COVID-19 VACCINE ROLL OUT - GPs are rolling up their sleeves for the rollout THE OFFICIAL PUBLICATION OF THE AUSTRALIAN MEDICAL ASSOCIATION OF NSW ...
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doctor
VOL 2 - N 07 - MARCH/APRIL 2021
THE NSW
THE OFFICIAL PUBLICATION OF THE AUSTRALIAN MEDICAL ASSOCIATION OF NSW
COVID-19
VACCINE
ROLL OUT
GPs are rolling
up their sleeves
for the rollout
Vaccine hesitancy • Regional quarantine • Managed care in obstetrics
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Contents
11
PATIENT FLOW 13
Dr Brian Morton shares his VACCINE
practice preparations for HESITANCY
COVID-19 vaccinations How to talk to
patients who are
unsure about getting
15
a COVID-19 vaccine
BUNDLED
OBSTETRICS
CARE
Dr Andrew Zuschmann
breaks down this model of
20
VACCINATING
REGULARS
managed care
STAFF 3
18
Can you force your staff to
Letter from the editor
be vaccinated?
7
MEDICARE
BILLING 22
RURAL
President’s Word
QUARANTINE 9
New quarantine solutions
From the CEO
need input from rural doctors
25
23 Classifieds
VEXATIOUS
COMPLAINTS
28
News
Developing a new framework
with AHPRA
30
Member Benefits
27 33
O WEEK Financial Paracetamol
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doctor From the Editor
THE NSW
THE OFFICIAL PUBLICATION OF THE AUSTRALIAN MEDICAL ASSOCIATION (NSW)
The Australian Medical
Association (NSW) Limited
ACN 000 001 614
Street address Is the TGA worried about The AMA and the RACGP have
TMI? The recent warning to both suggested that doctors play
69 Christie Street
ST LEONARDS NSW 2065
Mailing address
PO Box 121, ST LEONARDS NSW 1590
doctors to be careful about what an important role in combatting
Telephone (02) 9439 8822 they say on social media about fake news about vaccines.
COVID-19 vaccines caused
Outside Sydney Telephone 1800 813 423
Facsimile (02) 9438 3760
Outside Sydney Facsimile 1300 889 017
many doctors to go WT…? The TGA, AHPRA and National
Email enquiries@amansw.com.au
Website www.amansw.com.au
Boards all have a role in
The NSW Doctor is the bi-monthly In early March, the TGA quickly regulating advertising.
publication of the Australian Medical
Association (NSW) Limited. worked to mollify medical
professionals after it told the The National Boards and
Views expressed by contributors to The NSW publication Australian Doctor AHPRA released a Position
Doctor and advertisements appearing in
that doctors risked contravening Statement that includes
guidance on COVID-19 vaccine
The NSW Doctor are not necessarily
endorsed by the Australian Medical
medical advertising rules if they
Association (NSW) Limited. No responsibility
is accepted by the Australian Medical discussed vaccination on their information sharing and social
Association (NSW) Limited, the editors
social medial accounts. media.
or the printers for the accuracy of the
information contained in the text and
advertisements in The NSW Doctor. The
Whilst many are supportive The guidance explains that
acceptance of advertising in AMA (NSW)
publications, digital, or social channels or of the rules around medical medical professionals must
sponsorship of AMA (NSW) events does not
advertising, there is concern ensure their social media
in any way indicate or imply endorsement by
the AMA.
that gagging doctors leaves a activity is consistent with the
Executive Officers 2019-2021 vacuum in online forums that regulatory framework and does
President Dr Danielle McMullen
Vice President Dr Andrew Zuschmann anti-vaxxers are only too happy not contradict or counter public
Chair of Council Dr Michael Bonning
to fill with misinformation. health campaigns.
Hon Treasurer Dr Fred Betros
AMA (NSW) has spoken with
Chair, Hospital Practice Committee
Dr Sandy Jusuf
The TGA subsequently released
Chair, Professional Issues Committee
Dr Kean-Seng Lim a statement clarifying its both the TGA and the HCCC
Board Member Dr Kathryn Austin
position in The Australian. to explain the important role
of all doctors in supporting
Board Member Dr Costa Boyages
DIT Representative Dr Sanjay Hettige
Secretariat
“The TGA accepts that not all vaccinations, particularly in
Chief Executive Officer Fiona Davies information (including social vaccine hesitant communities,
Medical Director Dr Robyn Napier
Director, Services Kerry Evripidou media posts) is advertising and will continue to advocate on
Director, Workplace Relations
Dominique Egan
within the meaning of the this issue.
act. Distinguishing between
Editor
factual, balanced and non- In Twitter-speak, that’s referred
Andrea Cornish
andrea.cornish@amansw.com.au
promotional information, and to as calling out the ‘bulltwit’.
the promotion of the use or
Designer
Gilly Bibb Andrea Cornish,
gilly.bibb@amansw.com.au
supply of therapeutic goods (ie Editor
Advertising enquiries
Michelle Morgan-Mar
advertising) can be difficult and
michelle.morgan-mar@amansw.com.au needs to be assessed on a case-
by-case basis.”
3 I THE NSW DOCTOR I MARCH/APRIL 2021 amansw.com.au
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Letters to the Editor
Last edition, we asked readers the question, ‘Should you charge your
colleagues?’ following Dr Michael Steiner’s column that detailed the history and
professional ethical arguments of this professional courtesy.
