The RACP has warned that the government’s ‘radical’ move to introduce time-tiered MBS attendance items for specialists may have significant unintended consequences including higher gap fees, overcompensation of ‘procedural’ specialities and a workforce exodus from in-patient services.

In its response to proposals by the MBS Review Taskforce to replace standard attendance (initial and subsequent) with time-based items, the College says this could lead to specialists becoming clockwatchers and severely penalise those in non-procedural specialities where practice requires less hands-on time with patients but more background work.

A poll of the College’s 17,000 membership drew 566 responses, of which around 66% expressed some degree of agreement with the proposals from the Taskforce’s Specialist and Consultant Physician Consultation Clinical Committee.

However many respondents also had caveats about time-tiered attendance items, with about half saying some form of initial attendance item should be retained to compensate physicians “for the high upfront ‘expenditure’ of time for an initial attendance in laying the groundwork for future attendances.”

RACP members expressed 6 major concerns about a time-based attendance item system:

   1. It will reward inefficiency and promote ‘clock watching’.

Inexperienced or slow practitioners may be over-rewarded compared to efficient physicians. At the same time, if both doctor and patients have an ‘eye on the clock’, this may create conflict about the appropriate amount of time and payment for a consultation and damage doctor-patient trust and shared decision making.

   2. Difficult to implement, especially for in-patient settings

A time-based system could create more admin work for booking and managing appointments and take the focus off patient care. It will be especially difficult to account for time in in-patient settings where a physician may be ‘multi-tasking’, seeing several patients at one time but perhaps providing only brief face-to-face or phone advice for some. If undercompensated for non-patient facing time,  some consultant physicians to shift from in-patient to wholly outpatient attendances.

   3. Fears of being ‘time audited’ will promote  suboptimal ‘6 minute medicine’

Physicians in some specialities such as palliative care currently have consultations that take up to  – or over – an hour. These will be discouraged under a time-based system.

   4. Undervaluation of non-patient facing time will lead to higher gap fees

Physicians working in areas such as diabetes may have to do a lot of  work outside of a consultation such as reviewing a complex patient’s records, chasing up test results and interpreting data from devices. Time-based items that do not reward non-patient facing time  will put the ‘cognitive’ specialities at a financial disadvantage compared to doctors who work in more ‘procedural’ specialities. This in turn may lead some specialists to charge above patient rebate levels to recover their costs, resulting in more out of pocket charges.

   5. Discrimination against complex patients with chronic disease and multimorbidities

Non-patient facing time is higher for patients with complex and chronic disease, and the introduction of a time-based system of items  (and loss of complex plan items) will potentially result in a reduction in provision of these services for these patients.

   6. Lack of financial modelling

The MBS Review Taskforce has not  released any financial details for the time-based items or done any modelling  on the potential shifts in patient management it may encourage between private clinics, public hospitals and primary and community care.

The RACP concludes that there is insufficient detail in the MBS Review Taskforce proposals on rebate levels, time tiers, arrangements for complex patients, and remuneration for activities outside of face to face consultation.

“In the absence of the above key information and … and the potential for unintended adverse impacts on the ability of patients to access high quality and safe care, the RACP is not in a position to support or oppose the recommendations,” it concludes.