Technical Hitch

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A Traumatic Experience

For those who are unaware, there is a surgeon in Melbourne who has been the subject of a number of accusations leading to his suspension, amongst them that he is difficult to work with (or for), that he performs unnecessary operative procedures on serious trauma patients, and that he has been engaging in improper billing practices. These allegations are currently being hotly debated in the press and also the subject of a Supreme Court action.

I do not pass judgement about his character, surgical decision-making, or skill.

These two articles, however, have caught my attention:

TAC probes its links to hospitals - The Age
(Click to Expand)

TAC probes its links to hospitals
Richard Baker and Nick McKenzie
The Age, February 9, 2008

THE Transport Accident Commission is reviewing its relationship with Victoria's public hospitals, amid growing controversy over suspect billing practices by senior doctors.

In a move that could have funding implications for major hospitals reliant on TAC money, a spokeswoman for TAC Minister Tim Holding yesterday revealed the commission had initiated a review of services it is billed for by public hospitals in December last year.

The TAC, which pays multimillion-dollar amounts each year for treatment and income support for Victorian road accident victims, is also investigating the billing practices of surgeons as part of the review.

The commission is funded by a compulsory third-party insurance premium that is part of annual motor vehicle registration fees in Victoria.

The State Government's confirmation of the TAC review came after The Age yesterday revealed a secret TAC 2007 audit of The Alfred hospital was unable to verify if surgeons who had billed it for patient consults had actually seen the patients.

The draft audit found that irregular note-keeping in patient files made it impossible to correlate surgeons' billing records with the information in patient files.

It also questioned why the TAC was paying millions to public hospitals for services already funded by taxpayers.

The TAC began its review of its relationship with public hospitals after its board and senior executives were briefed on the draft findings of an Alfred hospital-commissioned medical panel investigating serious allegations against one of Victoria's most high-profile surgeons, The Alfred's suspended trauma director, Thomas Kossmann.

Mr Holding's spokeswoman said the TAC's hospital review would incorporate the medical panel's findings, which are expected to be made public once it delivers its final report to The Alfred's chief executive, Jennifer Williams, this month.

The medical panel's draft report made adverse findings against Professor Kossmann in the areas of clinical practice, TAC billing, supervision of staff and participation in peer review.

The TAC contacted Victoria Police after being briefed on the draft report and Professor Kossmann was stood down from The Alfred by Ms Williams because of the report's serious findings. He was also one of two doctors named in last year's secret TAC audit of The Alfred.

But the German-born surgeon has strenuously rejected the allegations and challenged many of the medical panel's findings against him in its draft report. He has also taken legal action to overturn his suspension in November by Bayside Health.

Opposition Leader Ted Baillieu yesterday said the TAC had to reassure Victorians that their funds were not being misused and called for greater disclosure.

Mr Baillieu said Mr Holding and Health Minister Daniel Andrews also must disclose how much TAC money has been paid to Professor Kossmann "in these questionable deals".

Surgeons' billing questioned by secret TAC audit - The Age
(Click to Expand)

Surgeons' billing questioned by secret TAC audit
Richard Baker and Nick McKenzie
The Age, February 8, 2008

A SECRET Transport Accident Commission audit of The Alfred hospital reveals surgeons may have billed the TAC for treating patients they had not actually seen.

The 2007 TAC draft audit also asks why the commission is pumping millions of dollars it receives from Victorian drivers into hospital services that are already taxpayer-funded.

The release of the audit under the Freedom of Information Act comes amid continuing controversy over the suspension of The Alfred's trauma director, Thomas Kossmann, who is being investigated by a medical panel over allegations that he performed unnecessary surgery on patients and wrongly billed the TAC. He has rejected the allegations.

The identities of two doctors named in the audit were removed from the documents, but The Age has confirmed Professor Kossmann is one of the doctors named. It has been reported that The Alfred received a percentage, possibly as much as 50%, from each of his TAC billings.