The column stirred many to respond – both for and against this practice.
Members shared anecdotal stories of their own experiences, as well as the
actions of their colleagues.
Here are a few responses (printed with permission and edited as little as
possible for space) below.
Thank you so much for raising this issue. It is so vitally In nearly 60 years of medical practice, I have never charged
important to all medical practitioners. I am an almost a colleague or their partner or children. I believe that the
completely retired specialist surgeon. compliment of one’s peer to show their confidence in one’s
ability was reward …
In my opinion and according to what I have done personally
over 40 years of practice in NSW, I have never charged I know a lot of my colleagues charged their peers “whatever
the following people: medical practitioners, nurses, the scheme provided”. Recently I have become aware of
paramedical personnel, ministers of religious pursuit, and colleagues being very out of pocket from AMA fee levels
many other categories of patients – and I still do not. It is charges whilst, of course, the rebate is little. The contra
only when younger medical practitioners get to my age that effect has been that when my family have not been charged,
they realise regular visits to their GP and various specialists I have given a present to the doctor which leaves me well
are a necessity of life! out of pocket. He (or she) receives a tax-free gift, whilst of
course, no deduction is available to me. I often think I would
The saying… “Do unto others what you would do unto
prefer to be charged!
yourself….” applies so very much in this context.
Thank you for taking the time to appreciate my feedback.
Thanks again for raising this important issue.
- Anonymous, Rural GP
- Dr Gamani Goonetilleka
I have been a GP for about 30 years. Once people become
I have a contrary view. I believe that other health
my regular patients, I do not charge a gap fee for doctors
professionals should be treated ‘professionally’ which
or nurses. I also used to be a nurse. If it is a one-off
means like every other patient including paying fees. If
consultation, I would charge, as continuity of care is
hardship is identified, then reduction/waiving of fees is
important to me. I still see my customers as patients rather
appropriate – as for every other patient. Your column
than health consumers. I develop caring relationships with
writer makes the point that doctors don’t see other health
them. I do not see staff, family or friends.
professionals because they don’t want to be a nuisance, but
surely if you know the other doctor is under some ill-defined I am generally bulk-billed as a GP, although I offer to pay.
antiquated pressure not to charge you then this only makes I’ve seen an old-fashioned specialist who would not even
it worse. By behaving like all other patients (ie making accept Medicare payments from me. It was a vulnerable time
proper appointments in hours, paying the appropriate health-wise and I was very touched by this sentiment.
fees) that allows the practice to treat you appropriately and I’m certainly not into medicine for the money – I work part-
professionally and not as some special class of patient who time, do home visits (bulk billed) and see mostly pensioners
can then ‘fall between the cracks’ with results, etc. Also how and vulnerable people so charge very few gap fees anyway.
far do we go with this – other doctors then, physios, nurses,
pharmacists, and what about clergy? To me it’s a rabbit - Dr Marie Healy
warren not to go down.
- Associate Professor Tim Skyring
5 I THE NSW DOCTOR I MARCH/APRIL 2021 amansw.com.au
Letters to the Editor I returned to the reception after my appointment with the A good philosophical question. specialist. The room was now filling up with patients and I I never charge colleagues or retired colleagues and I try to approached the counter ready with my credit card to pay. My cap costs for everyone else. doctor then approached the receptionist and confidentially mumbled something, after which the receptionist exclaimed I saw a surgeon last February and was told I needed surgery “Oh, you’re a medical student! We look after our own very urgently. The fee was $5000. The Medicare rebate for here!” I was taken aback by this—one, out of the sheer the item number was $550. unexpectedness—and two, out of embarrassment given the I paid the money as it was urgent but rang my dentist as I other patients in the waiting area who might have overheard felt unsure – he was disturbed. Two second opinions said I and might feel they are on the full-fee second-class track. didn’t need any surgery. After thanking the doctor and the receptionist for their generosity, I trotted off to class and thought more about I got no refund, and I was so very cross I complained to what had just happened. HCCC. He did nothing illegal. He is running a business. I continued to think about the privilege that comes with However, medicine is different. If we charged as other becoming a doctor. I would expect that my car salesperson businesses do, our health system would not bear it. would get a better deal than I when purchasing his/her We all spend huge unpaid hours in medicine helping, as own vehicle, but I am more uneasy with my doctor gaining we are asked: patients, committees, education, research, advantage over his/her own and others’ patients. I think that colleagues, colleges, students, reading – it’s just endless. the medical profession is unlike other professions, because All would fall over if we didn’t. doctors live to serve their community and ‘professional courtesy’ has become a euphemism rather than a necessity. I see another specialist for another matter who charges … nothing. That is how it should be. I now unwittingly owe a debt toward my physician, which I - Anonymous now feel I must one day repay and/or pay forward. However, I would prefer that instead of a monetary or preferential gesture, I and my fellow doctors should be expected to give the literal (and priceless) gifts of professional courtesy, such as mutual respect and mentorship. I am not yet sure whether professional courtesy is a good or bad thing, but the fact I felt uncomfortable was telling. In our futures, professional courtesy in all its forms is something we will have to be acutely aware of. It is important that a strong sense of collegiality within the medical profession be maintained; however, if professional courtesy is to continue in its traditional form, it should not be at the potential expense of our integrity, the reputation of ‘the humble and selfless profession’, and most importantly, our patients. While ‘professional courtesy’ is not yet a dusty relic of a by-gone era, redefining it may be an inevitable aspect of progress for the field. - Tim Outhred, Medical Student (excerpted from a reflective piece produced for a university assignment) 6 I THE NSW DOCTOR I MARCH/APRIL 2021 amansw.com.au
President’s Word
COVID-19 VACCINATIONS
GETTING STUCK IN
doses appears to be very limited. making sure we can keep being there for
The drip-feed of information has been our patients.
