The first rule of GP Vax Club

20 minute read

Now we know it’s 4600 GP practices, not 1000, vaccinating, the most important questions are starting to surface.

That 4600 general practices will be doing COVID vaccinations is either a testament to the government’s agility and flexibility, or perhaps an indication that we are amid a sort of Indiana Jones “I’m making this up as I go” paradigm.

One shouldn’t be too critical of not being able to predict the way things might roll in this pandemic of course.

That would be rich from me.

If you’d asked me on Tuesday how many EOIs would be going ahead, I would have expressed surprise at a number any higher than 1200 for various economic and logistical reasons.

Mind you, if you were on an RACGP webinar on the topic on Monday night, you were being told the same thing – be prepared for there only being a small number of practices being awarded the right to vaccinate. 

Nice to know the DoH keeps the RACGP leaders in the loop so well.

With so many moving parts, any form of planning which is too long term in this pandemic is bound to come a cropper in one way or another. So maybe making things up as you go isn’t such a bad strategy.

The government certainly didn’t have in mind that 4600 GP practices would be vaccinating patients when they started spruiking that GPs would be the “cornerstone” and “front and centre” of the vaccine program in late January. It had in mind about 1000 practices.

This was likely because at the time they knew that at the rate they were prepared to pay GPs to vaccinate – which is generally recognised as uneconomic – they thought that only that many practices would be able to do it and/or be prepared to take the risk of doing it.

You can’t imagine that at this point of time the government was actually that serious either about the “front and centre” thing given they were planning for only 1000 practices to be involved and they weren’t prepared to even pay those ones properly.

But then 5400 GP practices put their hands up.

GPs didn’t give a toss about the economics. They wanted to be involved and they wanted to be vaccinating their patients.

Why no one read the tea leaves on this (including this publication ) is interesting. It might go some way to explaining why GPs are so often misunderstood by their supposedly trusted institutions, by government, and, yes, by us.

GPs are a truly enigmatic herd.

We should as a country understand them collectively much better than we all obviously do.

But for now, we are where we are.

Even just a few days ago, the picture didn’t look like it would be a good one for the GPs that were planning to vaccinate:

  • The government hadn’t sorted out a booking and inventory system that would talk properly to the GP booking engines and co-ordinate supply with patient bookings
  • The economics looked all bad: it looked like a practice would need to set up for high throughput, and worse, it looked like, in the rush to get vaccinated, patients would push out the higher yield day to day business of a practice leading to potentially disastrous short to medium term revenue drops
  • The vaccine slated for GPs to use (AstraZeneca), was approved only on the basis that it be used only on a “case by case” basis for over-65s. This threw out the window most of the GP practice time in motion planning and seemed to damn any GP program to awful losses
  • Both the government and the RACGP were at a loss as to what to do at that stage.

Of course, a week is a long time in COVID-19.

Oh, to have been a fly on the wall of the meeting in the Department of Health (DoH) where they decided to pivot the whole vaccination program onto a new path and go for 4600 GP practices vaccinating rather than the 1000 to 2000 that the DoH had been planning.

It changes everything. Substantively.

Keeping in mind that we all know today’s great decision is tomorrow’s disastrous “what were they thinking” moment, where COVID-19 is concerned, it mostly seems like this could be a great decision.

Sometimes making things up as you go pans out.

We aren’t in a hurry, so why hurry?

The 4600 decision is almost certainly a decision made with the certainty that we have the time to do this vaccination program properly if we want (at least for now), so we should take that time.

That means use all the GPs you can get your hands on as patients trust them, it’s an extensive and professional network, and if you give them the time to fit vaccination into their workflow so the economics aren’t a tragedy, you have a safest case scenario.

Did someone in the DoH surface this idea against all the prevailing politics of getting everyone vaccinated by October 31 for an election this year?

Probably not.

A bit over a week ago the Prime Minster, Scott Morrison, announced proudly to everyone that he didn’t think going to an election early this year was the proper thing to do. He came up with a lot of noble reasons why he felt his government should go full term. But if his intel coming out of the DoH was accurate, you can be fairly certain that it had a lot to do with the decision.

Nothing is lining up for an October 31 deadline to get Australia vaccinated adequately. Not the technology (the booking and inventory systems), not the supply and not the local manufacturing set up (which is now running about a month over schedule).

