Under or over? General practitioner charging of Medicare.

BACKGROUND AND OBJECTIVES: In 2022, media reports alleged that doctors, particularly general practitioners (GPs), are defrauding Medicare, claiming $8 billion lost through fraud/non-compliance. This study examined Medicare Benefits Schedule billing patterns by consultation length to estimate overcharging or undercharging by GPs, and the cost/savings to Medicare. METHOD: A subset of data from the Bettering the Evaluation And Care of Health (BEACH) program from 2013 to 2016, which included length of consultation information, was analysed. RESULTS: Of 89,765 consultations, GPs undercharged 11.8% of consultations and overcharged 1.6%. Of the 2760 GPs sampled, 816 (29.6%) overcharged at least once and 2334 (84.6%) undercharged at least once. Of the GPs who overcharged at least once, 85.4% also undercharged. The total effect of GP undercharging and overcharging was a net saving of $351.7 million to Medicare. DISCUSSION: This study shows that GPs undercharging and overcharging saved Medicare over one-third of a billion dollars in 2021-22. The findings of this study do not support the media claims of widespread fraud by GPs.

General Practice Statistics in Australia: Pushing a Round Peg into a Square Hole.

In Australia, general practice forms a core part of the health system, with general practitioners (GPs) having a gatekeeper role for patients to receive care from other health services. GPs manage the care of patients across their lifespan and have roles in preventive health care, chronic condition management, multimorbidity and population health. Most people in Australia see a GP once in any given year. Draft reforms have been released by the Australian Government that may change the model of general practice currently implemented in Australia. In order to quantify the impact and effectiveness of any implemented reforms in the future, reliable and valid data about general practice clinical activity over time, will be needed. In this context, this commentary outlines the historical and current approaches used to obtain general practice statistics in Australia and highlights the benefits and limitations of these approaches. The role of data generated from GP electronic health record extractions is discussed. A methodology to generate high quality statistics from Australian general practice in the future is presented.

Validation of electronic medical data: Identifying diabetes prevalence in general practice.

BACKGROUND:: Electronic medical records are increasingly used for research with limited external validation of their data. OBJECTIVE:: This study investigates the validity of electronic medical data (EMD) for estimating diabetes prevalence in general practitioner (GP) patients by comparing EMD with national Bettering the Evaluation and Care of Health (BEACH) data. METHOD:: A "decision tree" was created using inclusion/exclusion of pre-agreed variables to determine the probability of diabetes in absence of diagnostic label, including diagnoses (coded/free-text diabetes, polycystic ovarian syndrome, impaired glucose tolerance, impaired fasting glucose), diabetic annual cycle of care (DACC), glycated haemoglobin (HbA1c) > 6.5%, and prescription (metformin, other diabetes medications). Via SQL query, cases were identified in EMD of five Illawarra and Southern Practice Network practices (30,007 active patients; from 2 years to January 2015). Patient-based Supplementary Analysis of Nominated Data (SAND) sub-studies from BEACH investigating diabetes prevalence (1172 GPs; 35,162 patients; November 2012 to February 2015) were comparison data. SAND results were adjusted for number of GP encounters per year, per patient, and then age-sex standardised to match age-sex distribution of EMD patients. Cluster-adjusted 95% confidence intervals (CIs) were calculated for both datasets. RESULTS:: EMD diabetes prevalence (T1 and/or T2) was 6.5% (95% CI: 4.1-8.9). Following age-sex standardisation, SAND prevalence, not significantly different, was 6.7% (95% CI: 6.3-7.1). Extracting only coded diagnosis missed 13.0% of probable cases, subsequently identified through the presence of metformin/other diabetes medications (*without other indicator variables) (6.1%), free-text diabetes label (3.8%), HbA1c result* (1.6%), DACC* (1.3%), and diabetes medications* (0.2%). DISCUSSION:: While complex, proxy variables can improve usefulness of EMD for research. Without their consideration, EMD results should be interpreted with caution. CONCLUSION:: Enforceable, transparent data linkages in EMRs would resolve many problems with identification of diagnoses. Ongoing data quality improvement remains essential.

What are chronic conditions that contribute to multimorbidity?

