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