If you’re wargaming this out somewhere in the depths of the DoH there has to a be a point where you and your team come to the initially awful conclusion that there are just too many things that can go wrong now if you keep pushing a very tight deadline.

This has probably been a building dilemma for the DoH and the politicians, who – outside of the growing hesitancy problem perhaps – are mostly doing a great job of massaging the message to the public that we have this thing well under control.

The individual who put their hand up in that DoH meeting and suggested that the person manning the whiteboard scribble 4600 GP practices at the top of board instead of 1200, was probably nervous, but possibly inspired.

That would have taken quite a bit of additional white boarding time for all in the room.  It likely went late into night – like buy-in pizza late. But it may have been worth it.

It is tempting here to speculate that the DoH didn’t actually think this through as speculated above at all. That 5400 practices put in an EOI, it surprised them, like everyone else, and without a lot of additional thought, they gave the right to everyone they could (about 800 weren’t accredited, so they were always not getting it). Hmmmm…

The 4600 paradigm

What might happen if we have 4600 GP practices vaccinating, not 1200?

  • GPs would be happy because 5400 put their hands up. It’s not a bad idea to provide some wins and encouragement to a crew of professionals who you already know are getting paid badly to do a big and important job.
  • Patients are going to be much happier as well. They are significantly hesitant. Much more hesitant than anyone guessed, spurred on a lot ironically by the fact that we don’t have a time constraint on deciding, like patients do in the UK and the US. They want to ask their GP and get their vaccination from their GP, that is, if they choose to get one.
  • 4600 gives you most of the GP network and most of the country. You have great coverage immediately.
  • If you let 4600 GPs participate, you are clearly meeting your promise now that GPs “are the cornerstone of the national vaccination program”. Very cool side effect.
  • But you do have a lot more potentially serious logistics problems feeding a much bigger and extended network and making sure patients align with vaccine bookings
  • All the logistics problems we have today are mostly associated with turnover and speed of vaccination that has an October 31 deadline. What if we sort of just kept a rolling commentary of small and believable issues to the public and the medical fraternity that kept pushing that deadline in inoffensive ways so, overall, we don’t have to keep that deadline?
  • That gives GPs more time to vaccinate as it suits them, logistically and financially.
  • What if we let GPs co bill their vaccine consults to ease the pain a little more as well.
  • And so on

By the end of the whiteboard session you can imagine that  the room in the DoH might have even been starting to get excited.

“This might work out…maybe ring Greg and see if he’s still awake.”

There are quite a few elements which today look like they are lining up to make this longer timeline-more GPs strategy work.

  • The technology isn’t ready and neither is the vaccine stock but if they are given more time, most GPs won’t need these elements to align perfectly. Given time, a GP can work their patient roster as they see fit , and, as they see suits them better economically. GPs are very pragmatic and practical when push comes to shove.
  • A lot of larger practices which were until last week gearing up for high and fast throughput have told The Medical Republic for this piece that they are pivoting along with the government. They are significantly winding back on their “big bang” plans to make things a lot easier for their staff and patients. What they are doing is winding back on risk, financial and otherwise. Among other things with 4600 practices not 1200 the whole competitive dynamic for patients is significantly altered. Big throughput isn’t needed because so many more practices are vaccinating. If you gear too high, you will almost certainly lose money now. Things are getting just a little more chill.
  • The Prime Minister has unofficially extended the deadline for everyone to get vaccinated by announcing he wants the government to serve full term and deliver two more budgets before going to an election.
  •  If we don’t achieve a decent percentage of vaccination until Xmas, 3 months late to the initial deadline,  but we are all safe and sound when it does get done, is anyone going to look back and say “hey, we missed that October deadline”! Not even Anthony Albanese would bother, you’d suspect.
  • There are still quite a few variables on the table vaccine wise which make slowing down a bit more sensible. If the government had its druthers it probably would have switched manufacturing locally to the Novavax option. Taking more time possibly allows for emerging options like these if things continue to go downhill on vaccine variants and the AZ vaccine, although there would be a lot of politics sewn up in that deal which would be very difficult to unpick.

In any safety bet today you’d put your money on well considered GP-moderated patient vaccination any day against football stadium mass vaccination given there is no current need to hurry like there is in places like the UK and US.

Keeping our options open

This last point isn’t to say that that Dr Mukesh Haikerwal and his innovative and energetic RACGP and AMA band in Victoria haven’t thought out something very important and neat in their AFL stadium trial idea.

