After hours: more data, less smoke and mirrors

7 minute read

After-hours bashing seems to be emerging as a national sport, but the debate lacks something vital: clear data

Why isn’t there any simple and clear empirical evidence available for such an important aspect of our healthcare system as the true net effect of increasing after-hours services in a given region of the country?

Currently, we are seeing the debate over after hours played out in the consumer press, and in Canberra between politicians, and various lobby groups.

The RACGP and the AMA are in Health Minister’s Greg Hunt’s ear – and why wouldn’t they be – and the minister is suddenly on TV, making allegations of potential over-servicing by these groups, which he’s going to put a stop to. It’s the thin end of a wedge that looks like it will end in Minister Hunt announcing some hack changes to MBS after-hours items in the upcoming budget. He may need to do that if he, as mooted, plans on unfreezing the Medicare rebates for GPs. But if he does, he almost certainly will be jumping at shadows without any clear evidence to back his move.

Why doesn’t the government actually know if the system is being rorted or not? Something so important should be black and white by now.

Hate them or love them,  these private groups are either doing a great cover-up job, or the actual incidence of over-servicing on urgent items is being way overblown by the media, the politicians and lobby groups. And if overblown,  the reasons look to be all political at this point, because there is no clear data available to make a proper call on the overservicing issue.

It’s not like these companies can keep their books secret from the government. Everything they do has been, and is being, scrutinised, and as much as no one likes the idea that private equity is in this game just  for a pay day, they aren’t usually so dumb that they’d hang such a huge investment on something so tenuous as convincing their doctors to somehow scam the nature of their calls and the MBS. Not systematically, anyway.

Yes, there are some overt and terrible examples to quote in the press, and they happened. But no, there is nothing so far that has been clearly identified as systemic. If it turns out there is, and we still haven’t discovered it, then the federal government should hang its head in shame. Because it has all the access it needs to prove it beyond a doubt if it does exist.

So what is going on?

For starters, the RACGP and the AMA are the natural enemy of the after-hours corporate. These after-hours companies don’t use a high proportion of GPs, they are sucking money at a rapid and increasing rate out of the MBS – money which their constituents compete for – and they don’t, like the RACGP and the AMA, share the common purpose of furthering  community health through better care. The companies want to build and sell a company first and foremost. For as much money as they get.

The problem for the RACGP, the AMA and others in their camp is that to build a company of real and sustainable value, the private equity people need to be thinking very deeply about the goal of overall better healthcare for the community somewhere in their strategy. And they do. Albeit, as a means to an end.

What if a lot more after hours is actually “good” for the community? How do we even measure that in a manner that will satisfy all sides in the debate? And who gets to decide what the criteria are? The doctors, the politicians, or the public?

It’s pretty clear that the public like after-hours services. Otherwise groups such as the National Home Doctor Service wouldn’t be going through the roof when it hits a new region and starts its shock and awe advertising campaigns.  But if it keeps going on like it is, there is going to be a big hole in the MBS in years to come. And if that happens, there had better be a good reason for it.

What we still don’t know for certain, but lots of people will tell you they do, is the actual effect on reducing ED emissions. We recently have had sets of research released which tells us variously that it reduces ED admissions significantly, it has had no effect, and, my favourite, ED admissions are going up (the research didn’t actually blame after hours for this, but with the methodology of most of these studies, it may as well have).

The government needs to commission proper empirical research on this question immediately. Even then, a result will be a while away.

Another question being raised now is “are after hours services actually dangerous?” This has been implied by the RACGP and the AMA, largely because the providers mostly don’t use GPs for the service. Answering this probably only requires some good paperwork research for some very clear evidence. Let’s do that and get a clear answer quickly, and stop using isolated emotive examples to cast a cloud over the whole industry.

If after hours doesn’t reduce ED admissions, are there are still reasons for after hours to exist and be growing like it currently is?  Maybe not. But again, we don’t have good enough evidence to understand this question properly.

If you clear the decks and ask the question “what would we lose or gain if we just close the whole industry down now?”, you do get some interesting starting points for a good researcher.

On the lose side:

·         A lot of public goodwill will probably disappear, unfortunately around GPs, because although they aren’t the major doctors performing the service, they are in the public’s mind.

·         A huge amount of training for registrars will go as they make up a big component of these groups workforces and are mentored and trained to a reasonable degree via the service.

·         Additional income for lots of training doctors will disappear – so it’s back to the service station and café for some.

·         Potentially, not proven yet, however, we will increase ED admissions, significantly in quite a few regions.

·         Potentially, a lot of workforce productivity. For those lucky souls who are, if you believe the companies, fixed up overnight so they can stoically return to the workforce the next day rather than be sick, or have to go to the day hours doctor (GP)

 On the gain side:

·         A lot more available MBS money, presumably which we’d like to pay to GPs so they can offset the loss in the service.

·         A couple less private-equity plays (we can always do with less of these).

·         Almost certainly a lot more hospital presentations and ambulance call outs.

·         A whole category of advertising on TV will disappear (no loss so we call that a gain)

At The Medical Republic we quite like after-hours stories because if you put “after hours” in a headline, you get lots of clicks on your website. Usually lots of angry clicks (we can feel how hard you are pressing the keys sometimes).

But the reality is, we are getting tired of the debate not ever moving forward properly.

After hours is a vital piece in the healthcare system puzzle. But we don’t know where to put the piece. We don’t have the data. We need that data, and we need it fast.

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