Written by the deputy of the TAC's clinical panel, David Bolzonello, the audit found irregular note-keeping in patient files at The Alfred made it impossible to correlate doctors' billing records with patient data.

The February 2007 audit, done without the knowledge of The Alfred, was unable to ascertain if senior doctors who had billed for treating patients had actually seen them or whether more junior doctors — who cannot charge the TAC — had done the work. It concluded: "It is unclear from the notes if this reflected actual review by these people themselves (who submitted bills) or the unit staff such as registrars as I could not see regular entries in the files to correlate the billing."

The TAC pays for the treatment of road accident victims in Victoria through compulsory third-party insurance premiums on motor vehicle registrations.

Several doctors at The Alfred have accused some senior colleagues of billing the TAC for work they have not done.

The disclosure of the audit has renewed pressure on the Brumby Government to review the relationship between the TAC, doctors and public hospitals, with Opposition Leader Ted Baillieu yesterday saying it enhanced his call for a judicial inquiry into the controversy at The Alfred. "There are numerous doctors and public officials involved in this matter and it is imperative that their roles and actions are clarified as soon as possible," he said.

Other issues raised by Dr Bolzonello's audit included:

• A review of the State Government policy governing financial transactions between public hospitals and the TAC. "… The Alfred and its equipment are owned already by the people of Victoria. The resident staff is also paid by public funding. The TAC is then billed at private rates for radiology, pathology and bed fees. There is some argument for review of this."
  
• A lack of clinical notes to summarise the "management and decision making" of The Alfred's emergency department.
  
• Queries over whether the use of scans and hospital equipment — for which the TAC could be billed — was excessive.

The TAC took no further action after receiving Dr Bolzonello's audit, which examined 50 patient files and concluded the medical management to be reasonable. His audit did not review individual billings.

A TAC spokesman said the rules governing billing "rely to some degree on the honesty of the individual or organisation submitting the account". Procedures were in place for fraud to be investigated, he said.

A spokeswoman for The Alfred said the hospital had not received any billing complaints from the TAC. "There is a funding system set up by the Department of Human Services and the TAC. We follow the rules and we are no different to other hospitals working in that system."

Professor Kossmann, who is awaiting the final report of a medical panel commissioned by The Alfred to investigate serious allegations against him, said the TAC audit contained nothing to undermine his reputation.

The German-born surgeon was suspended by The Alfred in November due to adverse findings in the panel's draft report. He has challenged his suspension by Bayside Health in the Supreme Court.

Professor Kossmann said he would be happy to work under a more efficient TAC billing system if one could be established. "I'm a surgeon not a policy maker. These issues are for the (TAC) minister and the TAC board."

The final report into the allegations against Professor Kossmann is expected to be released this month.

For those not familiar with the TAC (or Victorian Transport Accident Commission) its role is to act as a defacto private health insurer for those people sustaining personal injuries as a result of traffic accidents in Victoria, Australia - similar to the Motor Accidents Authority of NSW. It is funded by way of compulsory insurance premiums paid by all motor vehicle registrants in that state (currently around $300-$400 a year for a standard passenger vehicle).

From its website:

The TAC is a Victorian Government-owned organisation set up in 1986.

Its role is to pay for treatment and benefits for people injured in transport accidents. It is also involved in promoting road safety in Victoria and in improving Victoria's trauma system.

Funding used by the TAC to perform these functions comes from payments made by Victorian motorists when they register their vehicles each year with VicRoads.

The TAC is a "no-fault" scheme. This means that medical benefits will be paid to an injured person - regardless of who caused the accident.

Legislation guides the TAC in the types of benefits it can pay and any conditions that apply. This legislation is called the Transport Accident Act 1986.

To ensure it remains a long-term compensation scheme, the TAC uses its funds fairly and responsibly. This ensures the TAC is able to meet the needs of seriously injured people who need lifetime care.

