Almost too pissed off to attend specialty assessment meeting

[injuryupdate]

I am a sports physician and tomorrow in Sydney there is a preliminary meeting with the Australian Medical Council about the possibility of sports medicine being assessed as a recognised specialty. This may be a cause for great celebration if it actually leads to anything, as the Australiasian College of Sports Physicians has been waiting for over 10 years to be assessed (with previous lobbying falling on deaf ears).

I am invited to the meeting, but I think I am too angry to go. Because sports medicine is NOT considered a specialty, sports physicians lose out on many benefits compared to other doctors, for example, when a sports physician orders an MRI scan Medicare will not give the patient any rebate, so the costs are a minimum $250-300 out of pocket for the patient (which is the cheapest you can usually get a scan for).

Recently a patient of mine, who I had recommended have an MRI scan months ago, but she did not go ahead and get it because of the out of pocket costs, saw some other completely irrelevant specialist at a cocktail party (gastroenterologist maybe?) who ordered the test for her. The results were pretty relevant and she is now a bit annoyed that she didn't get the scan months earlier, although she couldn't have afforded it. I feel bad that I was powerless to get her the test at a reasonable price, and that she naively thought I was the best person to see to make the diagnosis so wouldn't go and visit another so-called specialist instead, even after I explained to her how the system worked. It shows how stupid the system is that a sports physician can't order an MRI scan under Medicare for a sports injury but a gastroenterologist or psychaitrist or anaesthetist can.

If I go the meeting tomorrow, I am liable to piss off the AMC representatives by asking sarcastic questions like "who do you think can do a better examine of the shoulder joint, a qualified sports physician or a qualified gastroenterologist?". The problem is that the bureaucrats would probably take this question seriously and say, "well really we aren't sure, we haven't gone that far along the assessment process yet and we don't know the relative ability of various doctors in that area......yada yada yada.....at this stage we can't conclusively say that qualified sports physicians know anything about sport or medicine or sports injuries at all but at some stage in the future we may address this question in more detail."

The 'specialisation' assessment is a closed shop rort that is basically a deal between the government and AMA to limit government spending in return for limiting competition to those who are 'in'. I don't know that I really want to spend an afternoon listen to a bunch of liars try to pass off the specialisation 'process' as anything different. I wish they would just give the sports physicians the name of the politician we have to bribe, which types of French wine he or she likes drinking, where he or she would like the 50 cases delivered and when we will be allowed into the inner sanctum in return for lining their pockets, which is the only language they understand. The governments will continue to treat cigarette companies, for example, like royalty, because they pay mega dollars in campaign donations, but will not listen to common sense if there is nothing in for them wrt dollars or votes.

I will never say that the process for managing medical specialists is fair when certain 'specialists' can order tests in areas for which they have no knowledge, whereas others are banned from ordering tests in areas where they are very knowledgable.

[SpPT]

Yeah, I can quite understand your aggrieved stance. As a Sports Physio I prefer to send patients to Sports Physicians, who in my humble opinion and general experience, provide excellent management strategies consistent with a 'Specialist' level of expertise.

You may be banging your head against a brick wall but unless you and your colleagues keep banging away, nothing will change. Go to the meeting and say your piece - Good luck!

DPR

[Snuffy]

So did you go in and blow your top or not?

[injuryupdate]

Went and left early because it was a complete waste of time. Was promoted as a meeting as part of the specialty assessment process and in fact was an internal Australiasian College of Sports Physicians meeting with no AMC representatives present.

There was no further news to report. The AMC have not gotten back to the ACSP on when specialty assessment will occur, although when they last spoke (early 2004) it was indicated that they would consider it in 2005.

I asked one question of the ACSP President whether the ACSP was going to complain or lobby in any way in about how sports physician rebates are now clearly well lower than any other recognised doctors (including GPs). He said that he doesn't know who to lobby to (I said try the Sports Minister and Health Minister) and basically they don't want to jeopardise the specialty assessment process by lobbying. Same answer as last 10 years, same non-timetable for assessment.

