Photos from Doomadgee

Doomadgee 2010

I will post my thoughts about my experience at Doomadgee in the near future.

Closing the Gap ... it's not just a gap y'know

Closing the Gap—PBS Co-payment Measure - this system is in place to subsidise prescriptions for those of an indigenous background

"who present with an existing chronic disease or are at risk of chronic disease and in the opinion of the prescriber:

would experience setbacks in the prevention or ongoing management of chronic disease if they did not take the prescribed medicine and
are unlikely to adhere to their medicines regimen without assistance through the measure."

A practice needs to be registered for PIP or an Indigenous Health Service (IHS).

I have been instructed that I cannot write Closing the Gap(CTG) scripts because I am neither employed by the IHS nor is there any formal agreement between myself and the IHS.

I am contracted by Queensland Health Service (QHS) via the locum service to provide medical services to the local community and as such not directly employed by the local IHS.

It therefore comes down to whether a formal agreement is in place between myself and the IHS ... and it appears there is none. There is currently an outstanding lack of agreement between the local IHS and QHS. I have, after some considered thought and attempting to seek independent verification, decided that a formal agreement is not required between QHS and the local IHS for a formal agreement to be in place between myself as an individual and the IHS.

I will pursue this avenue. Unless this issue is resolved the local community is disadvantaged. The community come in through a single door into a single facility (recently built at the cost of 16.3 million dollars) and if they cannot see the IHS employed doctor who can give them "free" prescriptions, they must see a QHS doctor who according the IHS management, cannot write a "free" prescription.

I hope while the major formal agreement is pending, a local arrangement can be entered into to support the community where it is needed.

An interesting historical mention of Eidsvold

Newspaper article about the Eidsvold Station ...

Brisbane Courier 1932

.. and a journalist opinion on the streets of Eidsvold 1888.

RockDoc Movember 2010

Mobile GP services to the rural community ... opportunistic health care is critical for the health of those living in rural and remote community. Brad, the Eidsvold GP, takes his mobile clinic to a Melbourne Cup local event.

Some photos from around Eidsvold

 
 
 
 

*waves* from Eidsvold Hospital

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Eidsvold

Arrived a short time ago. Flew Melbourne, Brisbane, Bundaberg then drove 2.5 hrs inland to get to Eidsvold. It was dark for most of the trip driving so I didn't see much of the surrounds inland of Bundaberg. I'm in shared accommodation - own bedroom, shared kitchen and bathroom/laundry. No Optus service here so mobile phone is out of action ... will be communicating via Telstra 3G internet (email, blogging etc.) and the local landline. Meet the admin tomorrow 08:00 to get my orientation and I will find out what my role will be for the next two weeks.

Will post again in the next few days ... with some photos. Keep an eye on Facebook too ... will probably keep in touch there too.

Mossman August 2010

Mossman ... what can I say ... yet again a great job and a beautiful place to be !

Heading back to Mossman soon ... but

.. I thought I'd post some photos from my Yarrabah trip. I have been conservative with taking photos in community as I do not know yet what is proper in respect to the cultural sensitivities of the community, but here are some of what is in fact one of the most beautiful coastal areas in Australia.

Second Beach - homes on the beach front.

From Rural Locums

Yarrabah from lookout.

Sunset at Yarrabah beach.


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Seriously guys!

If you work as a locum don't put in claims for days you didn't work and don't inflate callback times!

Not only are doctors (very few I hope) defrauding QHS at least one locum service is attempting to get two days payment from QHS for a 24hour period starting 08:00am, claiming a "24 hour period" rolls over at midnight, not 08:00am the next day !

This is the wording of the QHS policy :-"... base rate includes any on call or recall allowance and the agency fee. Any hours worked in excess of 12 hours in a 24 hour period are to be paid at an hourly rate determined as ..."

It's hard enough to provide a decent service to the community without the blatant greed of some of the "service" providers.

Pathetic really, it's not like we don't get very well paid for what we do anyway.

http://www.health.qld.gov.au/hrpolicies/resourcing/b_45.pdf

Medicare disadvantages Indigenous communities.

Medicare rewards efficiencies of time ... current rebate for 6 minutes is $34.30, and it just happens to be the same for 19 minutes. That's $343 per hour with the old "6 minute medicine" policy implemented. For somewhere between 20 and 40 minutes of time the medicare rebate is $66.45 or lets say x3 for just under $200 per hour. For over 40 minutes the medicare rebate is $97.80 or less than $100 per hour.

