7.           Analysis of Medicare and other data

In response to the identified concerns about the provision of urgent after-hours services, a comprehensive review of Medicare data was undertaken. The data and findings are summarised below.

7.1         Significant growth in urgent after-hours services

Key points:

                    Growth in the number of services and benefits for urgent after-hours services is significant. Between 2010–11 and 2015–16, the number of services increased by more than 150 per cent (or more than 1.1 million) and benefits paid increased by 170 per cent (or more than $155 million).

                    Growth in urgent after-hours services was significantly higher compared to in-hours GP services and standard after-hours attendances.

The use of urgent after-hours services had been increasing steadily but moderately until 2010–11. Since then, these services have been growing substantially. The volume has doubled since 2005–06 and has increased by approximately 150 per cent compared to the level in 2010–11 (see Table 2 and Figure 3). This rate of growth has not been seen in standard GP items more generally.

Table 2: Volume of urgent after-hours services (items 597, 598, 599 & 600) over 10 years

Year 

Number of services

Growth from previous year

2005-06

614,736

 

2006-07

615,378

0.1%

2007-08

672,953

9.4%

2008-09

696,368

3.5%

2009-10

715,291

2.7%

2010-11

733,685

2.6%

2011-12

817,043

11.4%

2012-13

946,926

15.9%

2013-14

1,167,191

23.3%

2014-15

1,475,547

26.4%

2015-16

1,868,727

26.6%

Growth over 5 years (2010-11 to 2015-16):

154.7%

Growth over 10 years (2005-06 to 2015-16):

204.0%

Note: Medicare data, date of processing, includes MBS items 597-600. 

Figure 3: Number of services for urgent after-hours items between 2005–06 and 2015–16

Figure two is a visual graph that shows the growth in all urgent after-hours items over a ten year period to 2015-16. The graph shows that there has been significant growth in the use of these items in the last 5 years.

Note: Medicare data, date of processing, includes MBS items 597-600. 

Table 3 shows growth in the individual urgent after-hours items, indicating the predominance of item 597.

Table 3: Number of services - urgent after-hours items

Item

2010-2011

2011-2012

2012-2013

2013-2014

2014-2015

2015-2016

597

562,497

629,654

724,129

907,993

1,179,106

1,516,916

598

38,017

41,934

49,132

42,954

47,447

68,391

599

125,025

136,447

161,815

204,827

235,453

257,774

600

8,146

9,008

11,850

11,417

13,541

25,646

TOTAL

733,685

817,043

946,926

1,167,191

1,475,547

1,868,727

Note: Medicare data, date of processing.

Table 4 shows that in 2015–16, a total of $245.9 million in MBS benefits were paid for urgent after-hour services. Of these, 80 per cent was paid under item 597, 16 per cent was paid under item 599, and 4 per cent was claimed under item 598 and 600.

Table 4: Benefits paid ($ million) – urgent after-hours items

Item

2010-11

2011-12

2012-13

2013-14

2014-15

2015-16

597

$68.3

$78.0

$91.4

$115.4

$152.9

$196.8

598

$3.7

$4.1

$4.8

$4.2

$4.6

$6.7

599

$17.9

$19.9

$24.1

$30.7

$36.0

$39.4

600

$0.9

$1.0

$1.3

$1.3

$1.5

$3.0

Total

$90.8

$103.0

$121.7

$151.6

$195.0

$245.9

Note: Medicare data, date of processing.

7.2         Claiming of ‘unsociable’ urgent and after-hours items

The number of ‘unsociable’ (between 11pm and 7am) urgent after-hours services (item 599) as a percentage of all urgent after-hours service has fallen from less than 20 per cent of all urgent after-hours services in 2013–14. This is despite the overall growth in urgent after-hours items since 2011–12. It might be expected that a higher number of urgent after-hours items would be claimed in the ‘unsociable’ period than is currently the case, as there are less mainstream after-hours GP clinics open during this time, compared to the standard urgent after-hours times—however data show that this is not the case.

