The perils of the accidental doctor-hopper

Patients double-enrolling with GPs are creating a glitch in the new Primary Health Organisation system, reports MARTIN JOHNSTON


After a feed of seafood at the wedding, Joseph started suffering gout, so the host took him to her own doctor. Joseph's own GP clinic was open, but farther away. A heart and diabetes patient, Joseph - not his real name - failed to tell the new doctor about his blood-thinning medicine and received a prescription for a conflicting drug, Voltaren anti-inflammatory painkillers.

"When he walked in there," says Joseph's original GP, Dr Gary Sinclair, "someone said the fee was $15 if he enrolled and $45 if he was casual. "As the patient told me: 'I had $20 and a sore foot, what should I do? So I paid $15 and was enrolled'."

Joseph, like many of us, hadn't grasped the meaning of enrolling with a Primary Health Organisation, or even what a PHO is. Even fewer would realise the clinical and financial problems their "doctor shopping" can cause.

Yet the Prime Minister last week described the rolling out of PHOs as one of the most thrilling developments of her time in office, and we are apparently expected to know all about them.

Formed since July last year, PHOs are the Government's controversial prescription for spending more primary healthcare cash - about $200 million extra a year by 2004-5 - to reduce fees for many, cut hospital admissions and improve the nation's health by earlier intervention.

In areas of poverty and higher Maori and Pacific population, PHOs - and some individual clinics - are being given more state cash for every patient. This allows lower fees for all enrolled patients, even wealthy ones. The Government says all other PHOs will be funded at this level eventually.

In the taxpayer-funding pyramid, the new organisations sit below the state's district health boards and above individual GPs and groups of doctors, nurses, community health workers and other staff. Joining is voluntary for the providers.

They provide an expanding role for nurses who work in teams with GPs and community workers to run chronic disease management schemes like diabetes clinics.

These schemes have been shown to help control diabetes and to reduce cholesterol, blood pressure, smoking - and hospital use.

Around $30 million of the new money this year is going into services designed to expand healthcare access for high-need groups.

In many areas, such as Otara, this translates into community health workers going to patients' homes to help with anything from medication to home insulation.

Joseph likes the lower fees enrolling in a PHO can offer. At home after the wedding, he accidentally cut his hand. His daughter took him to clinic number three. Faced with fees of $50 or $20, he picked $20 and enrolled.

The doctor stitched up his hand and, realising the bleeding was heavy, ascertained that Joseph was on blood-thinning Warfarin. Joseph added that he had gout and the Voltaren was not working.

The doctor replaced the Voltaren with a prescription for Prednisone, a corticosteroid drug which is appropriate with Warfarin, but not for diabetics. He did not know Joseph has diabetes.

Sinclair, of Mangere Family Doctors, says that three or four days later, Joseph arrived at his clinic in a diabetic crisis.

"He was in shock and nearly dead. We did resuscitation on him for an hour and sent him to Middlemore Hospital. He survived."

Sinclair says this case shows the serious financial and clinical risks created by funding clinics based on how many patients they have enrolled, the PHO system of "capitation".

"The ethical rule is that if you see a casual patient you send the notes back to the [home] GP. Neither did. They were entitled to think the patient was their patient because he was enrolled with them.

"At the end of the month we got a $30 deduction off our capitation, $15 for each of the two visits elsewhere, then two transfer-out letters telling us he was enrolled and to send his notes there. I sent the notes to both.

"Then the guy came to see me for his quarterly free diabetic check. I said, 'You're not enrolled here'. He said, 'You're my doctor. I've been here for nine years'.

"He's now re-enrolled with us and having to pay casual payments because his capitation has gone for three months to one of the others. We can't afford to waive that like some practices do."

Stories like Joseph's abound, especially in South Auckland, where many people float between GPs and where some people put off seeking medical help for financial reasons until they are seriously sick and end up at Middlemore's free emergency department.

Nationally, 8.6 per cent of enrolments are of patients who have signed up at, or without realising it, been registered on the books of, two or more PHOs. Worst is the Counties Manukau health district at 13.6 per cent.

