MOST Western societies appear to be shifting more and more to reliance on governments to fill roles once played by families, churches and other community associations.
The notion of self-reliance being supplanted by reliance on government is nowhere more apparent than in the health sector. In Australia, the addiction to free medicine grows by the day.
In the effort to keep things free, politicians create ever-multiplying health bureaucracies, which in turn manipulate the normal rules of supply and demand, price, and — sadly — the rules and customs of clinical medicine and referrals. A good example is waiting lists to get onto surgery waiting lists in NSW — something the AMA (NSW) is trying to tackle.
This has led to what is increasingly referred to as “gaming” — where patients are used as pawns in the funding game.
Within the inpatient hospital system, we have for some time seen “coders” taking on a greater importance, as funding is increasingly linked to particular diagnoses.
Pressure is put on doctors — especially junior doctors forced to fill in preliminary patient history sheets — to list every possible diagnosis and procedure, so that more money can be squeezed out of the government. The irony is that it is just a cost-shifting game, as it is one government entity squeezing another.
In private hospitals the same game occurs, with health funds partially replacing government departments as the cash cow.
Sadly, Australian nursing homes are now caught in this same trap as hospital wards — it is all about coding and funding, rather than about the residents.
Rather than being asked about how to treat a patient’s depression, I am now asked about why I do not list it in the health summary so the aged care facility gets more funding.
The 4-hour rule for emergency departments will result in all sorts of “games”. Patients will be re-classified, shifted, renamed and ultimately discriminated against in order for the departments to meet targets and protect funding.
Hospital outpatient clinics and staff specialist clinics are also caught in the web.
Once a doctor could write a referral to such a clinic, the patient would ring to book and be seen soon afterwards. The new pattern is for the clinic to insist on the GP faxing or emailing the referral before the patient is allocated an appointment.
If we are honest with ourselves, the motivations for this are to maximise income, for political expediency and just plain laziness.
The referring doctors are told it is “so that the right patient sees the right doctor” but does anyone really believe that? Why would a referrer want to send a patient to the wrong doctor?
It all appears to be a game to make the numbers work rather than provide timely, quality care to the patient.
And to complete the disaster, the game is now alive and well in general practice.
When a patient moves from one practice to another, it is common for the new practice to be more interested in when the patient last had a care plan and health assessment (attracting MBS primary care items), rather than what is actually wrong with the patient.
As Medicare Locals, large corporations and super clinics play more of a role in general practice, it is likely patients will suffer more discrimination, as they are made to fit within the services provided by “the system” or “the organisation” or “the team”.
Woe betide Mrs Jones if she wants to see a podiatrist, as our Medicare Local only funds diabetic foot checks. Thank goodness for smaller private practices. They may be the last bastion of the doctor–patient relationship before much longer.
Even for a nation that loves to gamble, gaming with our health may be taking it one step too far.
Dr Aniello Iannuzzi is a GP practising in Coonabarabran, NSW.