I am just going to put my fees up and explain in detail in a handout to the patients that my fees are very low compared to other doctors but the gaps are very high because sports physicians are considered less important than other doctors by the government.

[Snuffy]

Sometimes it doesn't do you much good but it can feel good to have a big dummy spit at someone. Best way to do this is to head down to the Coogee Bay tonight and pull the mobile phone out later in the evening. If you want to go one step further, when you get home bash out a quick editorial or opinion piece and email that off to a journal.

By the way, who is running ACSP these days?

[injuryupdate]

David Humphries is the President. Excellent bloke and very bright. Most intelligent thing he ever did was left Sydney 12 years ago to set up as the only sports physician in Hobart. He has a three month wait to see him as he is a good clinician and basically has no competition. With demand always greater than supply, rebates don't bother him, as he just puts his fees up further and the market keeps meeting them. Hopefully more sports physicians will take the tip and move to places where demand is greater.

For me, I make enough money to be satisfied, and most of my patients are happy to cop the gap. It might be an ego thing, but I can't stand that a psychiatrist is considered expert enough to order a knee MRI scan but a sports physician isn't, and that a GP who spends 6 minutes telling the patient that he or she doesn't know what the problem is and writes out a referral to see me, in doing that will generate a higher Medicare rebate than I will in actually diagnosing the problem. Surgeons who injure patients' patellar tendons in cutting through them to perform knee arthroscopes on patellar tendinopathy (and these guys actually exist) will generate hundreds of dollars in Medicare rebates, because the system presumes that all operations are justified and they all work, whereas there is only a measely amount of rebate available for me as the tendinopathy expert to try to fix the stuff up that the surgeon was given a handsome sum to create.

[injuryupdate]

Here is a letter I sent a few weeks ago to the Sydney Morning Herald, but they didn't publish it:

Our government is constantly promoting how much it is “strengthening” the Medicare system, but does not explain why it chooses to “strengthen” some areas far more than others.

The rebate given by Medicare to patients for similar medical services, performed by different doctors, varies substantially. An initial half hour consultation for patients of a general physician or cardiologist will generate Medicare rebates of $108.85, for patients of general practitioners it is $58.55 and for those of sports physicians it is $49.80. Rebates for patients of sports physicians have been lower (or equal to) every other recognised area of medicine for the last decade.

Presumably, the government does not see sports medicine as being as important an area to support as other areas. A further example is that the government has funding programs devoted to preventing injuries in many other areas but not sports injuries.

Injury (or fear of injury) is a common reason why people don’t exercise enough, and whilst the government maintains disincentives for people to exercise, the obesity epidemic will continue unabated. Future governments will need to budget for more services in cardiology and endocrinology because of the heart attacks and diabetes caused by lack of exercise.

[hhh]

Why not just become a FRACS and go with the flow? A surfie buddy of mine once said why makes waves when you can catch one?

[injuryupdate]

Surfers tend to smoke too much dope, so they wouldn't know much about getting ahead.

Should everyone be a surgeon (FRACS)? Why have conservative management at all? Why even have physical examination? Just book everyone in for an arthroscope of the joint that is painful.

Basically this is the 'HOW TO' of the Medicare system. Their null hypothesis is that "all surgery" is beneficial to the patient so will be given a substantial Medicare rebate. Any other management (other than surgery) is "unproven" and they will assess it within 20 years or so whenever it is proposed.

[hhh]

I meant be a FRACS just so you can order your scans and charge the higher prices with a rebate included. Essenitally you just do what you are doing now but instead of calling it "sports medicine consultation" you call it "surgical consultation". It will end up paying for itself and when the patient comes along that needs surgery, that fails your conservative management, you hit the jackpot and cash in by doing the surgery as well.

Then you whinge to FRACS that ACSP are getting ripped off, lets help them out. They jump on your side and the ACSP is a winner.

[injuryupdate]

I would love to join the surgical training program but I think on my record that I once voted ALP at an election, that I don't like wearing bow ties and that I think that not all surgery works 100% of the time would preclude me from getting selected for the training program.