No this is not another rant about equal pay for equal time, this is background for what I am about to say.

Indigenous health requires opportunistic care ... for example, someone comes in for management of a dog bite, you check their blood pressure, check their immunisation status (no not just their latest tetanus shot), check their urine for blood and/or protein, check their random blood glucose, review their medical past history and make sure their health check items are up-to-date (eg. HbA1c in diabetics), check their skin for other lesions (scabies, secondary infections with GpA strep etc.) look in their ears (chronic suppurative otitis media and cholesteatoma are not uncommon), check their drug and alcohol use, check their domestic situation is clean to return to, and then get on with cleaning and dressing the dog bite (at your own cost) AND then decide on whether or not a prescription of antibiotics will be filled (pension day is in five days time), whether the full course of antibiotics you provide (again out of your own funding) will be actually taken and completed, or you give a shot of long acting penicillin as the best of a not ideal treatment situation.

See where I am heading ?

The service at Yarrabah where I am currently working is funded by Queensland Health. Any attempt to fund the service primarily by medicare rebates will be doomed to a financial disaster.

Nicola's proposal to "voluntarily" register diabetic patients for block funding is another point of discrimination against the indigenous community. The whole care of a diabetic patient will be case managed by a GP (or will it be redirected to "Medicare locals"??) and all the care will be paid for by a single block fund. Block funding will be dependent on meeting outcomes, as yet unknown, but say for example, acceptable HbA1c levels (virtually impossible in a significant number of the indigenous community) perhaps even no admissions to hospital.

If the plan to hand over the medical services management to the community has in its hidden agenda switching over from Queensland Health funding to primarily self funding through the generation of medicare rebates, then this will be a disaster for Yarrabah and all communities like it.

*sigh* ... can I ever work somewhere and not get involved in the local politics and patient advocacy? probably not.

Otherwise .. working at Yarrabah has been a delight. The community has been appreciative, the staff a delight to work with and a medical and personal experience to not pass up. I have seen "medicine" I have not seen for years, I have done things I thought myself not capable of because I have not done the same for decades.

I have seen "the good, the bad and the ugly" and have had my own complacency challenged. I am most appreciative of the the opportunity of working here, and I will be back.

Bidgerdii - Rockhampton

I find myself some time past the locum at the Rockhampton Aboriginal Health Service and not made a blog entry.

I spent four weeks at the service in the main town centre of Rockhampton. This job has left a number of impressions so I will list them as they come to me.

1) Rockhampton is a large sprawling country city that at its heart is a series of old, historic buildings. It lay on the bank of a large (I believe tidal) river. For its promising initial appearance it is not inspiring, at least to me. It's a little lifeless. The population spreads out from Rockhampton to the north and along the river to the coast, and this is where the life seems to have been dragged kicking and screaming. The city itself is nothing of note once the pleasure of the old buildings and the river passes.

2) I have an Optus 3G telephone network subscription - the coverage in Rockhampton is pathetic. I can cross from one side of the street to the other and I lose signal. I got to lunch in the local pub and once inside the signal drops out. Even 2G sometimes vanishes, so I am without a telephone signal at all.

3) I was accommodated in a house out of town, not within walking distance of work or shops. Had its advantages and disadvantages, but a 10 minute drive to work was not to be complained about.

4) The staff of the service were wonderful people, many of an aboriginal background, some not. The CEO was off on maternity leave, so never got to meet her. The clinic had undergone some major staff changes, including the departure of all the clinic doctors and the clinic nurse. I arrived as a locum with the place in transition,, doing much of the work of what would have been done by a full time clinic nurse, if there had been one. The second two weeks, a new nurse arrived and it was a joy to see her enthusiastic about taking over the role and being involved in the day to day management of the clinical services.

5) A mixture of electronic and paper records does not work well. The handling of correspondence inwards, recall and followup is hard to implement with such a system.

Would I work there again? Possibly, but a clinic in the middle of a larger town is not personally attractive to me - I left that behind in Melbourne.

Would I recommend it for an experienced GP for the experience of working in a supportive aboriginal health team? definitely.

Diabetes registration scheme ... Rudd Rocks on !

