“Sixty percent of all claims sent to Medicare for payment are fraudulent”!

Community, Government, Health, Top 5

“Sixty percent of all claims sent to Medicare for payment are fraudulent”!

Oct 22, 2022

Australian Medicare Card over Money. Shallow focus, with copy space.

Is $8 billion dollars a year being rorted from Medicare? This claim for almost universal fraudulent behaviour is a nonsense. The entire bill for Medicare funded GP services is only $12 billion.

News outlets across the nation have been reporting the shocking news that as much as eight billion dollars is paid out to crooked doctors for services that were never provided or were grossly inflated. Gosh the entire bill for Medicare funded GP services is only around 12 billion dollars. That friendly, apparently competent GP of yours should probably be in gaol!

The number fell to three billion dollars as the reporting progressed but the office of budget management, the ‘watch dog’ for Medicare, reckons that is still a gross exaggeration. Now of course there are doctors guilty of fraud and some cases involving pseudo ‘cosmetic surgeons’ have received due publicity but this claim for almost universal fraudulent behaviour is a nonsense. The publicity however has had an upside as it has presented to a wide audience the inadequacies in the way we remunerate doctors, particularly our General Practitioners, among which are indeed numerous opportunities to “scam” the system.

Well before I started regularly sharing my frustrations re the ‘Fee for Service’ model of remuneration with tolerant P & I readers interested in health care, I, and many others were decrying the patently perverse incentives associate with remuneration based on the volume of patients seen by a GP rather than the quality of care provided. While acknowledging the problems a series of Commonwealth governments refused to change the system. Not so governments around the world many of which have abandoned or seriously modified the FFS model.

In Australia, a country that has proven to be stubbornly resistant to significant reforms for our ‘Primary Health Care’ system, we have placed enormous pressure on our GP’s to only charge Medicare , not patients, for services rendered (Bulk Billing) with the previous government deciding that Medicare payments to GPs would be maximised if they shortened the actual time spent with a patient. Not an immediately obvious tactic for improving the thoroughness of a consultation!

Until recently when the whole system started to ‘crash and burn’ about 84% of all consultations were ‘bulk billed’. The average GP makes about $100 an hour and gets just under $40 for a short consultation. In his dying moments as Health Minister Greg Hunt gave GPs a 0.60 cents increase in their remuneration. Can you imagine the electrician who needs more than $100 just to visit you and hundreds more to fix your problem being impressed with a 60 cents increase per visit!

Now it’s time to stop and ask if current payments are providing us with the primary health care we need? We all see the logic of health maintenance for our expensive car. Despite routine services there may be occasions when we need a specialist mechanic to fix a major issue and we may even need to leave the car with the service centre for a few days, however the maintenance program markedly lessens the likelihood of this situation developing. This logic should be at the heart of our Primary Health care system.

It isn’t.

Our Primary Health Care system is doctor and sickness centric. Less than 1% of our health budget is spent on preventive maintenance to go back to my automobile analogy. Truth be told we are not a particularly healthy country with 50% of us at age 50 suffering (literally) from at least one chronic, quality of life robbing, condition. Last year Australian hospitals experienced more than 12 million admissions. These were mainly for medical conditions a huge number of which were life style related and could have been avoided if Primary care focused effectively on prevention.

Now imagine you are 26 years old, two years out from medical school and just finished two years gaining practical experience in a hospital setting. Now you have to decide on the career in Medicine you will pursue. When I graduated (what a memory!) 40-50% of us chose ‘General Practice’ as our vocation. Today that figure is around 13%! It’s to be hoped that the new federal government will reverse the disastrous decision of the previous government to abolish ‘Health Work Force Australia’. Never has work force planning been more important. We are focusing on GPs herein and current realities suggest we face a shortage of 15.000 GPs by the end of the decade. Nurse shortages will run in the 100s of thousands.

Our young medical graduates grapple with the reality that GPs, who are specialists but not appreciated a such by many, are poorly paid compared to doctors in other specialities. Training is expensive and just as vigorous as training in more lucrative areas of Medicine. If you were to train in Gastroenterology you could work three days a week doing colonoscopies and take home $400,000 a year.

In this term of government it is to be hoped that the committee Mark Butler has set up with $750 million dollars to improve Primary care, will bite the bullet and tell government that we must in the short-term move to remunerating GPs via a “blended payment’ system, part salary, part fee for service and abandon bulk billing for Australians who could readily afford a $20 co-payment.

GPs and the corporations that so many now work for are struggling financially. So much so that many GPs are saying they cannot afford to immunise children against the Covid-19 virus as the time involved and the inadequate remuneration received won’t cover the costs incurred!

There is much detail to be considered but not here and now. But as I have so often urged in this publication our journey to provide Australians with a modern, evidence based, cost effective primary care system that creates a far healthier Australia needs us to have as a destination for the end of the decade the “Medical Home” model of care provision. I have described this model in great detail herein so, if interested, you will readily find articles on the model in the back catalogue of P & I articles.

The model sees Australians enrolled in their “Medical Home” where a multidisciplinary team works in one location providing continuity of care, ready access to in house nurse and allied health specialists, extension of care into the community and even one’s home. A single funder provider of health care for Australians makes available block grants to successful teams bidding for funds to establish the “Home” wherein the staff are salaried, fairly remunerated and enjoy the outcomes they achieve via the team medicine approach involved. Health is profitable, sickness ever more expensive. Global experience suggests that the additional costs involved would readily be covered by reductions in illness with its associated loss of productivity and ever increasing demands for hospital care.