After-hours doctor visits under scrutiny

The rising demand for costly after-hours home visits by medical practitioners is impacting negatively on the federal health budget and attracting criticism from various quarters, including the Australian Medical Association.

The increase in Medicare payments for the two main categories of after-hours home visits are now the subject of close examination by the government’s clinician-led Medicare Benefits Schedule Review Taskforce, which in its recent interim report made several key recommendations, including:

• Restricting the use of the high value urgent after-hours items so that medical deputising service doctors and practitioners working predominantly in the after-hours period are excluded from billing these items
• Providing a clearer definition of what is considered to be urgent for the purposes of the MBS urgent after-hours items, including changing the requirement to ‘urgent assessment’ as opposed to ‘urgent treatment’ 
• Removing the current right of patients to make an urgent after-hours appointment two hours before the commencement of the after-hours period.

Figures show the amount paid on after-hours items grew by 170 per cent between 2010-11 and 2015-16, from $90.8 million to $245.9 million. 

After-hours home visit figures* accessed by GP Speak reveal exceptionally high usage in the Coffs Harbour area, where in 2015-16 (the latest available data period) total billing was almost $2.0 million, with demand trebling from the previous year.

Urgent after-hours visits are covered by two MBS categories, Item 597 ‘Urgent attendance after-hours (7am-8am & 6pm-11pm)’, which attracts a fee of $129.80, and MBS Item 599 ‘Urgent attendance unsociable after-hours (11pm-7am)’, where the fee per patient is $153.00.

Non-urgent after hours home visits range from $54.95 to $143.70. Both categories are higher than in-hours home visits, and significantly more than practice consultations.

Between 2012-13 and 2015-16 Coffs Harbour’s demand soared from 276 Item 597 visits to 13,633, and eight Item 599s to 1411.

The general trend in other North Coast regions was mixed, but largely upwards, although the scale was much less. Richmond Valley Hinterland callouts totalled 197 for both Items, a rise of around 50%, while Richmond Valley Coastal went against its previously rising trend to record 588, a drop of around 20%. The Clarence Valley’s 294 home visits for Item 597 consultations was twice the previous year’s.

Tweed Valley recorded low demand for home visits, with only 42 in Item 597 and none in Item 599.

At the bottom end of the coast, Port Macquarie accounted for 973 urgent attendances, and a further 65 late night urgent callouts, for a total MBS cost of $126,295.

The Taskforce is considering the issue as part of its broader review of Medicare items, following concerns that after-hours costs were increasing far in excess of population growth.  

“The growth in provision of after-hours services… has coincided with the entry of new businesses into the market…” - MBS Review Taskforce

The AMA has said that, “direct marketing and the promotion of after-hours home visiting services as being free and easy to access is driving much of this growth, as opposed to genuine patient need.”

In recent times such names as National Home Doctor Service and Dial-a-Doctor have become well known for offering after-hours services on behalf of GP practices, including those in regional areas.

The response from the industry body, National Association for Medical Deputising Services, was that these services save the health system more than they cost, because many of the patients would otherwise go to emergency departments, which are vastly more expensive. 

It claimed that the changes would result in “rolling closures of services in regional communities and cost lives”. 

However, the Taskforce believes the current structure of urgent after-hours items provides low-value care and is not convinced the growth in home visits had significant reduced demand on hospital EDs. 

“The current use of urgent after-hours services does not reflect clinical need in Australia…” - Taskforce chair Prof Bruce Robinson

“The growth in provision of after-hours services appears not to be driven by increasing clinical need for these services, but has coincided with the entry of new businesses into the market with models that promote these services to consumers, emphasising convenience and no out-of-pocket costs,” the interim report said. 

“Many urgent after-hours services claimed as urgent are not truly urgent, as intended when the items were created, and the distinction between ‘urgent’ and ‘non-urgent ’ appears not to be well understood by many medical practitioners.” 

It recommended the rebate should only be payable when a GP who normally works during the day is recalled to manage a patient who needs urgent assistance. 

‘Urgent’ would refer to an assessment that cannot be delayed until the next in-hours period and would require doctors to visit the patient or reopen their rooms. 

Taskforce chairman Professor Bruce Robinson said, “The medical community recognises the need to remove MBS funding from unnecessary, outdated, ineffective and potentially unsafe services. It was the strong view of the Urgent After-hours Working Group and the Taskforce that the current use of urgent after-hours services does not reflect clinical need in Australia.

“The growth in use of urgent after-hours GP services does not seem to reflect patients’ clinical needs.

“After-hours services are important, but we must ensure that patients get the right test or treatment first time, every time and not be subjected to unnecessary and inappropriate care.” 

For its part, the AMA supports after-hours reform for various reasons, including: 

• The significant growth in the use of after-hours Medicare items, particularly the use of urgent after-hours items, and the detrimental impact this is having on the link between patients and their usual GP or general practice;
• concern that direct marketing and the promotion of after-hours home visiting services as being free and easy to access is driving much of this growth, as opposed to genuine patient need; and
• poor communication from some after-hours medical services to a patient’s usual GP or general practice – resulting in the fragmentation of care.

AMA President, Dr Michael Gannon, said, “Our focus will be on the Taskforce’s final after-hours report - which will be released later this year after the Taskforce has considered stakeholder feedback - and the Government response to the final report.

“If the final report and subsequent Government after-hours policy lead to MBS savings, they must be re-invested back into general practice.”

Reference: Department of Health, 2016. Medicare Benefits Schedule Data: MBS Data by ABS SA3.