BACKGROUND: There is currently no accepted standard definition for chronic conditions. OBJECTIVE: The objective of this article is to provide an overview of the characteristics that define health conditions as chronic. DISCUSSION: A list of health conditions classified as chronic should be made available to all general practitioners and policymakers in Australia. This will assist in the claims process for chronic disease management and aid the selection of patients for healthcare home enrolment. Based on assessment of the usual duration, prognosis, sequelae and pattern of recurrence or deterioration, a defined list of chronic conditions classified according to the International Classification of Primary Care, version 2 (ICPC-2) is available for consideration.

Lifestyle risk factors and corresponding levels of clinical advice and counselling in general practice.

BACKGROUND: The objective of this study was to examine prevalence rates of lifestyle risk factors in the Western Victorian Primary Health Network (WV PHN) general practice patient population and the corresponding levels of clinical advice and counselling. METHODS: Analysed data from the Bettering the Evaluation and Care of Health (BEACH) program from April 2011 to March 2015 were examined, providing a comparison of three geographical areas of general practice patients: WV PHN, Victoria and Australia. RESULTS: Rates of clinical advice and counselling for diet and exercise provided by general practitioners (GPs) in the WV PHN network were significantly lower than Victorian and Australian rates, despite the region's higher obesity rates. Smoking rates were higher in the WV PHN compared with Australia, but there was no difference in the levels of smoking cessation advice disseminated. Across all regions, one in four patients drank alcohol at hazardous levels. DISCUSSION: GPs in rural practice require further support, encouragement and resources to provide diet and exercise advice to their patients more frequently.

Assessment and management of asthma and chronic obstructive pulmonary disease in Australian general practice.

BACKGROUND: Dispensing data suggest potential issues with the quality use of medicines for airways disease. OBJECTIVE: The objective of this article was to describe the management of asthma and chronic obstructive pulmonary disease (COPD) in general practice, and investigate the appropriateness of prescribing. METHODS: The method used for this study consisted of a national cross­sectional survey of 91 Australian general practitioners (GPs) participating in the Bettering the Evaluation and Care of Health (BEACH) program. RESULTS: Data were available for 2589 patients (288 asthma; 135 COPD). For the patients with asthma, GPs classified asthma as well controlled in 76.4%; 54.3% were prescribed inhaled corticosteroids (ICS), mostly (84.9%) as combination therapy, and mostly at moderate-high dose; only 26.3% had a written action plan. GPs classified COPD as mild for 42.9%. Most patients with COPD (60.9%) were prescribed combination ICS therapy and 36.7% were prescribed triple therapy. DISCUSSION: There were substantial differences between guideline-based and GP- recorded assessment and prescription for asthma and COPD. Further research is needed to improve care and optimise patient outcomes with scarce health resources.

Management of chronic heart failure in general practice in Australia.

BACKGROUND: Chronic heart failure is a common clinical syndrome associated with high healthcare system use. OBJECTIVE: The aim of this study was to explore the management of chronic heart failure in Australian general practice. METHODS: Data from the Bettering the Evaluation and Care of Health program were used to determine the prevalence of chronic heart failure, use of natriuretic peptide testing, prescribing patterns, hospitalisation rates and referrals to community-based heart failure management programs in three study periods between 2010 and 2015. RESULTS: Data on 8989 patients from 308 general practitioners were analysed. Of these patients, 324 had chronic heart failure (prevalence 3.6%; 95% confidence interval [CI]: 3.1-4.2), 44% (95% CI: 34.5-53.6) of whom had been hospitalised for the condition. The mean number of prescribed heart failure medication agents was 2.26 (95% CI: 2.13-2.39) per patient. Discharge under community heart failure programs was not routine. DISCUSSION: Chronic heart failure is a significant burden in general practice. Strategies to optimise management and avoid hospitalisation, where possible, are needed.

General practice antibiotic prescribing for management of otitis media in children.

Otitis media (OM) is one of the most common infections in children. The cause can be viral, but is most often bacterial. It remains one of the most common reasons for antibiotic prescribing for children. Many episodes of acute OM are self-limiting and resolve without treatment, but antibiotics are often prescribed because these infections can develop into serious, sometimes life-threatening complications.

Estimating non-billable time in Australian general practice.