The Health Ministry encourages staying with one PHO and clinic long-term, saying that it helps to ensure children's vaccination courses are completed and improves management of chronic conditions like asthma. Yet it remains only a guideline.

T HE ministry has applied a range of financial and computer-system bandages to tighten the rules and help PHOs that are bleeding money because of floaters. Half the population, more than 2 million people, belong to one of the 53 PHOs. Just under 1 million are in those that can offer lower fees because they are on the "access" funding scheme and receive extra state cash. The rest are on an interim formula which means fees remain higher for many, except children.

For the patient, enrolment is voluntary but you are only supposed to be a member of one PHO at a time. You can enrol children aged 16 or younger who are under your care.

Many people may not realise that they are, in effect, already enrolled. Those on the books of clinics that join a PHO are deemed to be enrolled until their next visit, when they are supposed to be asked whether or not they wish to sign up. If they enrol at another PHO's clinic, it will start receiving the state funding instead.

Enrolment involves signing a form. Among the questions are a request for consent to transfer any records from your existing GP. Giving consent is not a condition of enrolment, but the PHO is obliged to ask.

Fees at access PHOs range from free to $22. They are usually free for under-6s, $10-$15 for 6 to 17-year-olds, and $15-$22 for adults.

At interim-funded PHOs, adults still need a community services card to obtain subsidised care. Daytime fees can commonly be $30 to $40.

Those without a card can expect to pay the same as they would outside PHOs: often $45 to $55 for a day-time consultation, and more at night and weekends.

Care for under-6s is free or cheap at many practices, PHO-linked or not, although dearer after hours - $18 at one. Last month, subsidies for school children at interim PHOs were increased to reduce their fees. The date for extra money to reduce fees for over-64s has yo-yoed and is now promised next July.

At pharmacies, most adult patients now pay a $15 "prescription charge" (plus fees for some drugs) or $3 with a community services card. The charges for children and high users are from free to $10.

The prescription charge will be capped at $3 next April for all PHO enrollees entitled to low-cost care.

Gripes over tracking patients and double enrolments are not the least of GPs' and Opposition parties' complaints about PHOs.

The additional taxpayer cash has been welcomed, but many say the extra services could easily be delivered without setting up a costly new layer of bureaucracy.

Some GPs wonder why the ministry has not carried out a major publicity campaign to rectify patients' ignorance of PHOs. The ministry says it will run such a campaign next year. Spokesman Dr Jim Primrose says having it last year when relatively few people were enrolled would have been pointless.

Clinics on the higher-fees side of the funding fence report that the two-tier set-up has undermined the continuity-of-care concept, luring long-term patients away to cheaper practices.

Frequent objections have been made against the state subsidising wealthy people's doctor visits in poor areas, while the poor in average or better-off areas have to pay more.

Partly to blunt this complaint, the ministry is testing a scheme that allows lower fees for individuals in poor health who need extra help from a GP clinic.

But Primrose says PHOs are a better way of targeting money than the community services card and the public is comfortable with other services, such as laboratory tests, being free to all regardless of wealth or poverty.

He suggests that one of primary healthcare's core problems, that PHOs are designed to help fix, is the skewed spread of GPs. Wealthy suburbs like Remuera attract more GPs per head of population - as they can charge higher fees - yet residents of these areas tend to need less healthcare than those in poor suburbs.

Independent Practitioners Association chairman Dr Paul McCormack says if doctors shift, it may be overseas, because of the financial uncertainty faced by many GPs here.

Three-quarters of PHOs so far are in the upper North Island, and the South Island has few. Primrose says this is because the upper North Island has many more areas of greater poverty and Maori and Pacific population.

Neil Woodhams, chief executive of South Auckland-based access PHO Te Kupenga O Hoturoa, says some clinics did not reduce their fees on joining as they were already low. Some patients paid nothing.

He says the extra money for access PHOs was insufficient to deal with the far higher needs in concentrated pockets of poor Maori and Pacific communities.

Meanwhile Gary Sinclair has his eyes set on January 1 to see what happens about Joseph. Until then, he will be charged $35 a visit as a casual patient, instead of the $15 levied on adult enrollees.

"Then we will find out whether or not he gets enrolled somewhere else over Christmas."