Panel Newsletter, June 2019
Case Outcomes for 2019
With a short time remaining in the financial year, PSR’s anticipated outcomes for the year are:
- 98+ requests to review received from the Chief Executive Medicare
- 90 ratified and effective s 92 agreements
- 8 effective final determinations
- 2+ ‘no further action’ outcomes
- $29,196,200 in repayment directions arising from the resolved matters
- 68 resolved matters involving a partial or total disqualification from Medicare
Members are reminded that case outcomes are posted on the PSR website on a monthly basis. See https://www.psr.gov.au/publications-and-resources/case-outcomes.
New appointments to the PSR panel in 2019
On 25 January 2019, the following appointments were made up to and including 29 May 2022:
- Dr Nicole Soo Len Goh, respiratory and sleep medicine physician
- Dr Caroline Luke, general practitioner
- Dr Emma Palfreyman, haematologist
- Dr Alison Garvin, obstetrician and gynaecologist
- Dr Pathma Edge, obstetrician and gynaecologist
- Dr Wayne Minter, chiropractor (also appointed as a Deputy Director)
- Dr Michael Badham, chiropractor
- Dr Robert Bailey, chiropractor
- Dr Mark McEwan, chiropractor
On 5 March 2019, the following appointments were made up to and including 31 March 2024.
- Professor Peter Hewett, general surgeon
- Professor John Thompson, general surgeon (also appointed as a Deputy Director)
- Dr Weng Soon Chin, respiratory and sleep medicine physician
- Dr Yan Chow, physician
- Dr Mona Marabani, physician
- Dr Susanna Proudman, physician
- Dr Richard Widmer, paediatric dentist
- Dr Rachel Christmas, general practitioner
On 2 May 2019, the following appointment was made up to and including 31 March 2024.
- Dr Caroline Wright, a general surgeon.
PSR has been advised that the Department of Health is systematically auditing the various medical specialty groups. As PSR receives referrals in new disciplines, it will be necessary to appoint specialists in those disciplines onto the PSR Panel.
I am currently interested in appointing two oncologists and two endocrinologists to the PSR Panel. I will also require one oncology reviewer to assist me at the Director’s stage of the PSR process. Closing dates for applications in these disciplines is Friday 26 July 2019.
Training days
Training days for established PSR Panel members were held on 4 and 11 May 2019. Training topics included an update on PSR regulations, recent case law, the GovTEAMS platform and changes to the Public Interest Disclosure Scheme. Slides will be made available to members via a shared GovTEAMS community. To gain access, please email zac.pagan@psr.gov.au.
Delays in securing random samples of records
PSR relies on securing a random sample of records from which it can extrapolate findings across a full year. In the past the random sample was identified by the Department of Human Services. However, this year this duty was transferred to the Department of Health. Unfortunately the preparation for the transfer disrupted data acquisition, resulting in significant delays. A process that previously took only two weeks took in excess of three months. Given Director’s stage reviews have a maximum statutory time frame of only 12 months, the delays resulted in consequential time limitations in other aspects of the Director’s reviews.
Random samples in corporate referrals
PSR has sought advice from an Australian expert in statistical sampling to determine the optimal way to sample data to secure a random sample suitable for extrapolation in the case of an employer or corporate Committee where multiple practitioners might provide services. PSR agreed to adopt the advice in the expert report and Committees established to review corporate or employer cases will be able to utilise the recommended sampling methodology.
Security issues and GovTEAMS
PSR is committed to protecting the personal data that it holds and transmits in the course of fulfilling its statutory functions. PSR is required to comply with the requirements of Privacy Act 1988, the secrecy provisions of the Health Insurance Act 1973, and the Australian Government’s Protective Security Policy Framework.
The risk of a data-breach is a significant matter of concern to PSR. In the past, we have sent documents by encrypted USB storage devices by courier services, or as password-protected documents within e- mails. While PSR is confident that these methods have been effective, every system has its risks, and the risk of a data-breach through the on-going use of these methods is not one that PSR can continue to bear given that there are more secure and efficient alternatives available.
Consequently, PSR now uses a secure online workspace called GovTEAMS, which is administered by the Department of Finance, to share documents with members of PSR Committees and the Determining Authority. When PSR Panel members are appointed to a Committee, a specific community will be set-up within GovTEAMS for that Committee, enabling more efficient collaboration in the writing of Draft and Final Reports and for the discussion of issues.