OBJECTIVES: To quantify the time that general practitioners spend on patient care that is not claimable from Medicare (non-billable) and the monetary value of this work were it claimable, and to identify variables independently associated with non-billable time. DESIGN: Prospective, cross-sectional survey, April 2012 - March 2014. SETTING: Australian general practice; a substudy of the national Bettering the Evaluation and Care of Health (BEACH) program. PARTICIPANTS: 1935 randomly sampled GPs (77.4% participation rate) from across Australia provided filled questionnaires on 66 458 patient encounters. MAIN OUTCOME MEASURES: Non-billable time spent on patient care since patient's previous consultation; duration of and reasons for non-billable time; estimate of its monetary value were it claimable from Medicare; variables associated with non-billable time. RESULTS: 69.5% of GPs reported non-billable care outside patient visits; 8019 patient encounters (12.1%) were associated with an occasion of non-billable time. Mean time spent per occasion was 10.1 min (range, 1-240 min). Reasons for non-billable time included arranging tests and referrals, consulting specialists or allied health professionals, medication renewals, and advice and education, and encompassed all International Classification of Primary Care Version 2 chapters. The notional average annual value per GP of this work was $10 525.95 (level A rebate) to $23 008.05 (level B). Non-billable time was independently associated with female GPs, younger GPs (under 55 years), female patients, patients aged 65 years or more, and one or more chronic problems being managed at the recorded encounter. CONCLUSION: Most GPs spend a significant amount of unpaid time on patient care between consultations, an inherent problem of the fee-for-service system. This work should inform discussions of future funding models.

General practitioners' prescribing of lipid-lowering medications for Indigenous and non-Indigenous Australians, 2001-2013.

OBJECTIVE: To examine the prescribing of lipid-lowering medications during general practitioner encounters with Indigenous and non-Indigenous Australians from 2001 to 2013. DESIGN, SETTING AND PARTICIPANTS: Observational time trend study, using data from the Bettering the Evaluation and Care of Health (BEACH) survey, of 9594 primary care encounters with Indigenous patients and 750 079 encounters with non-Indigenous patients aged 30 years or over. MAIN OUTCOME MEASURE: Prescription of at least one lipid-lowering medication. RESULTS: The age-sex standardised proportion of encounters that resulted in at least one lipid-lowering medication being prescribed was 5.5% (95% CI, 4.7%-6.3%) for Indigenous patients and 4.6% (95% CI, 4.5%-4.7%) for non-Indigenous patients. The proportion of encounters with Indigenous patients at which a lipid-lowering medication was prescribed increased significantly from 4.1% during 2001-2005 to 6.4% during 2009-2013 (P = 0.013 for trend). For encounters with non-Indigenous patients, the proportion increased significantly from 3.8% during 2001-2005 to 5.2% during 2009-2013 (P < 0.01). For encounters during which GPs managed diabetes, hypertension or ischaemic heart disease, the proportion of Indigenous encounters during which lipid-lowering medication was prescribed was similar to that for non-Indigenous patients. For encounters in which GPs managed a lipid disorder, however, the age-sex standardised proportion was significantly greater for Indigenous (78.4%; 95% CI, 72.6%-84.2%) than for non-Indigenous patients (65.2%; 95% CI, 64.5%-65.8%). CONCLUSION: We detected substantial increases in the prescribing of lipid-lowering medications from 2001 to 2013 for both Indigenous and non-Indigenous patients seen in Australian general practice. Providers were more likely to prescribe lipid-lowering medications for Indigenous than for non-Indigenous patients, suggesting some measure of success in expanding access to medications and reducing cardiovascular risk among Indigenous people.

The cost of freezing general practice.

OBJECTIVES: We aimed to assess the effect on general practitioners' income, and the amount of any copayment required for GPs to recoup lost income, of two policies (individually and combined) proposed by the Australian Government: a continued indexation freeze of Medicare schedule fees; and a $5 rebate reduction (now retracted). DESIGN, SETTING AND PARTICIPANTS: Analysis of data from the Bettering the Evaluation and Care of Health (BEACH) program, a continuous cross-sectional, national study of GP activity in Australia. We used data for April 2013 to March 2014 on direct encounters between patients and GPs for which at least one Medicare Benefits Schedule or Department of Veterans' Affairs general practice consultation item was claimable. MAIN OUTCOME MEASURES: The reduction in GP rebate income due to the policies and the size of any copayment needed to address this loss. RESULTS: The $5 rebate reduction would have reduced GPs' income by $219.53 per 100 consultations. This would have required a $4.81 copayment at all non-concessional patient consultations to recoup lost income. The freeze would cost GPs $384.32 in 2017-18 dollars per 100 consultations, requiring an $8.43 copayment per non-concessional patient consultation. Total estimated loss in rebate income to GPs would have been $603.85 in 2017-18 per 100 encounters, a reduction of 11.2%. The non-concessional consultation copayment required to cover lost income from both policies would have been $7-$8 in 2015-16, and $12-$15 by 2017-18. CONCLUSION: If both policies had gone ahead, GPs would have needed to charge substantially more than the suggested $5 copayment for consultations with non-concessional patients in order to maintain 2014-15 relative gross income. Even though the rebate reduction has been retracted, the freeze will have greater impact with time - nearly double the amount of the rebate reduction by 2017-18. For economic reasons, the freeze may still force GPs who currently bulk bill to charge copayments.

