Broken public health appointment system part 3

[cimorene]

In Non-functional public health appointments, part 2, we heard that when I called on the one day (out of 2 weeks) when you can book appointments with an MD, the appointments were all filled well before the end of the day and they told me to call back in 2 weeks as early as possible.

So that was Monday, and I called at 8:05 (5 minutes after opening) and put my message in their automatic callback queue. I didn't get called until after 11:00 and I could hear the receptionist's voice trembling with stress as she tried to gently and politely apologize because "It was so good that you called at eight, but unfortunately all the doctor slots were already full again!"

She asked again how soon I will run out of meds, and since I will not run out in the next two weeks, she told me to try calling back at eight am again on December first.

!!!!!!!

"Really really sorry, it's so unfortunate."

"Well, it's not your fault, I know," I said.

"Even so... yeah."

So. Two weeks. If I call at 8 on the dot, maybe I'll be early enough in the queue... or maybe I can't get an appointment until I'm about to run out and they therefore have to promote me to the 'urgent' (or semi-urgent) queue.

Wow... I'm so mad about this!!!!!!!!!!!!!!!!!!!

Remember that this was actually my third call because the first time I didn't call on the Appointment Day at all and had to be redirected (but unfortunately, even though she said they might fill up, I didn't realize it was like, CALL WITHIN FIVE MINUTES).

Comments

[princessofgeeks]

This is so stupid!

So sorry you have to go through this.

[cimorene]

It's such a waste of both my time and the nurses' who have to work in bookings!

And this is all because my medication came with a printed note that I HAD to book a time with an MD to check on the prescription: it wasn't my idea! It didn't say "But don't call until your medication has already run out, otherwise it isn't urgent enough to waste a doctor's time"!

[princessofgeeks]

Well, you shouldn't have to wait till you run out! That defeats the purpose!

I am cheering for you. So very stupid. Like, USA Healthcare levels of stupid and that's saying a lot.

[lilysea]

This is such a messed up system!

What if someone is working/driving to work at 8am on appointment day?

or driving their kids to school?

or has a migraine?

[cimorene]

Right? They've basically made it so the only times you can see an MD are when your need is already urgent! I assume there is a secret other way, if you are referred by a different practitioner from their system, so maybe you could go to a nurse first, and then the nurse could just refer you to a doctor maybe? But idk maybe they have to call in the first four minutes of the one day every two weeks as well!

It isn't quite as bad as totally eliminating non-urgent care (because you can still see a nurse practitioner), but it's... pretty close. And like, you don't even really have to enumerate what a dumb idea that is! And all the people working there must be miserable about it. After all, it's such hard work to be a nurse or doctor, and if they are working in public health that usually means they deliberately chose not to go private and make more money.

[lilysea]

Plus it's pennywise and pound foolish -

people who can't get in with their Dr for cholesterol or diabetes management

are going to end up costing the health system avoidable open heart surgery and amputations. :(

[cimorene]

EXACTLY!!! A system cut back so that it only has enough resources to go like 10% beyond covering emergencies is a system that is basically DESIGNED TO escalate all problems into emergencies in the hope that some of them will solve themselves first; that also means that, of the ones that do needlessly turn into emergencies instead of going away, by definition 100% are at greater risk, most will cost more to fix, and they're almost guaranteed to be causing excess deaths.

[lilysea]

Back when I worked for the Australian government in health policy (2003-2010ish)

the holy grail was spending more on GP consults and less on surgery/dialysis.

SO MUCH TALK about how $1 upstream saved $1000 or $10,000 downstream.

[cimorene]

I know the penny-pushers are pushing hard to have more people get advice over phone or chat or appointments with nurse practitioners, which isn't a bad idea at all as far as it goes, and probably really will save money. I wonder if this pressure is a side-effect of their attempt to force people who ask to see a doctor and don't really need to into those channels somehow? And of course it would be a badly-designed system for that purpose, given that I was ordered BY THEM to only see a GP, but they always have badly-designed systems, so that wouldn't be a surprise at all.

[lilysea]

Man, I know so many chronically ill/Disabled folk who would LOVE to be able to get advice over phone or chat without having to pay out of pocket.

Here, there is no rebate for telehealth unless you've seen that exact Dr face to face in the last 12 months.

There USED TO BE a rebate for telehealth [even if you hadn't seen a doctor face to face in the past 12 months] - they brought in the telehealth rebate in 2020 in response to COVID, kept it in 2021 and part of 2022, but then cancelled it in late 2022.

There is a Health Direct nurse hotline, but they're pretty useless - they're just there to triage your symptoms through a premade flowchart software and tell you
a) call an ambulance; or
b) go to the emergency room; or
c) go to the Dr within 24 hours; or
d) go to the Dr within 48 hours; or
e) go to the Dr within 72 hours; or
f) go to the Dr within 7 days.

They've basically been funded to try to divert non-emergencies from the emergency room.