painful for everyone. We often hear As doctors, it’s critical we follow the
from health officials that ‘there is much evidence and base decisions on the
learning’ to be done, which I suspect is current risk. The fastest way for all of us
code for ‘we are flying by the seat of our to return to pre-COVID activity is get as
pants’. many Australians vaccinated as possible
Instead of a well-developed plan, at to provide as much protection as we can
times it feels like Government is making it to the population. The primary goal of
up as it goes along. There is likely some our current vaccination program, as we
truth to that cynical view – we are, after all, understand it, is to reduce the likelihood
facing a once-in-a-lifetime pandemic. of severe disease and death when COVID
Against the backdrop of the vaccine inevitably reaches our shores again.
rollout for patients is the vaccination It’s also important to consider the
DR DANIELLE MCMULLEN of healthcare workers. There has been level of vaccine hesitancy that exists in
PRESIDENT, AMA (NSW) much angst in the profession about when, the general population. If we are going
where and how doctors will receive a to succeed in preventing people from
vaccine depending on which priority going to hospital and dying from COVID,
group they are in and what their risk level then it’s important we don’t inadvertently
is in terms of exposure. undermine the public’s confidence in any
Despite the national rollout of A significant number of members of the TGA-approved vaccines.
the COVID-19 vaccine in late have reached out to the AMA about the Given these factors and the number
February, the profession is still prioritisation of healthcare workers. of unknowns about the long-term
We have successfully advocated for effectiveness of any of the vaccines, we
waiting for important details. medical students to be considered as are recommending healthcare workers
Doctors, like their patients, healthcare workers when on clinical to follow the advice provided by the
placements, and for the rotations of Australian Technical Advisory Group
are being urged to exercise doctors-in-training to be taken into on Immunisation on priority population
patience. consideration. groups.
All doctors are in group 1a or 1b. If this pandemic has taught us anything,
With more vaccine doses coming into it’s how to adapt to an ever-evolving
the country and being produced locally, situation. It’s also a lesson I’m learning
we anticipate there will actually be a fair as President of AMA (NSW) – particularly
THE COVID-19 vaccination rollout is degree of overlap of 1a/1b and all doctors when writing this column which has been
somewhat off and running – not winning should receive their first dose soon. re-written three times before deadline to
any running races though. We are working with NSW health to keep up with all the new developments.
At time of writing, 1a is going well in ensure healthcare workers can access dr.
hospitals, aged care is creeping along either their GP or hospital hubs for their
and we’re days away from launching vaccine. Increasing real-world evidence as
group 1b in GP surgeries. But rather than to the efficacy of the AstraZeneca vaccine
launching with a bang, it seems it will be is reassuring.
more of a slow trickle. We acknowledge the significant role President@amansw.com.au
Understandably, there is high anxiety healthcare workers play in continuing to @_daniellemcm
amongst medical practitioners about the provide care to patients in this pandemic.
www.facebook.com/amansw
rollout, particularly as the initial rollout of Vaccinating our workforce is essential to
7 I THE NSW DOCTOR I MARCH/APRIL 2021 amansw.com.au
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FIRST THEY COME FOR
THE PROCEDURALISTS
IT WAS WITH significant concern consider the much more significant
that we have been advised that SIRA factors impacting on the ability of
will be cutting the fees payable to the scheme to return patients back
procedural specialists for treating to work. The RACP Statement on
workers compensation patients. For Helping People Return to Work states,
many years, procedural specialists “Research shows that being out of
have received 150% of the AMA fee work for extended periods of time is
for treating patients injured at work. bad for a person’s health. The longer
This fee covers both the treatment someone spends away from work, the
of the patient and all of the extensive less likely they will ever return.” Despite
paperwork associated with obtaining this, barriers to accessing care are
approvals and battling with the placed in front of doctors and injured
scheme agents to seek to get care workers at every turn. For patients
for patients. The justification for this requiring procedural specialist care,
FIONA DAVIES decision is that fees in other states every decision is subject to review and
CEO, AMA (NSW) are lower. SIRA also suggests that the scrutiny.
NSW return to work rates have not As the AMA represents all doctors,
improved despite this funding. AMA we understand that some members
(NSW) has responded to this change may question our battle to preserve
in the strongest possible terms and 150% of AMA Fees. However, if there
If there is one thing we know in highlighted that the blame is much is one thing we know in health, it’s that
health, it’s that cuts don’t stop more appropriately placed at the feet cuts don’t stop with one group, the
with one group of doctors... of iCare. same logic being used to reduce the
Whilst SIRA is the NSW government proceduralist fees could potentially
agency responsible for regulating the come to be used for GP specialists
workers compensation system, iCare is and other non-GP specialists providing
the state insurer. care to injured workers.