Given the uncertainty of containment, the threat of variants, and our quarantine track record to date, having a back stop that is a proven model for accelerating vaccine rollout is a great idea.

The government, state or otherwise should back these GPs and prove out their model if they can. Just in case.

If we accept the premise for now that we have time, and getting a lot more rather than a lot less GPs directly involved is potentially a great idea, then we should expect that we can start nailing down the detail so organisation and execution becomes easier.

Dealing with grey

But when you pivot so much and surprise everyone as the government has this week on the number of GP practices vaccinating, you inevitably create more questions.

Important ones.

Some, which seem to be pretty crucial, have a lot of room for interpretation still, but we suspect this might be a deliberate tactic on the part of the DoH (there we go again assuming they’re thinking this all through carefully).

A prime example might be at what frequency and under what circumstances you can use your COVID suitability consult item twice on the one patient. This could be a critical interpretation for GP practices wanting to streamline their vaccination process well with existing business.

The DoH has a pretty good Q&A that provides an example where you can bill twice:

“A patient who is assessed as suitable to receive a COVID-19 vaccine but who continues to have concerns about the vaccine and wants time to consider if they should receive it, may receive a suitability assessment service without choosing to have a vaccination. In this situation even though the patient has not received a vaccination, a further suitability assessment would need to be undertaken, and billed to Medicare using the relevant item number.”

But this is a pretty specific example.

What happens if you don’t have vaccine in stock the day you have arranged to do your assessment, despite the best intent of your practice, AZ and DHL? That’s likely to be a common occurrence and its equally likely that it won’t be the fault of a GP practice that stock didn’t make it to match the consult.

Aligning stock, a pre consult and a patient isn’t going to be easy.

Is there any leeway to streamline this process by doing a suitability consult knowing you likely won’t have, or even don’t have, stock? It doesn’t seem like there is on reading the DoH Q&A, but it’s not entirely clear.

You suspect the DoH might be waiting to see which way GPs jump on some of these grey areas and what situations they end up having to handle before they provide more clarification on something like this (not an entirely efficient approach but in keeping with “making it up as you go methodology” for sure).

And what happens in the reporting of a hesitant patient? Something like this is very sensitive most especially as far as the patient is concerned.

Is there any co-ordination of a patient who is hesitant, wants to think about it, and then goes to another practice?

Grey is a part of this process unfortunately.

Key guiding documents

There are two key documents every GP will need to be familiar with before they start pre consulting, vaccinating and billing or co-billing. Between them you have everything you need to try to interpret what the government is aiming for and where the boundaries on your interpretation of billing might actually be.$File/factsheet-vacsmar21.pdf

Unfortunately, the boundary still isn’t very clear in the case of pre-consulting.

To read the fact sheet on Vaccine Suitability Assessment Service items above, clearly the government wants GPs to assess and vaccinate in the one session, or at least the same day.

It’s a bit “der” of course.

They don’t want a GP to pre consult one day, vaccinate another, and charge for that twice using the same item number as some sort of systematic means of generating more revenue.

Doing that is against the general interpretation of all MBS item billing protocol, but when you are talking about practices that are trying to juggle their current booking load, concerned and potentially hesitant patients, and a supply chain that is very likely to be fickle at best, how does  the government draw the line on a practice which is just being sensible in its planning against the realities of its normal patient load, and one that is attempting to game the system?

Again this would explain why the government is perhaps trying to leave room for interpretation.  They can do the interpreting if need be later. Not that great for GPs but possibly the only practical way to get through the process.

Given all the unknowns emerging around vaccination supply, inventory and booking systems, and given the normal patient load in a normal practice, doing what the government is saying they would like as best practice, is likely not going to be feasible in quite a few circumstances.

You are also likely to get an odd practice that tests the edges of gaming the two suitability consult rule.

Sticking closely to the current rule set may turn out to be grossly uneconomic and potentially not workable at all, depending on how patients actually behave when the starting gun on phase 1b actually goes off.

The thing is, no one can predict the behaviour of patients when phase 1b actually starts , and no one can predict supply, so at this stage it is impossible to forecast what jury rigging GPs will need to do to get through the process.

Giving precise clarification now on something like this, as important as it is, just isn’t easy.