7.3         Growth in after-hours GP services, compared to in-hours GP services

Key points:

                    There has been a much higher growth rate in use of after-hours items compared to standard in-hours items.

                    There has been a much higher growth rate in the use of ‘urgent’ after-hours items compared to standard (non-urgent) after-hours items.

Since 2005–06, benefits paid per capita for all after-hours items have grown over 160 per cent. Figure 4 shows that the growth in benefits paid per capita for urgent after-hours items has contributed to a significant proportion of this growth.

MBS funding for all after-hours attendances (standard and urgent) has been growing at a much faster rate than in-hours GP services, which is also shown in Figure 4. In the 10 years from
2005–06, MBS funding per capita for in-hours GP services increased by a factor of 1.6 (or almost 60 per cent), whereas MBS funding per capita paid for standard after-hours items increased by a factor of 2.5 (or 150 per cent). Since 2005–06 MBS funding per capita for the four ‘urgent’ after-hours items increased by a factor of more than 3 (or 215 per cent).

Figure 4: Growth in MBS benefits per capita for in-hours primary care attendances vs standard after-hours attendances and urgent after-hours attendances (standardised to 2005–06)

Figure four is a line graph that shows the growth in MBS benefits paid per capita for in-hours primary care attendances against MBS after-hours attendance items. The graph separates standard non-urgent after-hours items from urgent after-hours items. The graph shows each financial year from 2006-07 to 2015-16. The graph demonstrates that the annual growth in after-hours items (both urgent and standard non-urgent) is far greater than the annual growth for in-hours primary care MBS items.

Notes: Date of processing. Primary care attendances includes MBS Groups A1, A2, A5, A6, A7, A14, A15, A18, A19, A20. After-hours attendances include MBS Groups A22, A23. Urgent afterhours attendances include MBS Group A11.

7.4         Growth does not appear to be driven by clinical need

Key points:

                    There has been much higher growth in use of urgent after-hours items compared to standard after-hours items.

                    There is a high geographical concentration of services, with the claiming of the urgent items apparently being more related to local models of service provision rather than patient factors.

                    There are an increasing number of urgent after-hours services provided in areas where MDSs have been established and direct-to-consumer advertising has commenced.

The growth rate of urgent after-hours consultations—specifically item 597, which can be claimed for consultations in a doctor’s consulting rooms and home visits (although evidence seems to indicate that a high proportion of claims are for home visits, rather than in doctor’s consulting rooms)—is higher than that of non-urgent standard after-hours home visits (Level B–item 5023, see Table 5). Since 2011–12, the volume of the former has increased by 141 per cent, compared to a 113 per cent increase for the latter over the same period.


Table 5: Volume of most commonly claimed home visit services over time

 

2011-12

2012-13

2013-14

2014-15

2015-16

% increase from 2011–12

Urgent after-hours home visits* (item 597)

629,654

724,129

907,993

1,179,106

1,516,916

141%

Standard after-hours home visits (item 5023)

154,314

178,754

214,877

260,172

328,726

113%

Notes: Medicare data, date of processing. *Note that this item can be claimed for both consultations in doctors’ consulting rooms and home visits. Evidence seems to indicate that a high proportion of claims are for home visits.

7.5         Service variation by geographical area

There is significant geographical variation in service usage for the urgent after-hours items, including by state and territory and by small statistical areas. Geographical variation is not necessarily indicative of inappropriate service provision or use, but can indicate that the service warrants examination[4].

Figure 5 demonstrates the state variation in the use of urgent after-hours items, with South Australia and Queensland having the highest rate of use per 1,000 people. However, high rates of growth can be observed for most states and territories over this period.

Figure 5: Urgent after-hours service per 1,000 people, 2010-11 to 2015-16

Figure four shows six sets of bar graphs for all the urgent after-hours items 597 to 600. There is one each for the financial years from 2010-11 to 2015-16. In each set of bar graphs, there is an individual bar for each state or territory in Australia. The bars show the number of services in each state or territory per 1000 people. The graph shows the differences in services usage for each state or territory, and that in each state and territory, there has been significant growth in the use of items per capita over each financial year.