Diabetes registration system ... government bribery for capitation, now its even more obvious. GP's complain about the iniquity of the system and what's the goverment response? .. offer more money !! ... "The Government had already promised practices would be paid $1200 per year for each enrolled patient, $950 of which would cover day-to-day GP care, and $250 to cover the costs of allied health care. But the additional measures will hand practices a $1500 upfront payment for signing up to the program plus an additional annual payment of $100 per registered patient."

Disgusting ... heaven forbid if you are a complicated diabetic patient, no one is going to sign you up "voluntarily" ... and if you are a non-complicated diabetic, then shop around for the "highest bidder", you are worth a fortune to the corporates !

Double dipping not allowed ? ...

Finally someone has the balls to deal with this issue .. well at least put a public appearance in of dealing with it. It aint going to be as easy as simply saying "you can't do it".

Hypothetical

The local bakery closes down. They say its cheaper to bake the bread the other side of the mountain and ship it to the local store. It looks cheaper because the bakery does not have to pay for the shipping costs, but the reality is that the over all cost of the provision of bread to the local community becomes more expensive. Just no one knows because the only politically sensitive cost is the production cost, not the shipping cost. At least the locals dont have to walk over the mountain to get their bread ... yet.

I am not talking about bread.

Screw Medicare ... screw me screw you

The Australian Medicare system was introduced in 1975, initially as "Medibank" and renamed as "Medicare" in 1984.

Since my graduation from medical school in 1982 I have been observer of (and sometimes complicit in) the manipulation, distortion and outright abuse of the Medicare system. The elements of human greed (no, doctors are not immune from this), the stupidity and shortsightedness of politics and the entitlement syndrome of the Australian psyche are all mixed to pollute what otherwise was a well intentioned but destined to fail system.

My first exposure to the iniquity of the system was when I received a cheque from Medicare in my first year of full time practice as payment for an operation I did not do and could not have done (as I neither had the expertise nor was in Australia at the time I allegedly performed the operation). I reported this to both the AMA (my medical "union") and Medicare. There was was no followup or feedback from this incident but there were rumors floating around at the time that some inhouse within Medicare were putting in false claims and diverting the payment cheques to themselves.

The flourishing of corporate bulk billing services from the early 1980's onwards, courtesy of highly creative entrepreneurs such as Geoffrey Edelsten and Ian McGoldrick (both who I have met personally, and I have worked in and observed their clinic machinations) and those emulating their service model led to quite extensive abuse of the Medicare system, if not illegally, certainly at a moral and ethical level. There certainly were illegal practices in some places but these were not widespread - the big corporates even at that early stage had (very) well paid legal advisors to tread the line but not overtly cross it.

Patients under workers compensation (specifically excluded from Medicare) required by clinic staff to sign a blank Medicare forms to be put in the patient file incase an employer/worker's comp. insurer refuses to pay the account. "Just in case" ... yes Medicare benefits are payable whilst liability is under dispute but not signing a blank cheque medicare claim form in addition to billing a private account. I worked for that clinic for less than a week.

A pile of blank, signed Medicare forms left in a patient's file. Obviously an elderly patient who was obtaining home visit care from the solo GP concerned but seriously a pile of blank, signed forms !! Another clinic I left shortly thereafter.

The system encouraged high turnover care .. bringing life to the term "6 minute medicine". The medicare rebate was (at that time) the same for 6 minutes of time as it was for 24 minutes of time. The answer is quite clear ... see 1 patient for 1 fee in 24 minutes or see 4 patients for 4 fees. It took a very long time for the Health Insurance Commission / Medicare auditors to identify this as inappropriate behaviour, but it was only the extreme ends over time that were ever dealt with in high profile individual cases.

The profitable procedural items were identified and used by certain less than savoury practitioners, in house referrals for radiology and pathology services, in house referrals to specialists who agree to bulk bill for their own 10 minute consultations, and not infrequently seen on the day of the GP consultation for a factitious reason as a "second opinion".

Then came the Medicare "safety net". Private hospital emergency departments who charged a small doctor's fee and a large (very large) "facility" fee literally overnight changed their billing practices so that the whole fee was a "doctor's fee" so that only a few visits to a private ED would trigger the safety net and make future visits "affordable" ... ie. scamming medicare to pay almost the whole, inflated fee. Private obstetricians also pre-safety net had a separate private "delivery fee", that was separate to and above their normal medical fees. Guess what happened to obstetric fees post-safety net?