In 2018, iCare made significant We don’t need more cuts. What we
changes to their claims model. The need is thoughtful discussion about
new model reduced the number of the challenges of caring for injured
claim agents from five to one, EML. workers in the current environment and
According to Janet Dore’s 2019 the role doctors can play in supporting
independent review of the nominal their patients. We need to ensure that
insurer the new claims model led as many doctors as possible remain
to a significant deterioration in the engaged with workers compensation
performance of the nominal insurer, so that patients can see their usual GP
through poorer return to work rates, and the specialist of their GP refers
underwriting losses, no competition them to and that the patient remains
and therefore, concentration of risk. the centre of this scheme. dr.
iCare has been beset by scandal
and plagued by incompetence and
mismanagement. If corrections need to fiona.davies@amansw.com.au
be made to the system, SIRA should @FionaDavies8
be looking at iCare, not doctors.
www.facebook.com/amansw
The proposed change fails to
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COVID-19 VACCINATIONS:
MANAGING PATIENT FLOW
ALL OF US have been waiting for the would allow us to not only provide
availability of a vaccine for relief from this service to our patients, but also
the COVID-19 pandemic. We have allow us to carry on with our regular
been told it’s the long-term solution to appointments.
opening the borders and life returning
to a semblance of normal. And just a Here is a step-by-step breakdown of
little over a year since COVID hit our our preparations to date:
shores, it appears we’re on the cusp of
being able to immunise patients from Step 1: Finding space
the worst of this disease. Fortunately, our building has vacant
Australia has secured 53.8 million office space, so our practice manager
doses of the AstraZeneca vaccine, of asked the landlord for access and we
which 50 million doses are to be made were generously given permission at
locally. The Commonwealth recently no rental cost.
DR BRIAN MORTON confirmed that the CSL facility in
GENERAL PRACTITIONER Melbourne was on track to deliver the Step 2: Developing a plan
first batch of doses to a limited number We held a practice meeting to reach
of general practices in the week starting agreement with all our staff and GPs to
on 22 March. action a clinic. All agreed with both the
There seems a moral imperative as a principle and the functional plan. It was
General practitioner and medium size general practice to provide agreed that separation of the COVID
former AMA (NSW) President, a vaccination clinic available to not vaccination clinic from normal daily
just our practice patients but also the activity would be essential.
Dr Brian Morton shares his local community. Our practice, which is
step-by-step preparations to located north of Sydney, has 10 general Step 3: Ordering supplies
run COVID-19 vaccinations at practitioners who have amalgamated At the time of writing, we had just
from separate practices in adjacent received confirmation from the Federal
his Sydney practice. communities. All of the original practices Government as to when we would
have been in the area for 40 years and receive our vaccines and how many
we have been in our current location doses we would be able to provide to
since 2008. Given this history, we are patients. But in the weeks leading up to
well-established in the community and this, we set about ordering the supplies
have a strong patient base. we would need to maintain a surgically
It became obvious from the EOI clean environment.
process that running COVID-19
vaccinations at your practice was not Step 4: Storage capacity
going to be ‘business as usual’. Hence, We next turned our thoughts to
a considerable amount of planning has freeing up space in our two vaccine
gone in to preparing our practice to refrigerators. We have some additional
accommodate the vaccine rollout. availability given that travel vaccines
In order to successfully incorporate have not been needed, and we
COVID-19 vaccinations into our have been allowing routine vaccine
practice, we developed a strategy that quantities to be reduced.
11 I THE NSW DOCTOR I MARCH/APRIL 2021 amansw.com.auColumn
Step 5: Bookings to go through our patient base and
and the other for inputting to the
identify those who are eligible patients
We are also anticipating increased calls Australian Immunisation Register and
in Phase 1b of the COVID-19 Vaccine
from patients who are looking for more the doctor’s clinical notes.
Rollout Strategy and create a listing for
information about COVID vaccinations calls for attendance.
and bookings. To deal with this, we put Step 9: Staffing
in place a telephone message, which To run the clinic as efficiently as We are anticipating we will need
instructs callers to go to our website possible, we determined we will require approximately five minutes per patient
for information about the clinic and for a receptionist (R), practice Nurse (N), for the vaccination and our bookings
online bookings. GP 1 (D1) and GP 2 (D2). will be made to reflect that.
Step 6: Updating our website Step 10: Rostering What’s next?
In order to provide patients with Based on the staffing requirements There will be other considerations and
the most up-to-date information as outlined above, we developed this processes that will need to be put in
possible, we are putting together some schedule: See chart below place, but this is a brief skeleton of our
unique content on our website, which practice’s logistical strategy thus far. Of
will provide background information Step 11: Bookings course, further considerations will have
on the vaccines, the COVID-19 Once we have received the vaccines to be made and we anticipate there will
Vaccine Rollout strategy and patient and are ready to go, then we will need be some learnings along the way. dr.
prioritisation and booking information.
