Doctors Versus The System

At the recent senate estimates in November, I spoke with Dr Antonio Di Dio, Director of Professional Review Services, asking why the current system was still biased against doctors. He denied this was the case, even though the agency maintains a 100% conviction rate of doctors in a system that does not allow merit appeals or the ability to challenge the facts used against a doctor.

Dr Di Dio conceded that the agency had not undergone a review, despite it being suggested many years ago during an inquiry. Senator Gallagher added that a review was unnecessary, asserting that the system was functioning well, despite evidence to the contrary.

Transcript

Senator ROBERTS: Thank you. Thank you for being here. Annual reports of the PSR, directed to the health minister, make no attempt whatsoever to disguise the fact that PSR operates in part as a debt recovery system from doctors of Medicare funds. Given that admissions have earlier been made before Senate estimates that committees are not chaired by a judge, that merit review on appeal is not allowed, and that no cross-examination of the committee’s case ever occurs, why is it not reasonable to conclude that PSR operates similarly to a robodebt scheme for doctors, with doctors who’ve come before it having as little meaningful defence as did robodebt’s victims? 

Dr Di Dio: That’s certainly not my view. When a practitioner is referred to PSR, a small minority of them are referred to a PSR committee. Last year it was 12 out of 109 referrals. When a practitioner appears before a PSR committee, the committee process is one in which peers interview and discuss with the practitioner under review whether or not, in their view, inappropriate practice has occurred. At every stage of that committee process, numerous times per day, the committee may say, ‘We have found preliminary concerns with this matter and invite your response.’ In other words, the entire process is made up of taking into account the practitioner’s response, over and over again. Furthermore, the practitioner, of course, is invited to bring their legal representative. In terms of a merits review, there is no formal merits review process as that term is commonly known. However, there are opportunities during and after the committee process to respond to the committee’s findings. For example, at the end of a committee, despite having opportunities to respond verbally all through the process, the practitioner under review also is invited, either themselves or through their legal representative, to make final comments about anything that has come up during the committee process. Furthermore, after the committee process is completed, there is a draft report issued by the committee to the practitioner under review, inviting comment and submissions to that draft report. So those committee findings are still deemed preliminary findings, because they are still awaiting further response and information from the practitioner under review. 

Senator ROBERTS: That sounds wonderful, but it does not discuss the fact that the PSR’s case cannot be scrutinised in terms of evidence. You omit that. Why do you repeatedly omit that? Every time we come to Senate estimates, you omit that. That’s fundamental to justice. 

Dr Di Dio: The PSR process is one in which, in order to elicit whether or not inappropriate practice has occurred, people’s medical records are reviewed. 

Senator ROBERTS: But your data is not open to scrutiny; your case is not open to scrutiny. The facts cannot be disputed—cannot even be challenged. 

Mr Topperwien: There are no facts found until the end of the committee process. There are no findings of fact until after the committee process, after all of the evidence has come in. Yes, the committee receives billing data from Medicare, but that’s open to inquiry and investigation as to how accurate that is, and that comes up often in hearings as to whether that data is accurate. And it’s open, then, for the practitioner to put on evidence to counter that data. And that happens regularly at committee hearings. The hearing is an investigation. It isn’t a prosecution. So the committee is inquiring into the information that the committee has already received in the way of the billing data and gets the patient records to see how they match up to what’s been billed as to whether the doctor has fulfilled their obligation to keep adequate and contemporaneous notes of what they did, and to then investigate, ‘What was this practitioner’s conduct in connection with the provision of these services?’ It’s only after they’ve conducted a full inquiry investigation, asked lots of questions, and looked at all of the evidence, that they then may find facts, which may show that the doctor has engaged in inappropriate conduct. 

Senator ROBERTS: I’ll come back. I don’t want an answer to this just yet, but I want to say that there has never been a comprehensive review of the process, despite a 2011 Senate inquiry saying there should be a comprehensive review within 12 months. So let me continue. Many of the annual reports of the PSR director, to the health minister, contain the assertion that the goals for care planning must accord with the acronym SMART, specific, measurable, achievable, relevant and time-based—notwithstanding that no explicit allusion to specific SMART goals appears in the care planning MBS descriptor. Given that, essentially, all doctors who appear before PSR committees who do care plans are found guilty, and given that merit review of the committee’s case is never allowed, how can the committee’s finding of all doctors’ care plans as being unacceptable be valid? 

