Wednesday, February 20, 2008

Technical Hitch

Apologies to those who have trouble expanding collapsed articles for reading. The relevant piece of HTML/Javascript magickery has been repaired.

Tuesday, February 19, 2008

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)

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

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:

Sunday, February 17, 2008

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.