The Medical Deputising Service Sector: An Industry Overview In Australia in recent years, community access to urgent after hours primary care has been a key focus of Government health care policy. The growth of the Medical Deputising Service sector reflects this. Medical Deputising Services (MDS) provide after hours medical care in homes and aged care facilities when GP services are not available. This document outlines the services provided, the historical framework, and how MDS are contributing to better health outcomes for the community while delivering considerable savings to our healthcare system. The role of Medical Deputising Services and the services they provide What is Medical Deputising? Medical Deputising Services (MDS) provide after hours primary care services to patients in homes and in aged care facilities on behalf of the patient s regular GP. They provide care to patients under two basic circumstances: At the request of the patient when regular GP services are unavailable and care is required on a timely basis for an acute episodic condition; and At the request of the GP when mobility issues inhibit attendance at the GP office (e.g. disability, frailty, those undergoing palliative care at home etc.) this can include routine care activities performed on behalf of the GP Complementing and supporting GP Services The proper term for our sector - Medical Deputising - reflects its role as an extension of and support to daytime general practice. It enables GPs to meet their obligation to provide complete, continuous and comprehensive medical care for their patients around the clock. The existence of a strong Medical Deputising Service (MDS) industry makes a career in General Practice more sustainable for GPs while also ensuring patients have 24 hour access to quality primary care. Working as a complementary service to General Practice, we ensure continuity of care for patients, that is, that patients maintain a strong ongoing relationship with their regular GP for all their care needs. The after hours defined MDS only deliver services during the defined after hours period. The after hours are defined in the Medicare Benefits Schedule (MBS) based on the times when GP offices are typically closed. These times represent approximately 70% of the hours in an average week i.e.: Weeknights from 6:00 PM to 8:00 AM the following morning Weekends from noon Saturday through to 8:00 AM on Monday morning All day on Public Holidays Patient initiated calls may be accepted from two hours prior to the after hours period commencing. GP referred calls may be accepted at any time, however any referrals made prior to two hours before the commencement of the after hours period cannot be billed as urgent.
History of the MDS Sector The early days Medical Deputising has been in existence for several decades. Historically MDS were small, sub-scale, localized organizations that sometimes struggled to survive. Early MDS were entirely focused on delivering their support to General Practices allowing Practices to hand over the demanding role of answering calls and attending to sick patients at night and on weekends. MDS received subscription payments from General Practice for providing this service and also charged patients for attendances. The introduction of Medicare in 1984 allowed MDS to bulk bill patients for the attendance, but MDS remained reliant on subscriptions as a funding source until as late as 2013 to subsidise the cost of overnight reception and medical coverage and the administration involved in reporting back to the regular GP. The demise of traditional GP house calls Home visits were a common element of General Practice right through to the 1980s. GPs would typically do rounds of home visits either in the morning, at lunchtime, or later in the afternoon and early evening. They would visit elderly and infirm patients and people who had difficulty getting to the GP. This often included young families with children who had become ill later in the day. As General Practice began to change in the late 80s and early 90s, GPs began to make fewer house calls. Some GPs continued to do their own home visits both in hours and out of hours, but between 1994 and 2010 the availability of home visits collapsed from 38.5 home visits per 100 people to only 21.2 home visits per 100 people. As a consequence, patients found it more difficult to access after hours care. Access to after hours primary care becomes an issue Community concern regarding after hours access to care grew in response to the declining availability of home visits. In the absence of a home visit option, patients and carers often turned to use of local Emergency Departments as the default option when they had difficulty accessing primary care in the afterhours period. For much of the 1990s and 2000s, improving access to primary health care after hours and reducing emergency department crowding were key health policy issues. State and Federal governments promised and delivered help lines, co-located clinics, workforce strategies and improved rebates and incentives with the intention of improving access to care and reducing pressure on hospital Emergency Departments. Practice Incentive