TIME STAFF REQUIRED
Step 7: Assessing the layout of
the clinic space
This includes looking at patient flow Morning session 8am to 12pm D1+D2
through the clinic from the registration
Lunch session 12pm to 2pm D1
desk, pre-vaccine waiting area, two
vaccination rooms set for privacy, post- Afternoon session 2pm to 6pm D1+D2
vaccination waiting area, and then the
exit desk. Evening session 6pm to 8pm D1
Weekend session Sat: 10am to 2pm D1*
Step 8: IT connectivity Sun: 10am to 2pm D1*
We identified that we will need two
laptops. One to be used for patient
identification, eligibility and registration, *Schedule is subject to change according to staffing availability and demand
12 I THE NSW DOCTOR I MARCH/APRIL 2021 amansw.com.auFeature
Vaccine hesitancy
in the age of COVID-19
Nearly three in four
Australians have indicated
they would get a vaccine, but
what can you do to build trust
among those who are unsure?
AFTER A YEAR of lockdowns, travel
bans, and PPE shortages, it seems
Australia is about to make its first
steps out of the most significant
pandemic in a century. With both the
Pfizer and AstraZeneca vaccines now
**Shutterstock image - not actual image of COVID vaccine/syringe
approved, we have a path back to
normalcy. But with differing vaccine
efficacies and uncertainty about the
level of population coverage needed
to reach herd immunity, an almighty
effort will be required to get people
vaccinated. There are clearly two
sides to this coin: supply and demand.
The supply debate is currently being
carried out in public, with criticism
being placed, rightly or wrongly, on the
Federal Government’s procurement
strategy. But the demand side to this
equation also needs to be addressed,
and doctors, particularly GPs, are well
placed to ensure wide vaccination
coverage. One hundred and fifty million
13 I THE NSW DOCTOR I MARCH/APRIL 2021 amansw.com.auFeature
vaccines are useless if only 150,000
people want them.
The best way to convince
Already almost 30% of Australians
are unsure about a COVID vaccine,
vaccine hesitators is to engage
and this level of vaccine hesitancy
may rise given recent news about
in a genuine dialogue, not a
novel variants of COVID-19 and
their variable responses to vaccines.
monologue.
Australia is also a victim of its own be taken, which should be reiterated fears. Furthermore, referring to certain
success, with relatively low amounts of after addressing patients’ concerns. trusted spokespeople and influencers
cases and deaths perhaps leading to This favours language such as ‘You are within communities can provide a
a lack of urgency in getting a vaccine. due for your COVID vaccine today’, unique legitimacy to a vaccine.
Despite the proliferation of Anti-Vaxxer rather than ‘What do you think about Finally, the best way to convince
sentiment on the internet, international getting your COVID vaccine today?’. vaccine hesitators is to engage in a
evidence still suggests that patients If the patient is still hesitant, clinicians genuine dialogue, not a monologue.
see their own healthcare providers as should switch to acknowledging Trust is fostered through active listening,
their most trusted source of vaccine and empathising with the patient’s acknowledge anxieties, and addressing
information. My own anecdotal concerns, while reinforcing the efficacy concerns, rather than dictating facts
experience supports this: I’ve already and safety of vaccines with short and dismissing worries. By building
sat in numerous consultations where simple statistics. If any misinformation rapport, the patient will also build trust
the patient has posed the question, is mentioned by the patient, experts in your judgement regarding vaccines
‘Should I get the COVID vaccine?’ state that misinformation should only and that will help convert vaccine
So how should doctors face this be referred to once and rebutted hesitators into acceptors.
challenge? How should doctors concisely with clear simple facts. For Obviously, the COVID vaccines
engender support in the vaccine, and example, if there are concerns about are different. The evidence base is
help build herd immunity? Luckily, there severe side effects, the clinician could emerging, there are multiple candidates
is a growing evidence base answering reply, ‘This vaccine was tested in a with seemingly differing efficacy and
this very question, of battling vaccine trial with over 40,000 people, of which tolerability. Nonetheless, the Australian
hesitancy. Firstly, the physician should mild side effects like fatigue, a sore medical profession is up to the
pick their battle. You can broadly group arm, and a headache were the most challenge of ensuring that a safe and
people’s views towards vaccines into common. Only four serious side effects effective vaccine is widely accepted,
three groups: acceptors, who largely were noted.’ Clear, easy to understand bringing us one step closer to a post-
accept vaccines unquestionably, detail is key to conveying confidence in COVID age. dr.
hesitators, who either delay vaccines or the vaccine.
are selective, and refusers, who refuse However, narratives and stories, in
all vaccines. While acceptors clearly do additional to datapoints, can further
not need to be convinced, you should reassure patients around COVID
not spend much time on total refusers: vaccines. A survey of US primary
they are unlikely to change their mind. care physicians found that personal
Rather, simply a brief consultation and statements around what they would do
leaving the door open to these patients for their own family, and what personal
if they ever change their mind is the experiences they have had, seemed
most suitable approach. to have the most effect in swaying ABOUT THE AUTHOR
The bulk of persuasion and skeptical patients. These stories and Leo Coleman is a final year medical student
reassurance should be placed on those facts should take into consideration at Prince of Wales Hospital. For article
who are hesitant towards vaccines. the patient’s background, as patients references please email the editor at
The Centre for Disease Control states within differing communities would news@amansw.com.au.
that a ‘presumptive’ stance should have varying motivations, concerns and
14 I THE NSW DOCTOR I MARCH/APRIL 2021 amansw.com.auFeature
BUNDLED
OBSTETRICS
CARE
– will managed
care models work
in Australia?