Drugs causing adverse events in patients aged 45 or older: a randomised survey of Australian general practice patients.

OBJECTIVE: To determine prevalence of adverse drug events (ADEs) in patients aged 45 years or older presenting to Australian general practitioners (GPs) and identify drug groups related to ADEs, their severity and manifestation. DESIGN: Substudy of the Bettering the Evaluation and Care of Health continuous survey of Australian GP clinical activity in which randomly selected GPs collected survey data from patients. Data are reported with 95% CIs. SETTING: General practice in Australia. MAIN OUTCOME MEASURES: Prevalence in the preceding 6 months, type, implicated drugs, severity (including hospitalisation) and manifestation of ADEs. PARTICIPANTS: From three survey samples, January-October 2007, and two samples, January-March 2010, responses were received from 482 GPs about 7561 patients aged 45 years or older. RESULTS: Of a final sample of 7518 patients (after duplicate patients removed), 871 (11.6%) reported ADEs in the previous 6 months. The type of ADE was recognised side effect (75.8%, 95% CI 72.0 to 79.7), drug sensitivity (9.9%, 95% CI 7.2 to 12.7) and drug allergy (7.4%, 95% CI 4.7 to 10.1). Drug interaction (1.0%, 95% CI 0.1 to 1.8), overdose (0.8%, 95% CI 0.0 to 1.5) and contraindications (0.2%, 95% CI 0.0 to 0.6) were very infrequent. A severity rating was provided for 846 patients. Almost half (45.9%, 95% CI 42.0 to 49.7) were rated as 'mild' events, 42.2% (95% CI 38.8 to 45.6) 'moderate', 11.8% (95% CI 9.5 to 14.1) severe and 5.4% (95% CI 3.8 to 7.0) had been hospitalised as a result of the most recent ADE. Thirteen commonly prescribed drug groups accounted for 58% of all ADEs, opioids being the group most often implicated. CONCLUSION: ADEs in patients aged 45 or older are frequent and are associated with significant morbidity. Most of ADEs result from commonly prescribed drugs at therapeutic dosage. The list of causative agents bears little relationship to published lists of 'inappropriate medications'.

Prevalence, causes, severity, impact, and management of chronic pain in Australian general practice patients.

OBJECTIVE: To determine the prevalence of chronic pain, its causes, severity, management, impact on sleep, mood and activity levels, and general practitioner (GP) and patient satisfaction with pain management. DESIGN: A subset of 197 GPs and 5,793 patients from the BEACH program, a continuous, national cross-sectional survey of Australian general practice. RESULTS: The prevalence of chronic pain was 19.2% (95% confidence interval: 17.4-21.0) (N = 1,113). The most commonly reported causal conditions were osteoarthritis (48.1%) and back problems (29.4%). For pain severity (using Von Korff's pain grades), 25.2% were at Grade I (lowest); 37.1% were at Grade II; 28.3% at Grade III; and 9.4% at Grade IV (highest). Medication was used for pain management by 86.1% of patients, and one third also used nonpharmacological managements. One third of patients were taking opioids, most commonly those at the highest pain severity grades. On "Live Better with Pain Log" scale, the impact of pain was similar across activity (mean = 4.0), sleep (mean = 4.8), and mood (mean = 4.8). On a scale of 1 (highest) to 5 (lowest), GPs' satisfaction (mean = 2.5) was highly correlated (r = 0.7) with patients' satisfaction (mean = 2.6) with pain management. CONCLUSIONS: Chronic pain impairs patient quality of life, and is a public health burden. This study provides a national overview of the prevalence, causes, severity, management and impact of chronic pain in Australian general practice patients, and the parity between GP and patient satisfaction with pain management.