In response to my recent article commenting on the ComminInsure scandal there was a feisty response from Richard Gilley on LinkedIn – in the Group Workers Compensation Australia.
The thrust of his comment was to point out the conflict between a GP’s need to earn a living and their often-stated primary goal of provision of patient care. The non-medical commentator pointed out that most GP’s charge fees for services rendered and suggested (having recently completed an environmental medicine course and the knowledge that it can take upwards of half an hour to take a comprehensive patient history) that GP’s spend insufficient time dealing with work injury matters and that it is ‘simply a matter of finances’. Further Richard suggested that when a compensation payer makes an arrangement with a care provider an important relationship develops with power by the payer over the payee and this issue is magnified when the care provider is an employee of the payer. The suggested solution was that all GP’s be salaried by the government, but suggested that doctors would strongly object.
In response to another comment by Rosemary McKenzie-Ferguson who runs a support service for injured workers in Adelaide, Richard suggested that to raise concerns about the matters referred to in the article was ’tilting at windmills’ presumably referring to the insurers (or perhaps the whole system) as Don Quixote’s windmills i.e. an imagined issue.
When I flagged the need for a considered response to his comments, Richard suggested that I relate my response ‘as a GP’ not as an occupational physician. This is difficult for me as I have not worked in General Practice for 30 years when the current issues did not exist (or I had not experienced them), but I can make observations about modern-day general practice based on discussions with GP colleagues.
Firstly, I would say that GP’s and some Medical Specialists and people involved in supporting injured workers see a side of our compensation systems, not seen first hand by most of the other participants. Referring to my own experience, I remain surprised about the sheer numbers of people who attend my practice who appear to have been unnecessarily ‘damaged’ by the system. In a small state like Tasmania, you might think the numbers would be small, but I usually see 2 or 3 people each week for IME assessments and I would say that the majority of those have suffered some unnecessary harm from the system. In addition, amongst those patients referred by their GP’s due to complexity there is a high rate of unnecessary damage. Recently adverse events affecting patients I am treating became so common that I have implemented ‘Adverse Event Reporting’ in my practice. Since this policy was implemented on 01 March, I have completed about 6 reports of significant adverse events that have complicated recovery. Some events relate to the management of the claim and some to medical and rehabilitation management. These are not minor events, but include significant clinical setbacks causing total incapacity for work, additional need for medical or psychological input and, in one, case psychiatric hospital admission. These reports are being circulated to WorkCover to help build a picture of what is happening at the coal face.
It might be useful for other participants to spend a day (or even a week) in a medical practice or an Injured Worker’s Support Facility to understand the reality of our current compensation systems.
I think I do have some understanding of the insurer’s and employer’s perspective. I have worked in a management role with a large employer (Health & Safety Manager for Hydro Tasmania), more recently than I have worked in general practice and much more recently I have had a role as adviser to an insurer. My knowledge of general practice comes from day-to-day interaction with GP’s who refer to my practice, in addition to interaction with GP’s through my role with the AMA’s Workers Compensation Reform Committee and more recently with the RACGP.
The first point to make is that the issues about potential conflict between the need to make a living and the goals you seek to achieve at work are common to everyone in our society. Doctors are not unique in that regard.
I was talking on the weekend to another doctor originally from the UK with an interest in medical ethics. He pointed out that the tradition of the UK medical fraternity is of independence from authority and a focus on a patient’s best interests.. A German colleague had apparently pointed out to him that it was unlikely that the UK medical fraternity would have got involved in the type of atrocities committed by doctors in Nazi Germany due to differing traditions. The ethics of Australian doctors are still probably largely based on those traditions from the UK.
Ethical Australian doctors do put patient care as their priority, but this is not to say that there are not financial imperatives that might drive the way that is undertaken. I too have reservations about some aspects of fee for service, enshrined in our systems, most notably our Medicare System which carries over into the AMA Fee schedule. The system dictates use of defined ‘item numbers’ that describe particular procedures and consultation activities, mainly those activities undertaken ‘face to face’ with a patient. This system can drive unhelpful practices. If a doctor can earn more per hour through multiple short appointments, when a single longer appointment to properly consider a complex issue would be better, then the billing system is counterproductive. If there is no item number for telephone contacts, meetings, prolonged consultations to take a proper history or other valuable activity then those activities might be neglected to the detriment of good outcomes. There might be an argument that doctors should just change an hourly rate for their services, like lawyers do. But that would introduce a whole new set of issues, for the payers I expect, and an opportunity for the very small proportion of unscrupulous doctors.
In my view, the issues of doctors doing the bidding of an insurer are not in the same league as the issues that drive doctors behaviour in a private practice. Most doctors still want to achieve the best health outcome for their patients, although the system might not support the best way to achieve those goals at present.
The suggestion that the average GP providing treatment is at risk of becoming beholden to a workers compensation insurer is a nonsense, especially in an underwritten state like Tasmania, where there are multiple private insurers. For the average GP treating work injuries is a tiny fraction of their workload. Drivers other than relationships with insurers are far more influential. A risk might arise in a practice that develops a preferred provider arrangement to provide treatment services for a large employer, but the most significant risks arise with direct contractual or employment arrangements between doctors and those organisations that carry liability, particularly when the doctors involved only do that type of work as highlighted the CommInsure scandal.
I agree there needs to be a review of remuneration arrangements for doctors providing both treatment and IME opinions, but I doubt anyone is going to support a change to a model where all GP’s are salaried by Government.
I don’t think we are ‘Tilting at Windmills’. There is increasing evidence, becoming increasingly apparent from ISCRR and other research, about the hazards associated with compensation systems. The windmills, or should I say the mist-shrouded giants, are real – the entrenched negative attitudes towards injured workers within the system and the short-sighted financial drivers within an insurance-based system that actually increase the costs in the long run from work-related ill-health and injury. That cost is ultimately borne by the whole community – measured in suffering, lost productivity and cost-shifting to our social security system for those who end up on the scrap-heap.
I thank Richard for his candid comments and look forward to his response.
Insult and Injury 