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When is the public health revolution coming?

Discussion in 'Australia' started by Atlas, Feb 2, 2010.

  1. Atlas

    Atlas Well-Known Member


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    I am biased; I have worked in private practice for much of my working life. In a decade of university life, i have been exposed to public health, particularly in community-health in metropolitan Melbourne.

    I realise that dollar, profit and territorial concerns can dominate too much in the private sector. But I am convinced that the community health sector needs an injection of private mentality.

    I have real concerns, in Victoria, about the cost-effectiveness of the public allied health system; it needs more than an injection; it needs a revolution. Over-information (meetings), over-assessment, excessive paperwork, insufficient patient through-put, big sandwich platters, insufficient patient-clinician contact hours, "patient-free"-days..etc.....

    We hear the mantra about "long waiting lists":boohoo:, yet how many public allied-health practioners will average over 10 patients per day? To the minority, I applaud you with 2 hands and 2 feet.

    Private practioners spend less time with patients, but how much does that compromise quality? And what good is quality, if quantity of throughput is low? Where is the balance in getting efficiency up, numbers though, waiting-lists controlled, and cost-effectiveness optimal?


    Reforms are needed so that public allied health clinicians can spend greater time as clinicians. Assessments need to be more efficient and relevant; and treatments need to be more targeted.


    As a private practioner, I might not have the right to call for reform; but as a taxpayer, I do. Accordingly, is the EPC program that contributes to the pockets of us private practioners, delivering value for money? Are GPs getting the referral system right? Should we be seeing healthy patients with healthy feet needing a trim?


    In Australia, we have the private-public/government balance pretty right. Unlike the US generally, we are not paranoid about some government intervention/funding and we realise that you can't give the private sector free-reign. But for the good of the public purse, public waiting lists, and sufficient outcome (quantity and quality) delivery, reform is overdue.



    Ron
    Physiotherapist (Masters) & Podiatrist
     
  2. Sarah B

    Sarah B Active Member

    All of the podiatrists I know who work in the public health system in my local area see more than 10 patients per day.

    For those working in high-risk clinics, there would be a mountain of administration and liaison with fellow health care professionals required. I know because I have done that kind of work (albeit in the UK). It takes time to obtain prescriptions for appropriate antibiotics, arrange community nurses to visit in order to redress a wound, try to get the patient to agree to at least try not to tamper with their dressing, etc. Do you seriously expect that staff should use their own time to carry out these kind of tasks? If you run your own practice, it is inevitable that admin will have to be carried out when there are no patients booked in, which you may consider your own time. However, the profits from the business are yours - not the same for an employee.

    There are so often calls for reform, but what is really needed is a proposal of what the reformed public health system should look like. Otherwise, how can change possibly occur, and how we can decide whether it is any better than the existing status quo?
     
  3. DAVOhorn

    DAVOhorn Well-Known Member

    The EPC system is so defrauded it is beyond comprehension.

    Trouble is it is not the provider of care that is committing the fraud.

    Look at how the money in EPC referrals goes.

    In this country GP's are reimbursed for every single activity and handsomely too.

    The pt endeavours to access Taxpayer funded care to which they are not entitled.

    The GP as the referring agent refers pts who fall outside the eligibility criteria to a wide variety of AHP's.
    I very rarely receive the EPC plan from the GP. Only receive the authorisation document which is usually incorrectly completed. This then leads to problems for the pt when they go to medicare to get theyre 85% rebate.

    So vast sums are squandered on providing unneccessary care to pts who do not fall into the eligibilty criteria.

    When Medicare does an audit it will kill this system.

    When Rudd gets his means tested discount for private health care through i anticipate wholesale reductions of young fit people maintaining their health care insurance.

    This will mean that the only people maintaining this insurance will be older people with health care needs. So ins co's will have less revenues and a higher proportion of insured claiming. This will result in massive increases in premiums for those few who keep ins.

    The Public system will be overwhelmed by the large number of people who have given thier Private Health Insurance.

    So what will the future be?

    David:craig:
     
  4. Paul Bowles

    Paul Bowles Well-Known Member

    How do your patients get an 85% rebate? Its about $50 - where is the 85% schedule?

    David I don't disagree with you - the GP gets more for signing the referral than the patient gets for the health care for an entire year.