Note: Medicare data, date of processing.

In some areas of Australia, more than 10 per cent of benefits paid for GP and primary care services are paid for urgent after-hours attendances (items 597, 598, 599 and 600 as a percentage of all other GP and other non-referred attendances).

Analysis of benefits paid per person by smaller geographical areas shows significant variation in urgent after-hours services usage.

Analysis based on SA3 data (a unit of geographical area defined by the Australian Bureau of Statistics to report on regional data), shows that urgent after-hours services are concentrated in urban areas. For example, the average benefit paid per person for urgent after-hours items in Playford, Adelaide, comprises 11.3 per cent of benefits paid for all GP services per person. In comparison, in the Adelaide Hills, this same figure is 1.4 per cent (see Table 11 in Section 11 – Additional data). Similarly, in Queensland the average benefit paid per person for urgent after-hours items in OrmeauOxenford on the Gold Coast comprises 11.4 per cent of the benefits paid for all GP services per person. In comparison, in Beaudesert this same figure is less than 1 per cent (see Table 10 in Section 11 – Additional data).

In general, it has been observed that the use of the urgent after-hours items is commonly higher in those areas where MDSs have been established. There is no compelling reason why clinical need for these urgent after-hours services should be higher in these areas relative to similar parts of Australia. Further data about benefits paid for urgent after-hours items by SA3 for New South Wales, Victoria, Queensland and South Australia is available in Section 11 – Additional data.

7.6         MDS providers commencing services and the relation to the use of urgent after-hours items

Between 2011–12 and 2015–16, MDS providers have expanded services to a number of regions around Australia. Medicare data suggest a high correlation between the emergence of new MDSs in certain regions, and an increase in the use of the urgent after-hours items in these areas.

MDSs are known to actively market the launch of their new services through advertising on TV, print, radio and other media. One large MDS provider, which launched into a number of the locations listed in table 6, publicly stated that “research shows only 31 per cent of the general public is aware of bulk billed, after hours doctor services. To address this, we recently launched a new advertising campaign that features GPs recommending the service for patients who need to see a doctor when their regular GP is closed.”[5]

Table 6 focuses on six SA4 locations across Australia where there have been a number of high-profile MDS services established. The commencement of these services has been accompanied by awareness/advertising campaigns across different platforms. In these six locations from five different states, there is a correlation between the growth in the use of all four urgent after-hours items and MDS providers commencing services.

Over a period of three years, where the first year was prior to the launch of a new MDS service, and the third year was well after the launch of a new MDS service, high levels of growth are evident. The growth in each of these markets ranges from 162 per cent in South-West Perth, where other MDS in-home providers were already active, and 1,090 per cent in the Australian Capital Territory, where other MDS providers were not providing in-home urgent after-hours services. Some of these locations witnessed more than one large MDS provider commence operations in their area within the three year period.

Table 6: Urgent after-hours MBS services by specific SA4 - where new MDS providers have commenced operations

State

Geographical Area (SA4)

MDS Launch Year

2011-12

2012-13

2013-14

2014-15

2015-16

3 year change

3 year % change

QLD

319: Wide Bay

2015

4,923

4,629

4,353

11,984

30,318

        25,964

596%

QLD

318: Townsville

2012

1,624

9,596

16,456

17,336

24,084

        14,831

913%

NSW

111: Newcastle and Lake Macquarie

2014

9,332

10,314

11,985

27,732

33,441

        21,455

179%

ACT

801: Australian Capital Territory

2014

1,618

1,549

1,750

14,082

20,826

        19,075

1090%

TAS

602: Launceston and North East

2016

2,217

2,151

2,133

2,295

7,459

         5,325

250%

WA

507: Perth - South West

2015

4,812

6,456

13,313

22,948

34,849

        21,535

162%

Note: Unpublished Medicare data, date of processing.