ANAESTHETISTS work with a Sometimes women present at the
Obstetricians have been the lot of different Medicare Benefits hospital during the antenatal period,
early adopters of managed care Schedule (MBS) item numbers. An old which also attracts a fee-for-service.
options overseas and Australian anaesthetist colleague once told me he The actual birth itself will involve the
was like a taxi driver – charging a flag obstetrician, the anaesthetist and a
practitioners are watching fall and then a per-kilometre rate. number of other specialties. Typically, it
closely, as Sydney obstetrician I’m not sure what analogy would will also include the paediatrician who
Dr Andrew Zuschmann explains. best suit the complicated billing would review the baby after birth. If the
practice of obstetricians but hope the woman is unwell with something like
following provides insight into our long preeclampsia, she may also have an
and winding road. ICU admission.
Much of the complication comes
from the fact that our care occurs OBSTETRIC ITEMS
partly in the community and partly in Before the Extended Medicare Safety
the hospital. Net (EMSN) came into existence
In the community, we’ll have the in 2004, simplified gap billing was
initial visits where the pregnancy is common.
diagnosed and investigations ordered. Obstetricians would typically divide
Then there will be a number of routine their fee over a number of visits during
antenatal appointments. Typically, the pregnancy, and the patient would
this might involve eight or 10 of these pay certain amounts per visit. The
episodes during a pregnancy. There EMSN brought in item number 16590
will also be bloods and scans, so we for the ‘Planning and Management of
will be involving pathology, ultrasound a Pregnancy’ and this was basically to
and radiology colleagues, along with capture the gap payment that occurred
GP and paediatric appointments in the in the community setting.
postnatal period as well. Initially, it was suggested this be split
15 I THE NSW DOCTOR I MARCH/APRIL 2021 amansw.com.auFeature
into the gap attributed to the antenatal clawing this back to reduce members’ care can create at some hospitals is
and birth components. So a typical out-of-pocket expenses. needing to run two on-call rosters.
pregnancy billing would look like: With most of the care being provided One for the obstetricians,
✔ 16401 for an initial attendance; in the community, the community anaesthetists and paediatricians who
✔ 16500 for each antenatal portion tends to attract a bigger gap, want to participate in a bundled care
attendance; with a smaller gap being apportioned arrangement and another for those
✔ 16590 for planning and management to hospital services. There’s a big who don’t. You can imagine the issues
of the pregnancy; insurer mark-up on the 16519s, which this creates having to potentially run
✔ 16519 for a simple birth; prevents the large out-of-pocket costs two anaesthetic rosters.
✔ 16522 for a complicated birth; or large out-of-pocket gaps in hospital One of the key considerations to
✔ 16404 postnatal attendance because many obstetricians, certainly be taken into account is that many
(in rooms). around Sydney, will no-gap the birth health funds consider women who
Note that vaginal birth and caesarean based on reasonable rebates. are participating in a bundled care
sections attract the same fee. The arrangement need to have exactly
complicated birth numbers include UPLIFT FEES the same care arrangement from the
things like diabetes, significant It is becoming increasingly obvious obstetricians.
hypertension, multiple pregnancy or that when it comes to bundled care From the maternity care provision
bleeding. An elective caesarean in arrangements the provision of uplift point of view, no two pregnancy
somebody with diabetes might be a fees is dependent on all community journeys are the same. That the
fairly straightforward procedure and no consultations with the obstetrician insurers are attempting to homogenise
different in those without diabetes. service bulk billed, which means the a woman having a baby speaks
We are all familiar with the different EMSN rebate is lost for the patient. All volumes to what their approach
patient rebates between the MBS bloods and scans must be at a bulk could be to so many other areas of
and the no or known-gap procedures, bill provider already in place with the healthcare. dr.
but you may not be aware of the true health fund. Many pathology services
impact of going even a little over the no- will bulk bill, but high-quality pregnancy
gap rebate for birth as our patients are ultrasound typically has a gap because
getting significant out-of-pocket costs. ultrasound and radiology rebates
The MBS rebate versus HCF no-gap, have been neglected. All anaesthetic
for example, has quite a difference: services must be provided at no out-
✔ 16519 – MBS $536 vs HCF $1,908 of-pocket cost to the patient, and this
or; includes the no-gap plus and uplift fee.
✔ 16522 – MBS $1,260 vs HCF From an obstetrician’s point of view,
$2,315. the uplift fee is significantly less than
ABOUT THE AUTHOR
many currently charge for the package
Dr Andrew Zuschmann is an obstetrician,
COMMUNITY CARE of obstetric care we provide. Although gynaecologist and fertility specialist
With there being three main types of there’s a wide variation of fees charged working in both public and private practice
private health insurance in Australia in Australia for private obstetric care, in the Sutherland Shire, Sydney. He is
– hospital, extras and ambulance – for many this would represent a Head of Department at The Sutherland
there is nothing that covers care in the significant 25% reduction in income (public) hospital, and O&G representative
community. This feeds into one of the per pregnancy. MAC, Kareena Private Hospital. Andrew is
also Vice-President AMA (NSW), NASOG
major public misconceptions about As a busy obstetrician, I’m comfortable
Councillor, and Chair RANZCOG NSW/ ACT
why their health fund is not paying with the workload that I’m doing and Training Accreditation Committee.