Plus I don't want to do a year at Wagga on call for 365 days and nights in a row.

The ACSP had Paul McCrory as President for 2 years. He has an FRACP and charges as a consultant and can order MRIs. He is also editor of the BJSM. Yet he didn't have enough pull to get the ACSP assessed by the AMC or HIC or get the RACP to offer a merger.

I think sports physicians should start charging other 'specialists' the Medicare rates for THEIR specialty when we see them (rather than bulk-billing them as is the professional courtesy).

With respect to my normal patients, I will tell them that the government is penalising them for being active, and that they will get much better funding if they sat on the couch and got fat. Then their cardiologist and diabetes specialist rebates will be much better than their sports physician rebates.

[AHP]

Stick to your guns. As an allied health professional who has had considerable, no extensive exposure to Sports docs and physio's, I empathise. My profession is also undervalued and has similar limitations placed upon it by the government in relation to medicare rebates. Stay focussed and fight the good fight. It is unjust and needs to be rectified.

Keep up the public exposure, ie letters to the editor, and the explanation to your normal patients, it is also warranted. Educate them, they'll talk to others and who knows, they may possibly lobby on your behalf. Stranger things have happened.

[injuryupdate]

The AMC, after 13 years of applications to various government departments, have actually agreed to open a file on sports medicine. I'll add extra posts as news comes to hand. In the meantime, they have called for submissions, with some of my comments below:

What % of your practice is primary care 30 (i.e. no referral). However, I specialise in muscle strains and tendinopathy and many of these patients, even if self-referred, are not seeing me as their first point of medical care.
What % of your practice is referral based 70 (i.e. 70% have a written referral from someone).
What % of your referrals are from medical sources 50 (other 50 percent from mainly sports physiotherapists, some from podiatrists and other health professionals)
Is your practice a solo or group practice Group
If group, is the group multi-disciplinary or medical only Multidisciplinary
Do you work full time or part time in your practice Part-time
What income sources do you have other than private clinical practice eg medico legal, 3rd party, team contract, surgical assisting Research consultancies from professional sports organisations (25% of workload); contract with professional football team (25% of workload); some occasional surgical assisting (5% of workload).
For a patient referred by a GP would you tend to develop a management plan for implementation by the GP or take over the primary care of the patient Always would write a letter back to the GP and would treat the GP as the primary care provider. Would provide follow-up for the particular problem that was referred but would expect the patient to return to the GP for any future problems.
Do you currently have a registrar in your practice Yes
If you become a specialist would you continue to train registrars or commence training registrars I will only continue to train registrars if sports medicine is accepted as a specialty and the government assists the ACSP and placement clinics with registrar training. It costs a large amount to train registrars, for which other recognised branches of medicine receive significant government assistance (i.e. through the public hospitals or RACGP). If the government does not feel as though sports medicine training is worth supporting, then I believe the training program should be ceased. Sports physicians should not be the only medical group in Australia funding a training program with no government assistance.
Do you anticipate any change to your referral base if you become a specialist Yes (I feel I am already practising as a specialist, but presume that the question refers to whether this is recognised).