7.7         Many after-hours services claimed as urgent are not truly urgent services

Key points:

                    Investigations by the Medicare compliance body, the Professional Services Review, have found that some practitioners have claimed an urgent after-hours item when the service should have been claimed under a standard after-hours item.

                    The number of urgent after-hours services claimed relative to non-urgent after-hour services is disproportionate. It would be expected that there should be a more even distribution, or more non-urgent services.

                    The number of urgent services claimed in the ‘unsociable’ after-hours period, between 11pm and 7am (item 599), is low in comparison to urgent services provided in other after-hours periods (item 597). It would be expected that the number of urgent services would be higher due to the lower number of after-hours clinics available at this time.

The Professional Services Review (PSR) was established in 1994 to protect the integrity of Medicare and the Pharmaceutical Benefits Scheme through a system of reviews conducted by doctors on their peers. The PSR protects patients and the community from the risks associated with inappropriate practice, and protects the Commonwealth from having to meet the cost of medical / health services provided as a result of inappropriate practice. The PSR’s Annual Report 2015–16 makes the following observations in relation to after-hours services:

  • During 2015–16, a number of practitioners have been referred to PSR with concerns about their provision of urgent after-hours services.
  • Examination of clinical records has shown that some practitioners have billed these items for medical conditions such as an uncomplicated rash, reissuing prescriptions for patients’ regular medication and for routine completion of medication charts in residential aged care facilities.
  • As there is a fee differential between urgent and non-urgent after-hours MBS items, potentially inappropriate use of these services has a significant financial impact on Medicare.

Members of the Taskforce and the Working Group have been advised of numerous examples of patients obtaining urgent after-hours home visits for conditions which prima facie did not need urgent attention. These include routine prescriptions and the need for medical certificates for carers leave.


7.8         Increasing use of urgent after-hours items by MDSs

Key points:

                    A growing proportion of urgent after-hours services are provided by MDSs using a medical workforce of largely non-VR GPs. Many of these non-VR GPs are less experienced doctors who are not participating in a GP or other training program.

                    Non-VR GPs provided double the number of urgent after-hour services provided by VR GPs in 2015–16.

                    It appears that the generous rebates for the urgent after-hours items have led to the proliferation of businesses which promote patient convenience in addition to access based on clinical need, with billing models structured to benefit from the higher rebates available for the urgent after-hours items.

The Taskforce’s role is to make certain that the structure of Medicare items ensures that people are receiving appropriate care and that the items support the provision of high-value care. The current structure of the urgent after-hours items and high rebates available appears to be driving use of the items and the proliferation of business models structured to benefit from the items.

Medicare data do not link an individual service to an individual business entity. It is therefore not possible to gauge precisely how many urgent after-hours services are being provided by a mainstream GP providing care to the patients of their own practice, and how many have been provided through a MDS.

However, the qualifications of each doctor and their eligibility to claim Medicare benefits are available and are linked to each service. The majority of urgent after-hours attendances are now provided by doctors who are not recognised as specialist GPs (that is, doctors who are not fellows of the RACGP or ACCRM), and nor are they formal GP trainees.

In 2015–16, non-VR GPs with access to VR GP items through their participation in a Commonwealth workforce program provided 63 per cent of all VR GP urgent after-hours attendances (Table 7). They also provided 52 per cent of non-urgent after-hours home visits (Level B). It is likely that a proportion of these services are the standard after-hours attendances that occur in the same household as the ‘original’ urgent attendance (as subsequent after-hours attendances provided in the same household must be claimed as standard after-hours items). Around 70 per cent of urgent after-hours services are provided by non-VR GPs and GP trainees employed by MDSs, who work exclusively in the after-hours period. This form of practice can be so lucrative as to disincentivise non-VR GPs from pursuing full qualification.

Table 7: Proportion of after-hours attendances provided by derived speciality, 2015–16.