The TAC is fairly flexible on what it pays out - it was established to cover all the long-term out-of-pocket and accessory costs of a serious traffic injury, such as those incurred by someone with a major spinal or head injury. Often these are costs which are not well funded through Medicare, or are often not covered under Private Health Insurance. It is analogous in function to the various WorkCover or WorkSafe schemes - and as such can be the subject of similar client (patient or claimant) abuse.

The way that it operates is very similar to that of a Private Health Insurer with fantastic "extras" cover - physiotherapy, long-term rehabilitation, dental care, transport costs, specialised equipment, carer's costs etc. In-hospital costs are paid for treatment in public and private hospitals. For public hospitals, these rates are agreed upon between the TAC and the Victorian Department of Human Services. Generally the TAC has to give written or telephone approval for anything outside of an emergency situation.

Obviously, public hospitals love TAC patients the same way that they love privately insured patients - it is money in the bank for them.

The TAC also has set fees for surgery and consultations which it will pay to doctors who engage in private practice, or have the right of private practice in a public hospital (i.e. Consultant Staff Specialists or VMOs). Where these fees are not paid directly to the doctor it is common that they are paid into a Private Practice Fund, "Dillon Fund", or some other trust fund often administered by the hospital.

The concerns raised in these two articles relate to firstly, whether Professor Kossman or his colleagues were entitled to TAC payments for services rendered by them or on their behalf, and secondly whether the TAC should be paying for services for which patients would be entitled to care in the public hospital system already.

These strike to the heart of several deeper issues:

1. Does the TAC require specialists to render services directly to the patient, or is it acceptable to (directly or indirectly) supervise or delegate this treatment to a junior or assistant?

There does not seem to be any specific rule about this, and it is common for orthopaedic registrars to perform procedures on TAC patients with the bill still going to the TAC. This is in contradiction to the general practice whereby privately insured patients should be directly operated upon by their chosen specialist - as this is a condition of Medicare funding their portion of the patient's medical fee.

Does the TAC draw upon Medicare to pay the bulk of these fees in the same way as a private health insurer? If not, then what rules exist to say that the operating surgeon or consulting physician must be the one who personally rendered the service?

Clearly The Alfred Hospital has been claiming TAC fees on behalf of Professor Kossman and his colleagues. Presumably these fees were paid into a pooled private practice fund of some sort. Was some arrangement as part of his employment contract reached whereby Professor Kossman received a greater proportion of these payments than other doctors? Does The Alfred have the right to use TAC or private insurance payments to "sweeten the deal"? Did Professor Kossman raise the profile of some questionable practices as a result of his high operative load?

As for the issue of demonstrating that consultations occurred - this relates to the perennial issue of medical record-keeping. Nobody I know is a perfect record keeper. I most certainly am not. I try to make a short entry every time I see someone in private, but I am not infallible. Generally I rely on my junior staff to do that in public - and I would not be surprised if they were to omit the fact of my attendance in the interests of brevity. It is not the least surprising that some consultations were undocumented.

2. Should the TAC pay for the costs incurred by a public hospital for covered patients?

If the TAC did not exist (such as in Queensland) the Victorian State Government would still have to pay for the care of these patients in the public hospital system, but there is no doubt that their out-of-hospital care would be cost-shifted to the Federal Government and also be of significantly poorer quality. It would, however, be cheaper.

However, part of the reason for the TAC's payment scheme is to allow patients to exit the public hospital system and be treated in private hospitals. This benefits the public hospital system by reducing demand on resources, and also encourages the development of efficient specialist treatment centres for people with severe traffic-related injuries. A number of private rehabilitation centres specialise in TAC-related work. The Austin Hospital's Spinal Injury Unit is constantly filled with TAC-funded patients. And Melbourne's Alfred Hospital is presumably an excellent first-line major trauma centre, and therefore handles large numbers of TAC-insured patients.