    Don't get me started on the EPC for Dentists - every 30 seconds someone loses a leg to Diabetes, Podiatrists get $250 a year to work with. Dentsits get $4500 over two years. Go figure. You just cant compare the seriousness of Dentistry to Podiatry in most instances. Its laughable.

    ...and before all you dentist loving hippies come out of the woodwork to say: Oh but Dentistry is very important and people get serious health complications...." Yadda Yadda Yadda tell someone who cares. Show me the evidence comparable in Dentistry to someone losing a leg every 30 seconds and I will sit up and listen!

    None of my local dentists see life threatening complications on a daily basis. Several of my Podiatry colleagues do!

    Back to topic - We have some amazing public sector Podiatrists - the sector is just under appreciated, under funded and usually staffed by dedicated people who do it because they care - not because the pay check is good!

    There is always the odd few who are just poor at their job, but this goes for any sector in any profession!

    Can Public Sector Podiatry Departments utilize the EPC system? I bet I can answer that question - but I hope I am wrong. Can anyone in public health shed some light on it?
     
  5. DAVOhorn

    DAVOhorn Well-Known Member

    Unfortunately Dentists are far far far better at PR than we are.

    People will still have a beautiful multi thousand dollar smile while sat in their wheelchair after having both legs amputated.

    When giving females advice on footwear i always ask do you want?

    Pretty Feet

    OR

    Pretty Shoes

    :bash:

    We do not bulk bill, but charge the scheduled fee of $59.00 which gives an 85% rebate of %50.05.

    While our fee structure is so pitifully low we will not be taken seriously.

    Feet are not sexy therefore the perceived value of comfortable feet is well below that of:

    BIG TITS

    WRINKLE FREE BOTOX PARALYSED FACIAL EXPRESSION

    Tummy Tuck

    Neck nip and tuck

    People pay a substantial sum of money on eye lens surgery so as not to have to wear glasses. So again Vanity wins out.

    What we do is covered by FOOTWEAR therefore has little or no value.

    Even a painful foot has little commercial value.

    I support this suppositiuon is supported by the number of fools (sorry pts) who would rather pay a couple of bucks to use a CORN CURE and only then when they are in real agony do they invest the paltry sum of $50.00 on getting the mess resolved by a skilled Health Care Professional.:deadhorse:

    If you want a laugh at our profession in UK go to THATFOOTSITE and regard the post on the Aus $16.00 home visit or nine quid to us Brits.

    Our profession does not value itself and is frightened to ask for a fee that reflects our skills.

    Look at the complementary therapies and their robust fee structures.

    After writing this i need a decent cup of strong hot coffee.

    Oh yeah why do i do this for a living?

    I hope to make a difference in the qaulity of life for those with sore feet.:drinks

    regards David
     
  6. Bug

    Bug Well-Known Member

    I've worked in the Public sector for 13+ years and in an 8 hour day easily seen that and more. You also need to remember that most in a public role work a 7.6 hour day, and who in the private sector does a "short day" of these hours?

    I know in my private work I have seen 10+ in an evening session of standard and non-complex clients however now that I mainly see children in my public and private work, I will admit to seeing far less. The notes, the follow up/marking standardised tests, the 1 hour+ appointments mean that some days I might see only 3-4, but some days 10-15 in either sector.