Payments One key policy step involved the introduction of After Hours Practice Incentive Payments (PIP) in 1998. These payments helped fund General Practice to pay for after hours coverage from a MDS. This allowed MDS coverage to grow, but typically only patients of subscribing practices would be seen, or patients of nonsubscribing practices would be charged a much higher rate (i.e. a gap on top of the bulk bill rate) for an attendance. The diversion of after hours PIP funding to Medicare Locals in 2013 changed this subscription model. In many locations MDS became reliant on fee-for-service income. In mid 2015, with the abolition of Medicare Locals, after hours PIP payments were returned to General Practice. Most General Practices now retain the PIP component of the funding and relatively few subscriptions are now paid to MDS organisations for providing the afterhours support 1. Changes to Medicare rebates A turning point for improved access to after hours care was the Howard Government s Round the Clock Medicare package of 2005 which increased rebates for after hours consultations in clinics and homes. In concert with the increase of the bulk bill rate to 100% of the Medicare Benefits Schedule (MBS) rebate, this increased the compensation for after hours attendances and made fee for service operation more sustainable. This in turn encouraged ongoing innovation and investment by the private sector in technology, processes and 1 PIP funding relating to afterhours care is complex and has five different levels of funding available to GPs depending on the level of support they provide directly to patients. More specific information is available on afterhours PIP funding as required.
clinical training and supervision to improve efficiency and quality. In 2007 these increases were extended to the transition period of 6-8pm on weekdays. The structure of Medicare Benefits for after hours services has remained constant since then. The key Medicare items that are used by MDS are: Item 597 urgent attendance afterhours (6PM-11PM and 7:00 AM to 8:00AM) - $129.80 Item 599 urgent attendance afterhours (11PM to 7:00AM) - $153.00 Item 5023 - non-urgent after hours home visit - $74.95 Item 5028 non urgent attendance to aged care facility - $95.70 These fee items are available to GPs conducting their own after hours calls and to Doctors working within MDS. Note that only the first visit at any location qualifies as urgent e.g. if a Doctor sees two family members in home, the second must be charged as non-urgent. Also note that to qualify as urgent the request must be initiated by the patient or their carer not more than two hours prior to the after hours period, and urgent medical treatment must be provided Improved Access The shift to fee for service funding of after hours services has been effective in improving access. This reflects the appropriateness of using fee-for-service funding models to support episodic care. While it took a few years for the effect of the improved funding for after hours items to be felt, use of after hours services began to increase strongly from 2010 onwards. The allocation of after hours funding to Medicare Locals from 2013 drove further growth in the sector as the Medicare Locals invested in building community awareness and subsidising MDS to provide access in less densely populated regions. (Prior to this, awareness of the availability of after hours Doctor home visits was largely the responsibility of GPs to communicate to their patient base, with mixed results.) According to analysis by National Home Doctor Service, well over 80% of the population now have access to a MDS and unprompted awareness of deputizing as an option for accessing after hours primary care has increased from a very low 17% in 2013 to 31% in 2015. Government policy a success The growth that has been experienced from 2010 reflects the success of government policy in response to community demand. Government policy encouraged investment by the private sector to deliver a positive response for the community. Today, MDS are often known as "after hours home visit services" reflecting the service they provide to patients as well as to GPs. Nonetheless, the responsibility to General Practice remains a core commitment for all quality MDS. Current size, growth, costs and benefits Number of after hours consultations In 2015 there were 1.6 million Urgent Home Visits to households and aged care facilities (ACF) in Australia. This is equivalent to less than 2 per GP in Australia per week. Home and ACF visits are a small part of how Australians access primary care after hours. There are also 8 million after hours consultations in GP clinics and 4 million low acuity presentations to hospital EDs. About 55% of hospital Emergency Department presentations occur after hours. It should be noted that there were a further 300,000 standard after hours visits to households and a further 400,000 standard after hours visits to aged care facilities (many of these done by regular GPs on a scheduled basis rather than by Deputising Services). Cost of after hours visits After hours urgent home visits in 2015 cost taxpayers $215 million. This is approximately 3% of total primary health MBS spend (~$6.8 billion). This compares to approximately ~$940 million on low acuity ED visits plus ~$290 million on ambulance costs for low acuity transports and attendances. In addition, government spends $104 million on the after hours Practice Incentive Payment much of which goes to practices that provide no or very little after hours services. This also compares to ~$110 million that the State and Commonwealth spend on nurse and GP helplines - which recommend the majority of callers attend ED or see a Doctor on an urgent basis. All up, the healthcare system spends approximately $2.1billion on providing primary care support and information to Australians in the after hours period; 13% of that expenditure goes to GPs doing house calls