And it was not just the private system rorting Medicare ... public hospitals closed their outpatient services some time back. Oh .. but surprise, surprise the same facilities, the same resources the same doctors continued to practice in private consulting clinics in the same fashion as the outpatient clinics except patients were refused attention without a "GP referral" so Medicare could be billed (bulk-billed so the patients didn't care) redirecting state health financial responsibilities onto the commonwealth !! Check this out here although bless "The Age", their dear hearts, they are only many years late in reporting this!! Other cost shifting occurs .. GPs doing public hospital pre-anaesthetic checks with consultation and investigations billed to medicare. Public hospital obstetric care ? ... women are lied to being told they can't get into their first consultation until, so it happens, after its too late for when most of the important antenatal screening tests should be done, so the women are given a list of tests their GP "needs to order", again billed to medicare instead of coming out of hospital funding. Oh by the way, the hospital is happy to do the ultrasound and blood tests with a "private" referral from the GP, billed to medicare of course, but NOT include in part of their own service obligations.

Now the way for GPs to scam Medicare is "value adding" consultations .. no longer will the corporates encourage GPs in their practices see 10+ patients per hour, its now on average 4.3 patients per hour, but many are "value added". But its not just the corporates, its community health centres, private GPs and others with access to the care planning medicare item numbers.

• Mental health care plans for patients not needing psychologists referrals (or to see a sex therapist who just happens to have a medicare provider number while there is no associated qualifying mental health issue), mental health referrals for drug and alcohol service clients who can't be provided adequate resources due to appalling funding arrangements for D&A services but they have found a private psychologist with an interest/expertise in D&A issues prepared to bulk-bill medicare.
• Care plans for patients requesting a referral to a physiotherapist, podiatrist or other allied health care worker but the patient does not qualify under the detailed guidelines or if they do, none of the procedural work to create a genuine care plan is put in place - medical software can create a template in 30 seconds !!
• Referrals to orthodontists for cosmetic work because the patient has an "anxiety disorder" that the orthodontic work can cure !

Why not turn a bulk billed consultation worth less than $40 into one worth over $200, especially if you are paid a percentage of what you "earn" ?

Charge deep laceration repairs for the superficial repairs. Charge removal of a deep, imbedded foreign body when it was a superficial splinter. Charge a removal of a corneal foreign body for the removal of a sub-tarsal foreign body. Charge standard consultations for 3 minutes of your time. If you do this carefully no one will find out .. because if everyone does it, it is never going to be flagged by the software algorithms.

And with bulk billing the patient will never know, because they were never directly billed for the amount you charged ... they just sign a medicare form. That's if you ever have the patient sign the form ... just today I saw my own GP who sadly has moved into a much larger facility where his practice is now "managed" and the receptionist was quite clear I did not need to sign a medicare form for being bulk billed - I asked, because I know I am supposed to, and she assured me that I did not need to sign a form. I will have to tell my GP that the practice management is allowing this to happen, it certainly will not be being done with his knowledge or approval (yes there are honest GPs out there ... in fact most are, but too many are not). I have no idea how much I was bulk-billed for today !

Medicare rorting does make the news .. but in a small way. You might be interested to read this recent media report.

Nicola .. do you have the political will to attempt to change this system ? I applaud recently publicised individual cases of medicare abuse, but this is not the rare individual, it is wide spread and a pervasive disease in the system. Good luck and godspeed.

So why do I say "screw medicare ... screw me screw you" ? ... because my taxes your taxes fund (at least in part) medicare. Rip off medicare, you and I are being ripped off and in the long term (for short term greed) the community suffers, badly. Feel free to report it if you see it.

( conceived years ago, document draft started February 2010, published after much consideration March 2010 )

Gladstone Superclinic

Due to the unprecedented success of the NT Superclinic, Gladstone gets its own ... $5 million dollars to set it up as a sop for the local politics. Any guesses on who is going to staff it, doctorwise ?

Oh by the way ... take a peek at the side article on how there are no shortages of doctors in Gladstone. Coralee, if you are watching ... you might want to be better informed before making such sweeping statements as "Gladstone Hospital has no shortage of doctors". Looks bad if you get it wrong, very bad.

Teaser ...

.. upcoming soon ..

"How to rip off Medicare"

I have pondered for some time speaking of my experiences over the decades of how the Australian Medicare system has been badly abused by both the medical consumer and the medical service provider.

Now is the time. Over my current locum at Gladstone I will be drafting an article for your pleasure and my catharsis ... watch this space !

Far North Queensland ... enjoy the view !