Item Description

Derived specialty

% of total provided by non-VR GPs

VR GP

Non-VR GP*

GP Trainee

Total

VR GP urgent after-hours home visits (item 597)

439,584

945,704

106,272

1,491,560

63%

VR GP standard after-hours home visits (item 5023)

140,117

168,901

16,072

325,090

52%

Notes: A small proportion of services were provided by other specialists. *Non-VR GPs affiliated with home deputising services can access the VR GP MBS items. Unpublished Medicare data, date of processing.

The RACGP position paper on after-hours visiting services in primary care states that:

The ‘gold standard’ for any GP working in Australia, either within usual practice hours or after hours, is registration as a Specialist GP. The quality and safety of patient care is at risk in the absence of appropriately trained and experienced GPs providing primary care services in the after-hours period[6].

7.9          Impact on hospital emergency departments

Key point:

                    Based on MBS and other available hospital data, the Taskforce is not convinced by the argument that the increasing use of urgent after-hours attendances has led to a reduction in visits to hospital emergency departments.

An argument used to support the recent growth in the use of urgent after-hours items is that it has relieved pressure on hospital emergency departments (EDs). The Taskforce does not accept this view as it has not been substantiated by compelling evidence.

The Taskforce believes that people present to an ED for a variety of reasons. A recent study has suggested that the main reason people visit an ED is their perception of urgency, or the need for ED care, rather than convenience or cost factors[7]. In contrast, it appears that major drivers of the growth in urgent after-hours services are convenience and because they are free at the point of care (99 per cent services bulk-billed). Recent marketing and campaigns by after-hours MDS providers across Australia targeted at consumers often emphasise these two factors—convenience and no cost to the consumer.

7.10     Urgent after-hours home visits compared to care received in an ED

Key point:

                    It is not appropriate to compare the level of care or the cost of a hospital ED presentation with a MBS-funded urgent after-hours home visit.

ED presentations and urgent after-hours home visits represent very different levels of care. Presenting to an ED provides a consumer with a level of resources and treatment far in advance of an in-home visit by a practitioner. Public EDs across Australia are often equipped with state-of-the-art resources such as diagnostic imaging, pathology and medicines. In a home visit setting, diagnostic and pathology services are limited to simple tests and the patient does not have the care from a specialist emergency physicians or support from nurse practitioner when required. The Taskforce does not accept that an ED presentation should be compared to that of an in-home after-hours visit.

For some patients a hospital ED is the most appropriate setting for treatment. The current rules for urgent after-hours MBS items allow consumers to book an attendance up to two hours before the actual after-hours period commences. This can result in the after-hours visit occurring more than two hours after the initial call to the service was made. The Australian College of Emergency Medicine policy on the Australian Triage Scale states a maximum waiting time for medical assessment and treatment for a category 4 and 5 to be 60 minutes and 120 minutes respectively[8].

Due to the differing levels of care it is also not appropriate or valid to compare the cost of a MBS-funded urgent after-hours service to the average cost of an ED presentation. Depending on the time of day or night it is more appropriate to compare the cost of an urgent after-hours service to the much lower cost of an in-hours consultation in rooms or home visit, or a non-urgent after-hours consultation or home visit.

7.11     The high MBS rebate for urgent after-hours items is driving use

Key points:

                    The urgent after-hours items are generously rebated in comparison to standard after-hours items and GP consultations provided in business hours.

                    The recent growth in use of these services is evidence of pricing failure. 

                    As some services claimed under the urgent after-hours items are not genuinely urgent and could be provided more efficiently by the patient’s usual GP or during business hours at consulting rooms, the payment of higher rebates for these services is diverting MBS expenditure away from higher-value services.

The urgent after-hours items have much higher rebates than standard after-hours items or standard GP attendance items. For example, item 597, an urgent after-hours attendance (during the periods 7am-8am and 6pm-11pm) has a rebate of $129.80. This is compared to a standard after-hours Level B GP attendance with a rebate of $49.00 if provided at the doctor’s consulting rooms (item 5020) or $74.95 if provided at the consumer’s home (item 5023). The rebate for a standard ‘in-hours’ Level B consultation is $37.05 when the GP sees the consumer in their consulting rooms (item 23) or $63.00 when visiting the consumer’s home (item 24).