and MDS. The remaining 87% is spent on low acuity items in EDs, low acuity ambulance carries, after hours clinic visits, PIP payments and helplines. Relieving Emergency Departments There is clear evidence that after hours urgent home visits help reduce pressure on hospital Emergency Departments by diverting low acuity presentations. There is a clear inverse relationship at a state level between the penetration of after hours home and ACF visiting and the level of low acuity presentations at hospital EDs. A state-by-state comparison shows that for every additional home visit per capita, approximately 0.4 low acuity ED presentations per capita are saved. This is consistent with patient survey data in which around 40% of patients say their only alternative to a home visit would have been to present to ED. Cost benefits to the healthcare system This shift away from using EDs as the default option delivers significant benefits to the healthcare system and to patients: reduced pressure translates into cost savings for taxpayers. The weighted average cost of a low acuity ED presentation is $440, and this increases to over $1100 if an ambulance is used. Compare this to an average of $130 for a home visit 2. With this in mind, we estimate that National Home Doctor Service alone delivers total net savings across Australia of $130 million per annum even after allowing for the higher cost of home visits versus daytime and after hours clinic visits. aged care facility residents can access more appropriate care without having to endure the stress of a late night ambulance carry patients in general (often children and the elderly) can access care at home without the exposure to hospital environment palliative care patients can be better supported in their home environment Research reveals the need A wide range of studies suggest that greater use of after hours primary care has the potential to further ease pressure on Emergency Departments. The Productivity Commission has identified that there are 2.2 million GP-type presentations to Emergency Departments annually and that 24% of all Emergency Department patients believe their care could have been carried out by a GP. Another study found that 26% of Emergency Department visits were due to a lack of alternative care. Increased demand for MDS, a policy success After Hours urgent home and ACF visits are growing, reflecting broader community demand for after hours primary care access. Between 2014 and 2015, urgent after hours home visits grew by 370,000 while after hours clinic consultations grew by 660,000. Growth reflects both increased awareness of home visiting services and increased coverage, with many parts of Australia only now having access to a medical deputizing service. By contrast, low acuity ED presentations (which occur across the whole day) have stopped growing in recent years. By any measure this is a significant policy success: unlike most aspects of policy where reigning in expenditure results in some compromise in patient experience, growth in provision of afterhours represents no such compromise: the patient receives more appropriate care and the healthcare system saves money. Industry Structure Established services The MDS sector comprises over one hundred deputising services across the country. However the larger, established services account for the overwhelming majority of patient services provided and of General Practices supported. 13SICK, National Home Doctor Service is the largest of these organisations and is responsible for around half of all the after hours home visits. It was formed via the consolidations of a number of long-standing, reputable MDS from across Australia. Most of the other large and longstanding organisations 2 This average reflects a mix of urgent and non-urgent items and bulk billing incentive payments