If yes, what changes do you anticipate Will immediately move to 95-100% referral based practice. Will initially (?phasing-in period of 3 months only) accept patients without a referral but warn that they will not receive the full Medicare rebate. I would hope that common sense is applied and that sports physiotherapists will be able to refer directly to sports physicians (in the same way that optometrists can refer directly to ophthalmologists). However, if this is not the case I will ask all patients who present with a physiotherapist referral to return to their GP to get an additional referral (this would place an unnecessary time and cost burden on the patient and cost burden on the Medicare system, but if that is the way the HIC wants it I would comply). If physiotherapists are able to refer directly to sports physicians, then I would always cc the patient’s GP in my letter back to the physiotherapist.
How would your practice change over the next 5-10 years if specialist recognition is not achieved
I may retire completely from private practice (as some of my colleagues have done) as there is sufficient non-Medicare work available which pays a much better effective hourly rate, or I may emigrate to a country where sports physicians are welcomed and treated as legitimate members of the medical community (as some of my colleagues have already done). If I was still in practice, I would cease taking on registrars and would expect the ACSP to wind down the training program. I would not be happy to contribute Fellowship fees to prop up a training program that was being shunned by the government. If our government doesn’t want sports medicine as part of the medical landscape, then those of us still in practice can gradually die out as we retire, with no need to replace us. It is possible that the various government departments have a long term plan that sport should only be played by elite athletes and not members of the community, and if that is the case, I can understand why they would expect sports medicine to be completely divorced from the Medicare system. There would obviously be a much greater need for training positions in cardiology, endocrinology and oncology due to the lack of activity, and medical students could be encouraged into these areas of need rather than sports medicine.
How would your practice change over the next 5-10 years if specialist recognition is achieved
I would expect that I would generate greater referrals from GPs as those GPs who currently avoid sports physician referral due to its lack of government recognition may lose their prejudices. Also, patients would be far more able to afford my fees with the rebate levels getting closer to the charges (which are currently similar to what other doctors charge, but with a currently huge ‘gap’ as sports medicine has lower rebates than all other areas of medicine). Therefore GPs who currently do not refer health care card holders, pensioners and students to sports physicians because these patients can’t afford the fees may be happy to start referring their disadvantaged patients on. This projected increase in referrals presumes that current levels of sports participation don’t drop even further, which they are in danger of doing given current government attitudes towards both sport and sports medicine. Specialist recognition of sports medicine may be one of the government’s first active policies to resist the trend towards inactivity in our community.
Please add anything you think may be relevant to this data collection process that hasn’t been asked
(1) New Zealand has a much better system of approach to sports injuries than Australia, in that all sports injuries have data collected regarding their occurrence. Therefore trends in sports injury rates can be noted and prevention measures can be incorporated by the ACC (Accident Compensation Corporation), which is the relevant department in New Zealand that incidentally has no equivalent in Australia. Even if sports physicians achieve specialty recognition in Australia, it will assist with improving the standard of treatment available to sports injuries, but will probably not help with respect to prevention. The fact that there is no Federal government department (in Australia) with a declared interest in sports injury prevention is an indicator of how far behind other countries we have fallen in our approach to sports injuries.
(2) It is a disgrace that after 13 years of the ACSP attempting to submit an application for specialty recognition that this is the first occasion in which someone from the appropriate department has actually made a step towards consideration of such an application. It is not necessarily the fault of the current administrators in charge of this process, but those who collectively are at fault can claim a slice of the blame as to why sports and exercise participation levels in our community have dropped so much over the past decade.