[cimorene]

Yikes! I have heard that at least some people think the nurse advice chats are working pretty well for people here. They do sometimes just tell you to see a doctor as well though. But they are free! I'm not sure how video chat appointments work in public healthcare here though, but I know they will do phone appointments. For example when my regular GP gave me sick leave and said that if it needed to be extended they could do a phone appointment with a different dr because she was off the rest of the week. I called and told the booking nurse that and she told me another doctor would call me within a certain number of hours and we spoke for about five minutes and then he wrote the extension.

[lilysea]

In Australia you can call whenever and get an appointment usually within 7 days (or for emergencies often the same-day), but the catch is

that unless you're under 16 or on the disability pension or on the aged pension

there will be an out of pocket cost of around $30, $40, $50

most surgeries require payment of the full amount (eg $60, $70, $80, $90) up front and then you get 50% or 60% or 70% back from Medicare deposited electronically into your bank account within 24 to 48 hours.

The upfront payment, and the gap between the fee and the rebate

are resulting in less people in Australia going to GPs and more people fronting up to emergency rooms.

It's less of a problem in Australia than in the US,

but in Australia you do still get families rocking up to the emergency room because eg they need a script for an asthma inhaler and they can't afford the out of pocket fee.

The government has done a whole bunch of financial incentives for more bulkbilling (free to patients) Dr appointments, but most Drs don't feel incentivised.

[cimorene]

Wow. Well, that does still sound pretty messed up! There are times when you have to pay for health center services, but it's not all of them and I think it's usually 28€ and under.

I have been through a number of appointments before without having this level of difficulty, but I've also never had a situation where I had to call without a referral and NEEDED to see an MD and not a nurse practitioner, so I don't know if the wait time has actually increased as much as it feels like. Maybe it always took about a month if you just needed a routine checkup of your medications, but it's just more hassle now that they won't book more than two weeks in advance. If they'd just taken my name and issued an appointment three months off the first time I called they could've saved everybody a lot of time.

[lilysea]

Yeah, the system in Australia def has problems too!

In the UK the problems are around if you move, it's very hard to get a new Dr's practice to accept you (a lot aren't taking new patients), and also you can't stay with your old Dr even if you've only moved a short way if you've moved out-of-catchment-area, and also it's hard to get an appt - you have to ring up 8am Monday for a Monday appt, 8am Tuesday for a Tuesday appt, no booking ahead of time. But the appointments are free, just hard to get.

In Australia the problems are around

a) upfront costs

b) out of pocket costs

c) a lot of outer suburban, regional, rural and remote areas don't have enough GPs. GPs can go where they want, and where they want to go is often where they can make the most money and/or have the most nice things like theatres and cinemas and restaurants and beaches.

d) A country town might have one Dr effectively on call 7 days a week, 365 days a year. (because regardless of "official" working hours, what Dr is going to refuse a stroke/a heart attack/broken leg on a Saturday or a Sunday?)

There have been lots of stories in the news where a Dr asked the town to pay a few thousand dollars for a locum (temporary doctor) to cover the surgery so he could have a holiday for the first time in 10 years, the town said "no that's too expensive"

so the Dr retired and quit

and now the town has zero doctors

[cimorene]

Wow... well, all of those things make this system look better overall. Except for the amount of work in actually getting the appointment right now. This is a regional issue: there was a reform about two years ago where to save money they took responsibility for their healthcare services from the municipalities and created a new organ for each region/sort of like provinces which has a little board and is responsible for all the healthcare in that region. It was done to save money and everything immediately got worse overall of course like closing day centers for seniors and reducing support in full service retirement homes. But the actual health center and appointments stayed pretty much the same until this recent disaster.

It seems to be partly because of shortage of GPs, and partly their queue systems, but also that my medication is classed as psychiatric. The division that handles psychiatric medication has stricter rules so they can't just book any gp and the doctors in the department are, I guess, even more short-staffed. Once you have seen a doctor about mental health they can continue to check on you with regular phone calls or you can see a psychiatric nurse instead, but you have to actually have seen the doctor first before those easier methods can begin.

[lilysea]

In Australia, there are no public GPs - all GPs are private -

but some GPs bulk-bill (bill the government with no cost to the patient) people under 16 and/or disability pensioners and/or aged pensioners

and some GPs bilk-bill every patient (this is A LOT rarer than it used to be in the 1990s or 2000s).

But the decision to bulkbill a patient is up to the individual Dr, and they can change their mind anytime.

[cimorene]

Oh wow, interesting! I had never heard of that before.

[lilysea]

Yes, bulk-billing means the Dr accepts the Medicare rebate (which is set by the Australian Federal government) plus the bulk-billing incentive payment(s) as payment in full.

The alternative is private billing - a Dr can charge whatever they like, $1 or $1000, but the patient will get the exact same rebate back from Medicare whatever they charge (Medicare rebates are based on the length/complexity of the appointment, not the fee).

There was a big scandal recently when one medical practice was caught charging patients $300 per year to bulk bill them for that calendar year, which is highly illegal - bulk billing means you can't charge one extra cent for that appointment.

It's perfectly legal to bulk bill short appointments but private bill long appointments, or vice versa - but an appointment that IS bulkbilled can't attract any other fees.

(also, in Australia Medicare is for every single Australian citizen/permanent resident, it's not like in the US where Medicare is only for certain low income groups)