    In the defense of the public work, a snap shot from my standard day.
    8am - 9am - Orthotic rev with 2 children from one family. 1 has JIA, 1 sever's, have to respond to paed rheum about how orthoses are going. So see kids, discuss shoes, letter to Dr etc. Write notes, stat the patient.
    9am -10am - Serial casting for something - toe walking, metadductus etc. Generally involving mess, crying and plaster, reassurance for mum, stat the patient, document the notes.
    10am - 11am - New client referral - toe walking from paediatrician. Assessment, looks neurological (Damn it.....has seen private pod or physio in the past so have to again discuss with mum that I am sure it is something wrong) sign off on appropriate forms on who I can talk to(legal requirement and all that), Letter to GP, letter to Vict Paed Rehab to short list them into assessment and treatment
    11am - 11:15 - Return call to mum with babe in a cast with a blister. Document in notes.
    11:15-11.30 - Manager walks in to discuss waiting list blow out and what we are going to do about maternity leave position. Also ensure appropriate documentation for latest report to Child protection made from podiatry from physical and emotion abuse.
    11:30-12:20pm (now running very late) - Assessment for flat feet: thank heavens they just are normally flat, and discuss shoes, that it is OK for them to be flat (still running late)
    12:20-12:40 - Orthotic review - sever's - fixed - YAY!
    12:40-1pm - Try and write notes and eat and have a break to think about afternoon. Answer emails from when we are going to have 3rd and 4th year podiatry student. Can we take a 1 day OT or a Physio placement and to lock in a date for the inservice on fire safety. Wish I had no appetite so I wouldn't miss the food I have just shoved down in order to keep energy going for the afternoon
    1pm - 2pm - Assessment for a child of a newly arrived refugee. Child is from Sudan and has excessively bowed legs. Confirmed Vit D deficiency (thank goodness for interpreters). Run the thin line between pushing formula for Vit D uptake in a breasteeding mum, and a child that obviously needs the Vit D from the suppliments and formula. Manage cultural sensitivities etc all while using someone else to discuss this therefore taking 2 times as long.
    2pm - 3:30 - Toddler Matters Group - walk into a group of 8 under 3's. 2 of them toe walk, 1 of them has flat feet, 2 of them aren't walking and the group is under staffed in OT and physiotherapists. Attempt some form of assessment in the toe walkers, some form as reassurance in the flat feet and some form of referral for the non-walkers.
    3:30-4pm - Caught rocking in the corner as you now have a performance appraisal due, must know what a code purple means and must know when to use the bloody hand hygiene protocol (and you haven't done any notes for the day).

    I'm not sure where you have done your CHS placements but I don't think you had a snap shot of the norm.

    I also have my own private practice. Every child under the age of 8 gets 45+ minutes of my time for assessment, treatment and follow up. At least 1/2 to 3/4 of them would get more than that as I do up a treatment plan and email/post it through, follow up with their GP or Paediatrician etc. Do I make money on this? Probably not, however it means that the practice I work in gets a good share of Paediatrician referrals in the area of Melbourne that I work in. The CHS services that I work in also have great relationships with the peadiatric specialists in our area and are well respected for thorough assessments, good follow up and appropriate treatment.

    I know there is general care and slow days in CHS but in my experience it is also up to the practitioner, the area they work in and the people that come through the doors. I think it goes both ways....the private pods are great with servicing the clients but not always the greatest at building relationships within the medical community and following through. I think the community health/sub and acute pods are good at building relationships with the medical community, complex assessments and treamtent but the system isn't designed to push clients through on a numbers basis because of the complexity of what walks through.

    You can't have it both ways.

    We can get a child into an paediatric orthopaedic surgeon in a public clinic without a GP referal in 2-3 weeks because of the community heath setting, I have the time to do a thorough assessment, I can write a damn good referral and don't even get me started on the amount of children I see that I have to refer for complex medical conditions that have seen a private podiatrist and the private podiatrist or physiotherapist has missed a diagnosis of CP or JIA because of the short assessment etc etc etc.

    I honestly think you need to walk a mile in the other sector's shoes for a substantial period of time to make this judgment. Does it need an private injection? Maybe in some people but not the sector.

    I think the private sector needs an injection of a public sector mentality of "thorough assessments", slow down and liaision with the other health service providers and provide better planning and follow up.

    I hope I am not the only one that thinks so, but given the 20 min in and outs that the private sector is fond of, I think I might be.
     
  7. aliciaj

    aliciaj Member

    Hi all,

    I am one of the luck practitioners that works in both the private and public sectors in Victoria. I get the gripe about community health waiting lists, I look at it myself and shake my head. Funding at community health isn't likely to dramatically increase. I don't think I can personally see anymore more patient. I don't attend all the meeting I am meant to attend. I often complete my paperwork after hours, my partner shakes his head the new phrase "are you paid enough to care after 11pm?"- of course I am their my patients.


    My public roster is a good mix two full days of paediatrics, half a day of multidiscplinary orthopaedic (paediatrics) clinic and one and a half general/adult/biomech/ulcer what ever walks through the door. Generally the Community health pracitioner shouldn't be just seeing toenails, priority by DHS now indicates high risk patient are the priority. I ask the private practioner are you going to fit more than 8 complex patients wounds/diabetes/orthopaedic/paediatrics in a day including the letters/referrals/liason with the acute physician and then following up that day with the concerned patient.