[injuryupdate]

The mood at the ACSP AGM was one of optimism as the AMC have actually looked at the application (although they haven't given any verdict and won't for at least 18 months). I wanted to put these motions but couldn't as I hadn't given 28 days notice.

Planned motions for the 2005 ACSP AGM (that didn't get put):

Preamble – the purpose of these motions is not to institute a sudden move towards militancy but to gradually increase the pressure we apply to organisations which have snubbed us over the years. It is appreciated that the optimists have good grounds for saying that we have made recent progress towards due recognition (and that we should not unduly annoy those bodies whose support we seek), but it must also be recognised that the pessimists (and realists) can point out that nothing concrete has changed in our status in the last five years. A good middle ground strategy should be that if quick progress is made in the next couple of years, we need not take any major action. If not, sterner action would be warranted, particularly if this was flagged in advance to the relevant bodies.

Motion 1 – That if in the AMA November 2006 schedule of recommended fees, the recommended value of sports physician fees is still far lower than those doctors to whom we are most similar (occupational physicians, rehabilitation physicians, rheumatologists) that the ACSP executive should recommend to its Australian members that they do not retain AMA membership. Proposed: J. Orchard, Seconded: M. Jamieson

Motion 2 - That if by January 2007 the Health Insurance Commission does not recognise sports physicians as specialists or consultants, that the ACSP executive should recommend to its Fellows that they do not serve on the Australian Sports Drug Medical Advisory Committee (ASDMAC). Proposed: J. Orchard, Seconded: M. Jamieson

Motion 3 – That if by January 2008 the Australian Federal government has not:

(1) instituted payments for practices to take registrars (at a similar level to the subsidy received to take registrars of the RACGP) and
(2) guaranteed permanent provider numbers for registrars and Fellows and
(3) maintained at least Medicare rebate parity for sports medicine registrars with registrars of the RACGP;

that the ACSP executive should recommend that only one new trainee be accepted in Australia each year. Proposed: J. Orchard, Seconded: K. Boundy

Notes on these motions:

(1) The AMA has claimed informally to some of our Fellows that it supports specialty recognition of sports and exercise medicine, yet it recommends that sports physicians charge the same fees as GPs, even when consulting on a referral basis. In NSW, the AMA sets de facto upper limits for charges under Workcover, due to a deal between Workcover and the AMA. In some ways this is an even greater issue than low Medicare rebates, as there is no facility for a sports physician to charge a higher fee under Workcover than that prescribed (indirectly by the AMA). Motion one, if passed, would not prevent an ACSP member from being a member of the AMA, but it would let the AMA know that we reject the notion that they support the concept of sports physicians as specialists and that we therefore cannot recommend their membership to our members.

(2) ASDMAC is probably the only body whose panel members literally would be irreplaceable by non-sports physicians. Again this motion would not force ASDMAC panel members to resign on January 1 2007, but the members could pass on this motion to their bosses in the sports ministry, to let them know how strongly sports physicians feel about the lack of support that the sports minister has afforded us within the government ranks. It is the height of government hypocrisy that there is an important bureaucratic specialist panel completely comprised of ‘non-specialists’, and that the same government which for years has appreciated a need for specialist knowledge in sports medicine to staff the ASDMAC panel does not see a pressing need for specialist sports medicine knowledge in the wider community.

(3) Currently the RACGP (with direct government funding) gives practices who take on a registrar a payment in the order $60,000 annually for training of the registrar. Almost all other specialties are trained in hospitals, with the salary of the trainee and teaching staff all paid for completely by the various state governments. The ACSP is the only training program which exists without direct government financial support. It should not be the responsibility of Fellows of the ACSP to pay large annual fees to support the infrastructure of a training program, when all other training programs are directly subsidised by the government. By taking one registrar nationally, it could not be argued that our training program has ceased, and therefore we would not jeopardise our specialty status assessment. This motion does potentially penalise those current medical students who would be interested in sports medicine and who may find it extremely difficult to obtain training with such a restriction. However, those registrars who currently join the program get a vastly substandard deal. There is no incentive for their practice principals to teach them, as the teaching work is unpaid; they have no guarantee of a long-term provider number under legislation which says they do not warrant one; and their patients must accept Medicare rebates which are insulting (and which are dropping in real terms every year, due to the government policy of not indexing them). If we do nothing indefinitely and continue to run a full training program at our own cost, there is no incentive for the government to ever agree to fund it. It may only be when there were complaints to the government (e.g. by sporting bodies who need team doctors) that there was a vast shortage of sports physicians, that the government would feel a need to fund the training program.

[injuryupdate]

ACSP has made a submission to the AMC but as at Nov 21, 2005, nothing has been made of it on the AMC website:

http://www.amc.org.au/submissions.asp

The general mood at the sports physicians' conference was enjoyment of the continued process of being bent over by the Health Dept. ACSP hacks were ecstatic that Tony Abbott has actually replied to some letters, but 15 years after first applying to be specialists and there hasn't been a formal acknowledgment that we are under consideration.

[injuryupdate]

NB AMC just updated their website and has still made no mention of the sports medicine application (even though it was originally submitted in 1993).

Some things work slowly when you are "not a priority area".

http://www.amc.org.au/submissions.asp

[Unregistered]

Responses for the specialty recognition process for ACSP are now available at:

http://www.amc.org.au/forms/Recognition/sem/responses.asp

[Nicholas]

Is this the only time that this has happened? :o