Mr Topperwien: The committee examines random samples, usually, of the practitioner’s care plans. The practitioners who are examining those are practitioners who themselves do care plans. They are experts in what the general body of their specialty or profession do in their practice. And the reality is the law requires adequate records to be kept, and care plans that are meaningful. And, quite often, the sorts of care plans that committees see are blank templates. There’s nothing in them other than the patient’s name with goals that are totally meaningless. And so those sorts of care plans are ones on which they will find, ‘This is not a care plan that’s adequate and of any use to this patient. It is not a clinically relevant service that’s been provided.’ 

Dr Di Dio: Senator, if it helps, I do care plans every couple of weeks in my practice. I could take you through what one should like. But I think what you really want to know is: this is a peer review scheme, and so what the people on committees determine is what the general body of peers would be considering is appropriate or not. 

Senator ROBERTS: This is an apparent peer review scheme, but it’s not. You claimed in the past that it is peer reviewed, and we’ve given examples where it’s not. Your predecessor, I think, offered to have a conversation with me—on the basis that it was not to discuss a specific doctor’s case; he made that clear. I accepted that offer straightaway, and I said, ‘That’s no problem at all.’ Soon after, he left. So we’ve never had that. Would you be willing to give us a briefing and have an exchange on that? 

Dr Di Dio: I think you’ll find that the person who had that conversation with you was me, Senator.  

Senator ROBERTS: No, it wasn’t. 

Dr Di Dio: Right. Well, Senator, I can further discuss— 

Senator ROBERTS: Are you willing to have a meeting with us and give us a briefing? 

Dr Di Dio: Senator, in order for me to do that, I need to get the appropriate permissions from my own minister, but, should that be the case, I would be very pleased to discuss with you or anybody else how the PSR system works—on the condition, of course, that it does not discuss any particular case or any particular practitioner. I can refer to some correspondence that I’ve had with you about this in the past, if you wish. 

Senator ROBERTS: Sure. 

Dr Di Dio: We most recently corresponded with you on 21 March of this year and confirmed that we’d offered to meet with you in the context of providing general information about the PSR scheme and would happily provide that general information, and additionally on any questions you may have on procedural fairness. We said the discussion would not be able to include any specific matter or case before us and that I was not able to meet with any other person being reviewed or their legal representative or anyone else. 

Senator ROBERTS: Does that still apply? 

Dr Di Dio: Well, yes, because— 

Senator ROBERTS: Good. Okay, let’s accept it, and we’ll set up a date. 

Dr Di Dio: Well, nice to hear back from you, Senator. 

Senator ROBERTS: Good. Many doctors, and all the medical defence organisations, complain emphatically that committees routinely make up rules in passing their judgement. Why is this not solid evidence of dysfunction, injustice and systemic injustice? 

Dr Di Dio: I meet regularly with the medical defence organisations, most recently less than two weeks ago, and I present regularly to thousands of doctors in toto, various colleges and representative groups. That is not the impression that I get, talking to hundreds of doctors around the country. We attempt to do what we exist to do, which is to protect the Commonwealth from paying from inappropriate health care and to protect citizens from potential harms from inappropriate health care through a process that we consider to be as fair as possible. 

Senator ROBERTS: And we applaud that. We just want procedural fairness and justice. Minister, when will this government review this broken system? It’s got to be changed. 

Senator Gallagher: Well, I don’t accept that it is broken, Senator Roberts. That’s your assertion. The department provides advice to the minister about the operations of all parts of the health portfolio, and we are very confident in the processes and the leadership that’s being provided through the Professional Services Review system. 

Senator ROBERTS: There’s been no review since the 2011 Senate inquiry saying there should be a comprehensive review within 12 months—no review. Clearly, it was a problem back then. 

Ms Shakespeare: Senator, there have been reviews of aspects of the PSR scheme on several occasions since then. I am happy to— 

Senator ROBERTS: Could I have, on notice, those reviews and the dates, please, and the topics and the scope? 

Ms Shakespeare: Certainly. 

Senator ROBERTS: Thank you, Chair.