What’s wrong with Medicare? – Cardiologists in the firing line

On the face of it, it is hard to see the exact motive behind Tony Webber’s spray that was published in the Medical Journal of Australia this week. Sour grapes at the DoHA in their failure to respond to some of his concern? Frustration that despite all that hard work as chair of the Professional Service Review Board he was unable to implement any real improvement in an inherently flawed system? Or just good old fashioned professional jealousy?

Either way, cardiologists were clearly in the firing line.

As others have been quick to point out, the position chairing the committee responsible for dealing with the worst cases of abuse of the Medicare system is perhaps not the best vantage point for taking an objective view of the functionality of the system as a whole. Furthermore, the cost of ‘waste’ quoted at $2-3billion per annum appears to be little more than Webber’s personal estimate based upon a calculation that he doesn’t care to share with the readership.

In fact, Dr Webber’s tilt at cardiologists seems a little misplaced. Whilst mourning the inability of Ms Roxon to arrange to cut the medicare rebate to ophthalmologists for cataract operations by 50% he simply ignores the fact that in the same budget cardiology practices and their patients were forced to absorb a 20% reduction in the rebate for cardiac catheterisation without any discussion, consideration or consultation. Add to that the fact that rebates for cardiac diagnostic imaging services such as echocardiography have not been indexed in the memory of most practising cardiologists (resulting in an effective cut of >40% compared to CPI) and his assertion that once rebates have been set they are never reconsidered seems at best baseless, and at worst a deception.

Whilst Webber goes to some lengths to point out that not all specialists abuse the Medicare system it’s unlikely that this is how his comments will be interpreted. At least not if the first round of associated newspapers headlines are concerned

Sydney Morning Herald – ‘Medicare rorts cost $3bn’

The Age – ‘Don’t let rorters undermine Medicare’

Fortunately, we were able to rely on the journalists from The Australian who weren’t able to see too much past the fact that…

‘…the safety net has been used to “subsidise cosmetic procedures such as surgery for ‘designer vaginas’…

Fundamentally, Webber’s comments are poorly written, randomly directed, lacking detail and unsubstantiated. In many ways it is surprising that the MJA even agreed to publish the article in this form. Perhaps even more disappointing is the total lack of even a suggestion of a solution. Without that it is likely that as Webber slides back into obscurity as a suburban Sydney GP his comments will follow him.

1 comment
  1. ubpdqn said:

    To paraphrase Carl Sagan, “extraordinary claims require extraordinary evidence”,
    1. Medicare can detect frequencies and patterns of clinician activity and identify extremes (unusual) patterns. Causal inferences require more information, particularly clinician-patient level data. Not all extremes are “inappropriate” clinician activity. Further, the definition of “appropriate” is a non-trivial exercise. Some patterns relate to particular characteristics of practices and patient populations served. Further, patterns change across time, such as the shift to chronic disease management plans in general practice. This embeds systematic re-evaluations that could appear anomalous but are part of a clinically deliberate strategy in the patient interest.
    2. The Medicare supervision is driven by utilisation (cost) and not efficacy (or appropriateness). This is a complex area and clinicians would agree that some of the managements we use have limited evidence for benefit (let alone cost effectiveness). However, Medicare data provides no insights into resolving this matter. This is an issue best addressed by the Scientific components of the professional bodies.
    3. There is no doubt there are individuals who inappropriately utilise resources for various motives. Medicare investigations may identify these. The identification of particular groups in the article implies a systematic or generic flaw. The conflation of individual misbehaviour with the behaviour of the group, in the absence of evidence to support this, is incorrect to say the least. The author is targeting disciplines with significant self referral (and not all) without proving any problem: qualitatively or quantitatively.
    4. An obvious way to look at whether economics would be to compare utilisations between the public and private sector. However, this has major pitfalls:
    (a) differences could relate to resourcing differences, differences in patient populations etc
    (b) the absence of definitions or a standard make interpretations of such differences difficult is it overutilisation by one group or underutilisation by the other or some combination

    I raise this to make the point that no sophisticated arguments are presented just provocative opinion,

    5. Perhaps, most disappointing, as you express (TheLastGeneralCardiologist) is that this was published in a peer review journal. I am certain that the author would have valuable insights into patterns of clinical practice and a number of hypothesis-generating questions from his experience in Medicare. However, the current piece does not edify, does not provide direction or suggest solutions and detracts from both the authority of the author and the journal.Whatever lessons from the data and analytical insights are now obfuscated by an evidence-free opinion piece and the media maelstrom (with penchant for polarization: “rorters” versus “holy clinicians”).

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