­ports if wrong­do­ing is es­tab­lished. More al­lied health pro­fes­sion­als are also com­ing un­der scru­tiny.

In ad­di­tion to high-vol­ume use of Medi­care items, slap­dash approach to care plans and poor records, whether or not linked to com­put­ers, the re­port high­lights var­i­ous other ar­eas of con­cern.

Th­ese in­clude overuse of of­ten lu­cra­tive Medi­care re­bates for skin treat­ments, and in­dis­crim­i­nate use of pathol­ogy tests in lieu of di­ag­nos­tic skill.

One doc­tor, iden­ti­fied only as ‘‘ Dr B’’ and whose med­i­cal notes were de­scribed as ‘‘ hand­writ­ten, dis­or­gan­ised and barely leg­i­ble’’, or­dered a bat­tery of sim­i­lar tests for each pa­tient.

Newer ar­eas of con­cern that are be­com­ing ap­par­ent since the pe­riod of time cov­ered by the re­port in­clude prac­tice pat­terns in spe­cial- ised med­i­cal clin­ics, such as those fo­cus­ing on skin, heart and im­po­tence prob­lems.

‘‘ They have been re­ferred for high vol­umes (of ser­vices), and they are be­ing in­ves­ti­gated now,’’ Web­ber says. ‘‘ They are cer­tainly much higher than their peer group (GPs), and that’s who they are com­pared to. Th­ese peo­ple in heart clin­ics are not car­di­ol­o­gists, and they stand out a long way when com­pared to their gen­eral prac­ti­tioner peers.’’

Al­though the PSR has also in the past been crit­i­cised as an ex­er­cise in pro­tect­ing the Com­mon­wealth’s purse re­gard­less of what is good or bad for pa­tients, Web­ber also re­jects this and says a fo­cus on pa­tient safety is writ­ten into the agency’s gov­ern­ing leg­is­la­tion.

‘‘ It’s not just a cost-re­cov­ery is­sue, al­though (PSR in­ves­ti­gat­ing) com­mit­tees in gen­eral have been more aware of that (safety) is­sue and have been more proac­tive.

‘‘ Med­i­cal boards have much bet­ter mech­a­nisms for han­dling th­ese is­sues than pre­vi­ously. NSW has a very ef­fec­tive reg­i­men for reed­u­cat­ing and re­train­ing prac­ti­tion­ers that have a prob­lem.’’

Pic­ture: Kym Smith

No cat­e­gory ex­cluded: Pro­fes­sional Ser­vices Re­view di­rec­tor Tony Web­ber says spe­cial­ists as well as GPs are be­ing in­ves­ti­gated

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