are members of the National Association of Medical Deputising Services (NAMDS). Membership includes ALMS which is owned by the Sonic Group; Dial a Doctor, a privately owned group operating in Perth, Cairns and Darwin; SydMed, WADMS and Radio Doctor Illawarra, all operatives based in Sydney, Perth and Wollongong respectively. Industry newcomers In recent years there has been a proliferation of small MDS that have received accreditation and access to workforce. NAMDS has expressed concern that very few of these new entrants have any operating history as deputising services and lack genuine engagement with General Practice. NAMDS is concerned that some of these organisations are behaving in ways that pose risks to continuity of care and patient and Doctor safety. Who uses after hours urgent home visits and for what reasons? Focus on acute, episodic care The NAMDS services are focused on patients with acute episodic conditions where the patient needs to be seen on an urgent basis. National Home Doctor Service report that over 90% of callers to their service believe they (or the person they provide care for) need medical attention before their GP will re-open. Many of those patients are referred after having called their regular GP to get an urgent appointment or having called a nurse help line (and then being redirected to see a Doctor urgently). Unlike General Practice, after hours Doctors do not manage chronic disease; chronic disease management requires ongoing comprehensive care and this properly falls within the purview of general practice. Data on patient mix Data collected by National Home Doctor Service shows that the mix of patients seen in the after hours, and the reasons why, are very different than the typical mix of patients and symptoms presented in a regular daytime GP practice: One in four (24%) patients seen are children under 4 years, which is 3.5 times the proportion typically seen in General Practice. The next largest group is elderly patients. One in seven (14%) patients are adults over 75 years. 13% are in residential aged care facilities, which rises up to 30% in Melbourne. These are higher percentages than seen in typical General Practice. A high proportion of patients also have other disadvantages, such as carer responsibilities and mobility issues and other disabilities. Most MDS services are 100% bulk-billed, which ensures that those who need after-hours care can access that care, particularly the elderly, young families and concession card holders. Over 70% patients are eligible for the bulk billing incentive payment. It is salient to note that over 60% of calls to 13SICK,National Home Doctor Service are made by carers such as parents, family members or aged care nurses, rather than by the patient themselves. In terms of urgent matters, National Home Doctor Service data shows that its Doctors see only 6 of the top 15 reasons that typically draw patients to present to General Practice. It is National Home Doctor policy that any convenience-based requests (e.g. request for referrals, script repeats, etc.) are triaged back to the patient s regular GP unless there is an urgent medical need or the matter has been referred to us by the patient s GP. Importance of face to face assessment It has been suggested by some commentators that perhaps many calls for after hours visits could be excluded on the basis of a more extensive, clinician led telephone triage being conducted first. The evidence does not support this view. The reality is that it can be very difficult to determine the true acuity of a presentation by telephone, especially when the patient is an infant or young child or very elderly, as many of our patients are. Indeed the evidence suggests that this sort of telephone triage would not significantly reduce the proportion of calls leading to home visits: the very high rates of disposition to either Emergency Departments or urgent care by clinician led tele-triage services such as the Hunter GP Access Patient Streaming Service indicate that the vast majority of callers in the after hours setting have genuine concerns requiring urgent attention (GP Access Cost Study 2015). In addition, these clinician triage processes are expensive to operate (due to the length of calls and the hourly rates of more highly trained staff). Given they divert few patients away from
more urgent responses, these triage process in fact introduce additional costs to the system. It is also important to remember that many apparently mild symptoms and ostensibly minor illnesses can mask more serious conditions or can have a significant impact on more vulnerable patients. For example, the key presentations seen in the after hours can be potentially serious illnesses that are responsible for 270,000 Potentially Preventable Hospitalisations per year: upper respiratory tract infections, urinary tract infections cellulitis exacerbations of asthma and symptoms associated with chronic obstructive pulmonary disease. Preventing possible misuse National Home Doctor Service is also aware of the possible misuse of the service by certain patients. National Home Doctor Service has strict protocols to ensure appropriate usage by patients, and monitor repeat users on a monthly basis. In consultation with the patient s regular GP, restrictions and/or bans can be placed on people using the service inappropriately. That most patients use the after hours service appropriately is demonstrated by the facts that over half of all patients see an after hours doctor only once in any given year and the average patient only 1.5 times per year. These levels are particularly low given the relative vulnerability of the patients seen in the after hours. For more information: http://www.namds.com/ https://homedoctor.com.au/ Or contact Martin Palin martin@palin.com.au June 2016