Better to intimate that you shouldn’t be doing certain stuff but leave some room for it to be done, just in case. ie, better to make it up as you go a bit.

You don’t really want to be the pioneer of testing this boundary though.

Having contacted a few larger practices to get their view, most are starting well on the safe side of the two suitability consult rule fence.

They will only bill the suitability item once in most circumstances, and try to align the pre-consult as closely as they can to vaccination, as the government would like.

What about co-payments on pre consults?

Another important but grey area is the idea that you can technically book another item during your pre-consult.

The ability to do this though doesn’t really synchronise very well with how GPs are being guided on getting a suitability consult and vaccination done.

You can’t exactly sms your patients and ask if they have something on their minds to get fixed that you can do while you give them a suitability consult and injection.

There is no way to plan co-payment revenue then. This means the co-payment rule though a nice thought, isn’t all that practical in helping practices manage the tight economics.

What you might be able to do is start planning to add the vaccination items to your normal patient booking load.

But that’s a bit awkward. Literally, “while you’re here Betty, would you like to stay on a bit and get this silly COVID vaccine thing knocked off”?

Some practice managers are considering this, but most have told TMR that such a process will likely be impossible in the early stages of phase 1b.

As one practice manager has pointed out, “we are already getting inundated with calls from hesitant patients with lots of questions”.

“When we press that button that says ‘open for vaccination’, there will be some sort of initial rush for sure, which we aren’t going to be able to fit into business as usual.”

First rule of GP Vax Club

You do get that we had to bury this bit deep into the article so you would at least have to forage this far to find out right?

Time on page helps our online stats a lot, so if you are still here, a big thankyou.

What is the First rule of GP Vax Club?

How we’d love it to be something innovative, ingenious…urbane even.

Alas, it’s much more dull, practical and predictable.

Which is why we had to bury it all the way back here in the article, sorry.

First rule of GP Vax club is that:

The rules so far aren’t so much rules as guidelines, which may change, so be wholly aware that you will be held accountable for what you do, not what the government, the TGA, your practice manager, or the RACGP says you are allowed to do. 

OK, you probably immediately recognise this rule. 

You’re on your own.

The context is probably important though.

You’re getting paid poorly to be on your own and interpret grey stuff in a once-a-century pandemic where your patients are desperately worried and relying on you and the government is now firmly depending on you to make them look great and get re-elected next year.

But you’re on your own none the less.

What’s new?

Not much.

On “case by case”, DoH Q&As, college guidelines, and actually getting sued

As an illustration of the First Rule of GP Vax club, there is quite a bit of grey and confusion for quite a few GPs and practice managers around the announcement from the TGA that over 65 year olds getting the Astra Zeneca vaccine must be assessed on a “case by case basis”.

The note sits awkwardly against an apparent clarification from the Department of Health in the form of a statement from the deputy chief medical officer. Professor Michael Kidd, earlier this week in his COVID-19 update newsletter to GPs.

“There is no requirement for people over the age of 65 to discuss with their GP whether they should or should not have the AstraZeneca vaccine, unless they are very frail and/or rapidly approaching the end of life,” he said.

He added that patients who are very frail, or their carers, are advised to discuss any vaccination with their GP.

Such a consult would be billed as a ‘suitability assessment’ where the patient must receive a face-to-face attendance from a GP, or suitably qualified health professional.

TMR does not have an in house lawyer but we have a couple of staff with sexually transmitted law degrees, and one at least who studied law in their dim past, and none of this felt like entirely sound legal advice to us.

So we contacted a few practice managers, some with law degrees, and a barrister, and as you may have predicted, the general view is that you can ignore entirely what the DoH has said if you think that would form any sort of defence if you actually did end up getting sued by someone for not doing an ‘appropriate’ assessment on an over-65.

This might just mean a decision based on an assessment of your patient’s record, and not necessarily a consult – unless they’re not your patient, in which case it probably does mean you need a consult.

Sorry for even more grey, really.

There’s been a lot of vaccination done before we start in Australia and problems like these aren’t arising anywhere else so far, so it’s probably all academic, but the DoH position, and any guideline or advice you might get from the RACGP, or like bodies of supposed authority, is going to be about as useful to you in defending a case as relying on advice you might see on a Pete Evans Facebook feed (I don’t think BTW he was blocked as news, which is encouraging, isn’t it).

Remember, first rule of GP Vax Club.

You’re on your own.

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