    I then go to private where like most pracitioner I have a 30 minute consultation for patients, I get worried did I just miss something I did the doppler, ABI and neurovascular it was normal, it will be fine! The jump from public where appropriate continum of care is my main priority to I have to see 8 patients in 4 hours I hope I don't miss anything attitude creeps in. My main worry is I have referrals from doctors who know my public practice skills can I maintain this level of care in 30 minutes?

    I challange my fellow practitioner charge for your time, not for the appointment. If I need to spend 60 minutes with a paediatric client in private I will charge for the time, if I then need to send a letter of support to the special needs school this is also in the time. Speechies, Occupational Therapist and Pscyhologist are charging by time, if you miss somthing because you were running to 20 or even 30 ,minute consultations are you in fact a law suit waiting to happen?

    I think public and private could work hand in hand. Stop worrying about how many people are being seen and start thinking are they recieving the appropriate care, are they at the most appropriate provider.

    Alicia
     
  8. Atlas

    Atlas Well-Known Member

    You bring up good points Alicia. We are so afraid of a law suit, that, from the top-down we are forced to over-do assessments, notes etc. It's like being afraid of getting hit by a car so we stay indoors. The allied health profession needs to step outside and realise that there is a good chance you wont get t-boned.

    This over-assessment, profuse duplicitous note-taking is actually forcing you to do less of your primary role, and use less of your strengths. Meanwhile the "waiting lists" are growing.


    The other thing is this. In so many circumstances, I have seen the most comprehensive assessment, whose findings don't alter the treatment one iota! Mapping a wound for goodness sakes to the nth degree! As clinicians we should chase significant change, and not debate whether we have made half-a-percent difference.

    When a patient reports his/her blood sugars at 18-20 after lengthy probing on the 8th visit, does this influence what we do?

    When we get that abnormal ABI after mucking around for 7 minutes, do many of us divert from the mundane course?



    Do we address pain and function enough? We muck around with copious notes, over-assess to the point of confirming yet again, a high ABI and blood-sugar count; map to the level of James Cook, that a wound has shrunk by .001 % with the implementation of a new budget-breaking wound pad.....
    yet the patient limps out on an inverted foot because of a sessamoiditis or a massive corn under the 1st MPJ!



    I know some of you get the patient numbers through. I know some of you are amazing clinicians. Unfortunately this is not the case across-the-board. Unfortuanately, it could be.

    From the top-down, the bureaucratic culture of small-picture-inefficiency needs to be smashed. The overrated fear of litigation needs to be realised. Assessments need to relevant; the outcome of which needs to change treatment. Note-taking needs to be less copious, less duplicitous, less fluffy. It needs to be virtually point-form and get to the crux.


    Absolutely correct in that the private and public sectors have different skill-sets and strengths. Imagine the benefits to practitioners and patients if the sectors could interplay and add to the missing pieces of the jigsaw puzzle.

    We realise our strengths, but we must confront our weaknesses. I will, as most should, continue to worry about how many people are seen. The tax payer needs value-for-money. A health system needs reform so that adequate numbers are catered for. No good if quality is B grade, yet throughput is E grade. Probably better-off with C and C.




    Ron
    Physiotherapist (Masters) & Podiatrist
     
  9. Bug

    Bug Well-Known Member

    I guess we failed to asked the question though.....in what way is it broken? We can't just count numbers on waiting lists as brokenness. Or it is simply an indicator of the high demand of a social sector that community health services and that the lower the economic status the higher the complex health needs are.

    Vic has one of the largest community health structures in Australia, I would be interested to hear from the other states and wonder what the difference in foot health is between states?


    I get where you are coming from. What is value for money though? Bums on seats is only a small component. Why do we have to compromise quality for quantity. I know I'd rather a small block of high grade chocolate to a large block of cooking chocolate.

    ETA: Paul, we can't utilise an EPC in community health unless we set up a clinic especially for it. I think there is one in Vic that has employed someone especially for it. We actually use it as a screening "out" for those that want more that CHS can provide. We don't do general toe nail cutting unless the person's toe will fall off if we don't.
     
  10. markjohconley

    markjohconley Well-Known Member

    Jeez Ron where do you get the "big sandwich platters" i'm applying! As for the rest above SPOT ON! and well said, yours truly, mostly public sector podiatrist last 20 odd years
     
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