more obstetric cover. for me to take a 25% reduction in fees
The majority of pregnancy care, with the expectation that I’m actually
including 24/7 access to a specialist going to increase the workload, is really This article first appeared in Australian
obstetrician and gynaecologist, challenging. Especially in the era of safe Anaesthetist and is reprinted with
permission. The ASA is hosting a series
actually occurs in the community and working hours and of work-life balance
of webinars on managed care with
is outside the remit of private health in medicine, it’s just not particularly information about upcoming webinars
insurance. So, we can see that health acceptable. available on www.asa.org.au.
funds are really looking at ways of The other challenge that bundled
16 I THE NSW DOCTOR I MARCH/APRIL 2021 amansw.com.auYou’ve read
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SIMPLE_DJ_MIGA032Workplace Relations
A GUIDE TO MEDICARE
COMPLIANCE PROCESSES
Private Patient Billing for Out- Commonwealth Medicare Benefits
Patients in Public Hospitals Schedule. With respect to Visiting
Under the National Health Reform Medical Officers and Staff Specialists,
Agreement, patients must be providing private patient services in
given the choice to receive public public hospitals this means:
hospital services free of charge as • Regularly reviewing Medicare claims
public patients, access to public submitted by the hospital on their
hospital services is to be provided behalf. If anomalies are identified they
based on clinical need and within a should be raised with the hospital and
clinically appropriate timeframe, and Medicare.
arrangements are to be in place that • Claims should only be made under
ensure equitable access to services. a Visiting Medical Officer’s or Staff
Private out-patient services can be Specialist’s Provider Number if that
DOMINIQUE EGAN provided in public hospitals provided: person provided the service. Services
• Patients are given the choice to be provided by other practitioners should
DIRECTOR OF WORKPLACE treated as public or private; not be claimed under the Visiting
RELATIONS, AMA (NSW) • Public patients must be provided Medical Officer’s or Staff Specialist’s
with the same access to services as Provider Number.
private patients;
• If a patient chooses to be treated Visiting Medical Officers should also
2021 is well underway, and with as a private patient, they must have be aware that if a claim is submitted
the new year we have seen an been referred to a named medical to Medicare for a medical service, a
specialist; Visiting Medical Officer should not be
increase in member enquiries in • Informed financial consent must be paid under his or her Visiting Medical
relation to Medicare compliance provided to patients. Officer Contract for the provision
processes. of that service (other than in limited
Referral pathways must not be circumstances where an exemption
controlled so that a named referral is has been given by the Department of
a pre-requisite to access out-patient Health).
services. A patient must be able to
access out-patient services as a public Billing for Out-Patient
patient. procedures
NSW Health will be publishing a Some members have recently been
Guideline to provide guidance for contacted by the Department of Health
NSW Health organisations when billing in relation to the billing undertaken for
for privately referred non-inpatients out-patient procedures.
services in NSW public hospitals. The Under the provisions of the Health
Guideline reflects the position under Insurance Act, the Medicare benefit
the National Health Reform Agreement payable for a service provided as a part
and the Health Insurance Act 1973. of an episode of hospital treatment is
Medical practitioners are responsible 75% of the Schedule Fee.
for ensuring that services billed under Hospital Treatment, for the purposes
their provider number are billed in of the Health Insurance Act, is
accordance with the requirements treatment, inter ala, that is provided at
of the Health Insurance Act and the a hospital. No distinction is made as
18 I THE NSW DOCTOR I MARCH/APRIL 2021 amansw.com.auWorkplace Relations
RKPLA
WO
CE
RE
S
LA
TIO
N
to whether a patient is an in-patient Shared Debt Recovery Process
or an out-patient when they receive The shared debt recovery process
treatment. may be of assistance to practitioners
who are formally audited by the If you are considering making a
DOH calling doctors Department of Health. It is not available voluntary repayment should you
We understand that the Department of to medical practitioners who complete become aware of an inappropriate
Health has recently begun contacting a Voluntary Acknowledgement of billing practice at your hospital,
medical practitioners about how and Incorrect Payments after receiving please contact your MDO or AMA
by whom private patient billing is correspondence from the Department (NSW)’s Workplace Relations Team
undertaken in public hospitals. of Health asking the practitioner to at workplace@amansw.com.au for
If you receive such a call, we would review his or her billings. advice. dr.
like to hear from you.
AMA (NSW)
Council Elections
Are you interested in making a
contribution to the profession and
the future of healthcare in NSW?
Nominations close
Thursday 25 March 2021
Contact Claudia.gillis@amansw.com.au
for nomination forms.
19 I THE NSW DOCTOR I MARCH/APRIL 2021 amansw.com.auWorkplace Relations
COVID-19 VACCINES
AND YOUR STAFF
Q: I run a private practice and after and reasonable directions to their
a tough year business has picked employees, but whether a direction is
up and we’re now very busy. With lawful and reasonable will depend on
the vaccine rollout underway, I want the circumstances. Currently, there
my practice staff to be vaccinated is no legal requirement or authority
for COVID-19. Can I require this? that allows employers to mandate the
A: Generally speaking, no. Even COVID-19 vaccine for staff in private
though you run a busy practice, you practice. So, a direction that practice
cannot require that your practice staff be vaccinated for COVID-19
staff be vaccinated for COVID-19. would not be lawful. This position may
The State and Federal Governments change in the future if new laws are
have announced that the COVID-19 made, or cases are determined by the
vaccination is voluntary and there Courts.