The MBS rebates for item 597 and other urgent after-hours items were originally introduced to compensate GPs who have made themselves available to treat their patients outside normal operating hours in the patient’s home, where the service is unplanned or unscheduled, and requires treatment which cannot wait until the following day. However the same rebate is also available to GPs providing home visits exclusively in the after-hours periods. These providers will have different costs structures and through technological advancements such as route optimising mobile applications, are able to schedule patients to maximise business efficiencies and throughputs. The current MBS rebates do not reflect this. A GP who predominantly operates in-hours has a very different business structure and overhead costs to that of an after-hours-only provider of GP services. This has therefore seen the market adapt to these prices, by increasing the provision of these services and distorting the appropriateness of the care provided.

The distortion in the provision and fee of GP services comes at a cost to the taxpayer. The opportunity cost of the use of urgent after-hours items is large; with some urgent after-hours rebates almost $100 more than GP service provided at the GP’s clinic during business hours. The growth in MBS expenditure on urgent after-hours items ultimately means that there are fewer resources available for other higher-value care.



7.12 Potential impacts on continuity and quality of care

Key points:

                    Some patients are receiving all their primary care through these urgent after-hours home visit services and are no longer receiving mainstream GP care. The shift in patients is disrupting continuity of care.

                    Some GPs have raised concerns about the quality of care provided by after-hours doctors as they do not have access to patient histories or records.

MBS data show that of the over 180,000 patients who received three or more urgent after-hours services in a 12 month period between 2014 and 2016, over 10,000 received no standard, in-hours GP care at all. This suggests that some patients are substituting after-hours home visits for routine general practice care.

The RACGP position statement on after-hours home visits states that:

GPs provide continuous, coordinated and comprehensive healthcare. GPs know their patients’ medical history, can undertake preventive care, manage chronic health conditions and coordinate their patients’ multidisciplinary care needs. This enables highly efficient primary care. Care provided outside of this model causes fragmentation which results in wasted health resources, largely through duplication of services and the provision of unnecessary services.

Therefore, it is strongly recommended that patients are encouraged and supported to see their regular GP or practice and only utilise dedicated after-hours home visiting services when this is not possible. Patients should only have access to after-hours home visiting services that have formal links with general practices and emergency departments[9].

 

 


[4] Appleby et al. 2011. Variations in health care: The good, the bad and the inexplicable. The King’s Fund. Available at http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/Variations-in-health-care-good-bad-inexplicable-report-The-Kings-Fund-April-2011.pdf 

[5] The West Australian, advertising liftout, 15 April 2016.

[6] Royal Australian College of General Practitioners. 2016. After-hours home visiting services in primary healthcare: Position Statement. Available at http://www.racgp.org.au/download/Documents/Policies/Health%20systems/After-hours-position-statement.pdf

[7] Douglas K, Aleksandric V, Shaw H, Batt K. (2015). Low acuity presentations to the Emergency Department in the ACT - Why aren't they seen in the elsewhere in the primary health care system? In: 2015 Primary Health Care Research Conference: Program & Abstracts. Primary Health Care Research and Information Service, Australia. phcris.org.au/conference/abstract/8241

[8] Australian College of Emergency Medicine. 2016. Guidelines on the implementation of the Australasian Triage Scale in Emergency Departments. Available at https://acem.org.au/getattachment/4320524e-ad60-4e7c-a96d-bdf90cd7966c/G24-Implementation-of-the-Australasian-Triage-Scal.aspx

[9] Royal Australian College of General Practitioners. 2016. After-hours home visiting services in primary healthcare: Position Statement. Available at http://www.racgp.org.au/download/Documents/Policies/Health%20systems/After-hours-position-statement.pdf