Safety nets in Australia’s Medicare questioned while expert claims $3 billion inappropriate use

By Dr. Ananya Mandal, MDJan 16 2012

In a scathing article for the Medical Journal of Australia published on Monday, GP Dr Tony Webber has described the Medicare scheme as a “monster”. He wrote, “I estimate that $2 billion to $3 billion are spent inappropriately each year.” As former chief of the Professional Services Review - set up to police Medicare - he said he gained insight into how dysfunctional the system had become.

Two items listed on the Medicare Benefits Schedule which are subsidized by the government and create “opportunities for a bonanza” are General Practice Management Plans (GPMPs) and Team Care Arrangements (TCAs), Dr Webber said. They aim to allow doctors to spend time with complex patients, such as those who have diabetes, kidney failure and hypertension. But “perverse incentives” and a badly drawn-up scheme had created opportunities for abuse, he said.

Under Medicare a normal consultation of at least 20 minutes carries a benefit of $69.00. If a GP wants to refer a patient to a Medicare allied health service, a GPMP and TCA need to be drawn up. A GPMP attracts a Medicare benefit of $138.75, a TCA has a benefit of $109.95. “That's created a monster because many of these items are being done for inappropriate reasons for people for whom their medical conditions would ordinarily be managed quite happily in the course of the normal general practice,” Dr Webber told AAP.

Items listed on Medicare also needed to be re-evaluated to reflect their true cost, he said. While once cataract surgery was a “big deal”, with patients staying for a week, it now takes around 20 minutes. Despite this, private patients are sometimes charged more than $4000 for this procedure, with top providers performing more than 20 procedures in one day, he wrote. “Not bad work if you can get it but very poor public policy,” he said.

A spokesperson for the acting minister for health, Nicola Roxon, said “a broad compliance regime” monitored the MBS and the PBS. The Department of Human Services spokeswoman said it used sophisticated data modeling to identify practitioners whose practice profile was significantly different to their peers, with cases investigated for possible referral to the review. She said $28.24 million in incorrectly claimed benefits were identified for recovery last financial year. “Items listed on the Medicare Benefits Schedule are placed there because they are clinically necessary,” she said. The spokesperson also said Dr Webber, who was responsible for running a peer review arrangement on around 270 doctors, “has no responsibility in the area of health policy or funding”. “Accordingly, he is unable to comment with authority on these matters.”

Australian Medical Association president Steve Hambleton said Dr Webber's style and language were overblown, and he had not previously heard any suggestion that the safety net - set up as catastrophe insurance - had been used to cover cosmetic treatments, let alone highly controversial genital procedures for non-medical reasons. “The safety net has been fantastic ... I know there's misuse of the safety net, and I think that's unfortunate, but we certainly support it because in many cases it has done exactly what it was intended to do,” Dr Hambleton said. “As director of the PSR, he was looking at a very small percentage of the profession, and it appears he has extrapolated that to the broader profession.”