LYNDALL HUMPHRIES is currently no legal requirement or
authority that allows for mandatory Q: I understand I can’t direct my
SENIOR WORKPLACE RELATIONS vaccinations for staff in private employees to be vaccinated for
ADVISOR (EMPLOYMENT LAW), practice. COVID-19, but I’d still really like to
ask them. Is that okay?
AMA (NSW)
Q: I have a medical condition and A: Yes, you should consult with your
am immunocompromised. If my employees about the COVID-19
staff are vaccinated for COVID-19, vaccine and can encourage and
I’ll feel safer about working in a request that they be vaccinated. In
Here are some common busy practice. Does this change your discussions you should cover
questions we receive from things? relevant factors including the nature
private practice employers about A: No. The fact that you (or your staff of your practice, the risk profile of
or patients) have a medical condition patients and individual staff members,
COVID-19 vaccines and their does not change that the COVID-19 the nature of each staff member’s role
practice staff. vaccination is voluntary. To ensure and the working environment. It is up
your own health and safety, and the to each employee to make their own
health and safety of staff, patients and decision.
others at your practice, you will need
to continue to apply practical safety Q: One of my employees doesn’t
measures such as physical distancing, want to be vaccinated because she
good hygiene and regular cleaning and is pregnant/on religious grounds/on
maintenance. medical grounds/due to personal
preference. Is there anything I can
Q: But I’ve read that an employer do?
can issue lawful and reasonable A: No. As COVID-19 vaccination is
directions to their employees. voluntary you will have to respect
Given my medical condition, would your employee’s decision. You should
it be lawful and reasonable for me continue with the practical safety
to direct my practice staff to be measures at your practice and you
vaccinated for COVID-19? may need to revisit or update your
A: You’re correct that an employer risk assessment with any additional
generally has a right to issue lawful information. dr.
20 I THE NSW DOCTOR I MARCH/APRIL 2021 amansw.com.auFOCP 12 F
D
R H RE
N O E
U U
R R
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Register Free Pass
Dates: 17 - 18 March 2021
Time: 10AM - 4PM Daily
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www.austhealthweek.com.auFeature
RURAL QUARANTINE
NEEDS RURAL
LEADERSHIP
Consultation with rural and regional doctors needs to happen before
new quarantine solutions are developed.
THERE HAS been much ado of late managing small, localised outbreaks has been no meaningful consultation
regarding Australia’s hotel quarantine when and if they occur. with rural doctors in primary or
system. Amongst other factors, a Importantly, the process of secondary care on any of these
systemic failure of the Australian establishing and implementing Howard proposals. In addition, the leadership
Government’s Infection Control Expert Springs was driven by local doctors. As of these sites will be from capital cities,
Group (ICEG) guidelines regarding luck would have it, these local doctors who have not proven themselves
airborne transmission has led to were based in the decision-making capable of making good decisions for
numerous instances of COVID-19 centre of the Territory (i.e. Darwin) rural and regional Australia.
escaping capital city-based hotel and were able to make good quality Do not mistake me, regional and rural
quarantine and generating a threat to decisions in the interests of the territory. quarantine can work under the right
the community. In response, State and The same cannot be said of regional circumstances. These circumstances
Territory governments as well as the quarantine proposals in other states. need to be managed by local doctors
Federal Government have proposed Proposals in Queensland and Victoria, and doctors with significant rural
the setup of regional quarantine whilst also with their merits, have expertise. These doctors are currently
stations in areas ranging from regional been made by predominantly city- ignored in a very systematic and
towns to remote mining camps. based “experts” and bureaucrats obvious way by the bureaucracy. As
The concept enjoys broad support, without involvement of rural doctors rural doctors we must insist on rural
particularly amongst doctors and or the broader rural health system. leadership as the centrepiece of any
politicians based in cities. The proposals ignore many issues regional quarantine system. dr.
As a rural doctor, what is the key to around workforce sustainability and
making something like this succeed? the management of outbreaks, both
When talking about regional quarantine, in primary care and hospitals, for the
many people cite the Howard Springs political expediency of removing the
Quarantine facility in Darwin as a “gold problem of quarantine from marginal
standard” for how things should be seats in capital cities.
done. Whilst Howard Springs has been These proposals currently reflect
a successful example of how quarantine the standard of geographic narcissism
should be done well, it is far from an that we have come to expect from
example of “regional” quarantine. The government. Rural health is a litany
facility is 20-30 minutes’ drive from of capital city-based bureaucrats and
a major centre, with a nearby airport managers telling rural doctors what to ABOUT THE AUTHOR
capable of handling heavy jet traffic. do without having even visited rural Dr Marco Giuseppin is chair of AMA Council
Sick patients (not that this occurs Australia or without any understanding of Rural Doctors (CRD) and a member of
frequently) do not require aeromedical of local context. This has led to a poorly AMA Queensland Council. He is a practising
Rural Generalist based in Queensland and
transfer to a larger city hospital for designed and under resourced rural
a retrieval doctor with the the Royal Flying
ongoing care, and the public health health system that ignores the needs of Doctors Service.
system in the NT is very capable of communities and doctors. To date, there
22 I THE NSW DOCTOR I MARCH/APRIL 2021 amansw.com.auYou can also read
