Professor Julie Quinlivan is stepping down as director of the Professional Services Review, after five years at the regulator.
In this candid interview, Professor Quinlivan reflects on what has changed at the Medicare watchdog and explains why a growing number of specialists are coming under scrutiny for their billing.
She also shares why she has concerns about the Queensland Government’s proposed pharmacy prescribing trial and responds to criticism that the regulator is unfair on doctors.
the limbic: You have been PSR director for more than five years now, it must be one of the toughest roles in government and in medicine.
Professor Julie Quinlivan: Being a regulator is really difficult because you don’t set policy. Your job is simply to implement policy set by government and to follow the law. That’s the role. It isn’t to do what you want to do, you have to do what the law says.
What has to be remembered is 99.9% of practitioners are doing the right thing, but the sad reality is there are a small number who aren’t and who need to be nudged back into the herd. With the PSR, we are seeing less than one in 1000 practitioners in Australia.
the limbic: Who are those doctors coming under review? Are there any common themes?
Professor Quinlivan: About a third are actually people who probably were really good practitioners in the past, but have developed an impairment in some way. They might have developed early dementia or a mental health condition or some other condition, and that has led them to start doing some very bizarre and unusual things.
Particularly with early dementia, the medical records become quite bizarre and then the medicine can become bizarre as well. So really it then becomes a Medical Board of Australia issue, which is why we make quite a large number of referrals to the board.
But then there is another group of people who are definitely doing the wrong thing and must know it. We have our fair share of people billing for dead patients, billing when people are overseas and billing when there is no evidence a service was ever performed at all. Sadly that is the next big chunk of cases that we have.
I’m just thinking of the two latest committee reports that I have read. Both committees concluded the person under review had billed patients they hadn’t seen.
the limbic: Shouldn’t more of these doctors be investigated for fraud?
Professor Quinlivan: There is a question over whether some of these people should be prosecuted for fraud. At the end of the day, it’s probably easier to leave it at the PSR level because with fraud you’re going into criminal courts and things like that.
We do sometimes make fraud referrals, though – especially when people have billed patients who are no longer alive.
the limbic: How have things changed since you took on the role in 2017?
Professor Quinlivan: The first thing is that the dollars have increased. If you look at everyone billing Medicare, there is probably only a slight increase in average claims on five years ago.
But if you look at certain people on the extremes it has been a sizable shift. So there is a very small group who are billing a lot more now than they did five years ago.
The other change is that we now look at everybody whereas previously we only looked at GPs. Today, the PSR really looks at everybody who bills and prescribes.
If I look at my current committee list, I have chiropractors, nurse practitioners, midwives, optometrists, dentists, a whole range of specialists and only a few GPs. That’s fair too. It really wasn’t fair in the past that compliance was just for GPs, it really should be on everybody.
Besides that, we are now looking at corporates as well as individual doctors. That’s really important, because it brings accountability to corporate practice.
The limbic: Do you think the PSR has done a good job?
Professor Quinlivan: I do actually. Historically, the PSR really only ever won about 50% of its Federal Court of Australia actions. Today, we are consistently winning all of them.
That shows we have really good procedural fairness in place. Every single person appointed to a PSR panel receives annual training in procedural fairness as well as in how to ask questions and listen respectfully.
The quality of our committee reports has improved as well. Back in the beginning some ran to about 30 pages. Today, they’re typically 400-500 pages with lots of detail. When we say there’s a concern, we will footnote it and give six examples. So it will be a high quality document.
the limbic: A lot of people accuse the PSR of being unfair though, it’s been called a star chamber, operating in secrecy. There are complaints about doctors having limited representation while being forced to hand over their records.
Professor Quinlivan: Well there is a lot of misinformation out there about how we operate and claims that we have unusual powers. In fact virtually every regulator in Australia can require relevant documents and for the PSR that happens to be medical records. So that is not an unusual power.
However we do have to be really careful about privacy, given the nature of medical records. An agricultural regulator doesn’t have that same sensitivity but if I want to work out if someone who has billed Medicare for a hemicolectomy actually performed it or if they actually just biopsied a polyp, I’d actually need to look at the medical records to see whether there was a pathology specimen for example and what did it show.
It’s also untrue that you aren’t entitled to representation. In fact you can have a legal representative at every step of the process and 95% of people do. Of course some people do sack their lawyers and they will tend to be unrepresented for a period of time.
the limbic: How do you respond to the criticism that Medicare has become more complex though. It’s been argued that most doctors are at risk of non-compliance, even with the best intentions in the world.
Professor Quinlivan: My answer to that is that I’m a specialist and I see patients and I bill Medicare. Yes, there’s over 5,000 items on the MBS, but I really only bill about 15 of them.
Reviewing GPs, we see the same 10 items over and over again plus their telehealth equivalents. And when we look at cases it is very rare that the concern is that someone has misread the item number. Overwhelmingly, the concern is that the service wasn’t performed or that the clinical record was really poor or that the management was inadequate.
I can think of one recently where the presenting complaint was a unilateral red eye. The patient record made no mention of any diagnosis or any other history but it said the management was an ear drop. Now, has that person misunderstood the item number? No. The concern is just that the record makes no sense whatsoever.
the limbic: The criticisms of the PSR do seem to get quite personal at times. Has that been tough personally for you?
Professor Quinlivan: It can be at times. I have had a death threat. We notified the Australian Federal Police and it was managed but that was an interesting experience.
Overall it’s been a really great job though because we also deal with a lot of really good people, especially all of our reviewers. And when an issue comes up we do feed back to the relevant college and to the Department of Health, which can lead to change and be very rewarding. We’ve actually been responsible for rewriting several item numbers to make them clearer, particularly those related to sleep medicine.
We have also had some positive feedback from people under review. Of course not everyone will be happy but many are honestly lovely people. There have been situations where people have been overworked or let things drift and I’ve actually had a couple of people who have ended up writing letters thanking us for the dealing with them fairly and professionally.
If people who are unhappy attack the messenger rather than the facts then that is difficult. It can also be difficult as a female in the role because the vast majority of people under review are male. I think it’s really important to pull back and say it’s not a criticism from me personally. There is a process.
the limbic: You recently took the unusual step of publicly criticising the Queensland Government’s proposed pharmacy prescribing trial. Why are you so concerned about it?
Professor Quinlivan: We looked into it after being asked to comment by the AMA. I think it is important that there isn’t an area of medicine that’s not regulated. It doesn’t mean bad things will happen but it can.
It would also get around federal legislation governing who can prescribe, which means two things: One is there would be no role for the federal health department to manage compliance or escalate the matter to the PSR.
The other is that it bypasses the TGA, which has recently rejected applications to down-schedule a number of the medicines being considered for pharmacy prescribing. In each case the TGA did a very comprehensive assessment and said ‘no, these should remain prescription-only’. Including them in this trial ignores that whole process.
the limbic: Finally, what are you planning to do once you step down for good?
Professor Quinlivan: I’m going to be Dean of Medicine at Curtin University in Western Australia. It will be a much bigger job but I feel like I’m leaving the PSR in a good place.