No doubt having specialised centres giving excellent care may drive down the short-term costs (by way of volume and system efficiency savings) and long-term costs (by way of giving the best clinical and functional result, thereby leading to fewer ongoing care costs) for these groups of patients, but it also means that these centres will strive to provide the best care available to them by engaging to treatments and investigations which are costly in the short term and potentially less rewarding in the long term... effectively having a decreasing "bang for the buck" to put it crudely.

Perhaps these are issues which raise more questions than answers, but I believe that they deserve more attention than what is portrayed in the news and general media.

Background News Articles from The Age:

• Top surgeon stood down after inquiry
  
• Hospital divided over surgeon
  
• The charismatic surgeon and the mutiny
  
• Experts to probe complaints against trauma surgeon

Walking backwards, slowly.

I have been following, on and off, a thread on Paging Dr about how to "Survive First Year". After three pages of posts it is a bit muddled about the first year of what, but all the talk about work-life balance has raised the hairs on the back of my neck.

Now don't get me wrong, I am not against doctors having a social life and being able to wind down away from work. Heaven forbid, my family would be very unhappy if I completely ignored them to work all day and all night.

But this concept that doctors (and medical students) are entitled to a fun and enjoyable experience during their work or study irks me. Medical school is meant to get you trained up as a decent doctor... but it just so happens that all the students want it to be fun and enjoyable. Being a doctor is about treating patients as best as you can, and drawing appropriate reward (personal satisfaction is a form of reward) from doing so.

There are many previous generations of doctors who chose to let (or failed to stop) work taking over their lives. 50 years ago it was normal to eat, breathe and sleep medicine all day every day while you were a RMO or Registrar. Even as a GP in a solo practice it was normal. And your patients appreciated it. Doctoring was not a job, it was a lifestyle.

These days, nobody (in any profession) wants to make any personal sacrifices for the sake of work. We all want to clock off at the end of our shift, turn off our pagers and forget about work. And by that I don't mean just doctors, but everyone in the wider community. No longer is the community expectation "8 hours work, 8 hours rest, 8 hours sleep" (care of the trade union movement) but so is the 2 week overseas holiday, investment property, beach-house, private school education, 4WD, and token sustainable garden. Are we becoming a society of spoilt brats?

I increasingly see it in the surgical trainees (and I must confess that I am and was no exception). They don't want to move out of town for rural rotations, let alone interstate or overseas, for fear of disrupting their personal or family arrangements (neither did I, at that stage). They want to claim every single dollar of their award entitlements (as do I), though obviously this eats into the budget for treating patients. There is a cost and a benefit to each of these decisions - though self-interest increasingly outweighs that of community-interest.

But back to the point - if you want to give up your social life you will make significant professional and educational advances. If you want to prioritise your social life you will suffer some impediment to your career or study (in comparison to those geeks who don't sleep and talk med all day long). You may well live longer as well. BUT IT IS YOUR CHOICE.

Some people like to blame "the system" for making medicine stressful and demanding. Blame it all you like. "The System" is the way it is, and if you want to go into medical politics and change it for everyone else, it will have community-wide ramifications (not necessarily all for the better). A plethora of large and small organisations from the AMA to the DRS push their views on how to improve the health system and also working conditions for doctors.

Sometimes I don't know whether reform of the medical profession or medical employment is for the better or worse. I find it a rather ego-centric view that we have to demarcate roles, engage professional industrial representatives, or wage public campaigns in order to maintain wages and conditions for doctors.

It feels like we are stooping to a lower level, and that it demeans us as a profession that we have to engage in underhand tactics, or play hardball in order to maintain conditions. Every "victory" over some measly little payment or benefit seems to degrade my professional self-respect even more. Perhaps it says more about our government, our industrial landscape, or our lawyers. Most of all, it sickens me that the time spent on this detracts from what I want to do - treat my patients well.

I'd like to see someone stand up and say "Good Job, Doctors. Here's a pat on the back, a few days off, and a pay rise because you deserve it." But I know I'm just dreaming.