Anything written within a Committee GovTEAMS community in relation to the Committee’s deliberations can be viewed only by the members of that Committee and the PSR staff allocated to that Committee, and has the legal protection of sections 106F and 106ZR of the Health Insurance Act 1973.
GovTEAMS is not available for use by persons under review or their legal advisers, but PSR is continuing to consider the best approaches to security of personal information in meeting its statutory obligations and procedural fairness requirements when providing information to persons under review.
The latest research relevant to PSR
Routine ECG in health assessments
Screening for atrial fibrillation in the population by ECGs has been shown to be unhelpful as a routine investigation (Myerburg JAMA 2018;319:2277-8). The finding has been adopted by the US Preventative Services Task Force (JAMA 2018;319:478-8a).
Prostate specific antigen
Recent research validates the conclusion that prostate specific antigen (PSA) should not be used as a screening tool. Men who are screened end up being diagnosed with, and treated for, a malignancy that would never have affected their wellbeing (Journal article summary service, December 2018). Morbidity is significantly increased in screened men, and there is no benefit in mortality. Another large study supports this conclusion. A trial involving 400 000 English men found no significant difference in mortality between those screened or not screened. An expert group which considered all published evidence in relation to PSA advised against screening and further recommended that primary healthcare providers should not raise the issue of PSA measurement in routine consultations (Tikkinen et al BMJ 2018; 361:k3581).
Topical treatments for skin lesions
The Cancer Council have published a number of alternative treatments, other than excision, for the effective treatment of some skin cancers. As part of informed consent, medical practitioners should ensure patients receive information about reasonable treatment alternatives. This is especially the case when excisional treatments affect cosmetic appearance or might involve a need for secondary surgical procedures such as skin grafts or advancement flaps.
Failure to secure informed consent might be a concern that leads to a finding by a Committee of peers that there was inappropriate conduct in connection with the rendering of a service.
Therapies mentioned by the Cancer Council include:
Immunotherapy
Sunspots, superficial BCCs and squamous cell carcinoma in situ (Bowen disease) can be treated using a cream called imiquimod, that is applied directly to the affected area once a day at night, usually five days a week for six weeks. Side effects include scabbing, crusting, redness, local inflammation and tenderness.
Serious reactions are rare. The side effect profile compares favourably against excision, and avoids long term scarring.
Chemotherapy
There are two commonly used topical chemotherapy therapies for skin cancer. These are 5-fluorouracil (5- FU) and Ingenol mebutate.
5FU cream can be used to treat superficial BCCs, sunspots and some cases of squamous cell carcinoma in situ (Bowen disease). It works best on the face and scalp. The cream is applied twice a day for three to four weeks. During therapy, the skin is more photosensitive and patients should stay out of the sun. The treated skin may become red, peel and feel uncomfortable. Side effects usually settle within a few weeks after cessation of therapy.
Ingenol mebutate is a topical gel applied once a day for two or three days. Side effects can include skin reddening, flaking or scaling. Side effects usually resolve within a couple of weeks of completing treatment.
The side effect profiles of both therapies compare favourably against excision, and avoid long term scarring. For more information see the Cancer Council. Topical treatment for skin cancer. Accessed on 7 May 2019 at: https://www.cancercouncil.com.au/skin-cancer/treatment/topical-treatments/
Antibiotics
A number of practitioners under review have had antibiotic prescribing listed as an area of concern. The most common item of concern is Amoxicillin + Clavulanic Acid (PBS item 8254K).
Widespread inappropriate use of antibiotics contributes to antibiotic resistance in the community. The Third Annual Surveillance Report on antibiotic use in Australia has found a rise in antibiotic resistance. More than 26 million prescriptions for antibiotics were issued in 2017. It is important that antibiotics are only issued where there is clear evidence of a bacterial infection. If indicated, the narrowest spectrum, lowest tier antibiotic should be administered.
The good news in the latest report is that antibiotic prescribing by medical practitioners has started to fall. This is because medical practitioners appear to have accepted the message that before prescribing an antibiotic they should assess the patient to determine if an antibiotic is clinically indicated.
Non contemporaneous records
A number of practitioners have provided non contemporaneous records to the PSR and failed to disclose this. It may be an offence under the Health Insurance Act 1973 and also the Criminal Code Act 1995 (s137.1) to provide false or misleading information or documents to a Commonwealth entity.
Practitioners should seek legal advice if they are in doubt when asked to produce documents to the Professional Services Review.
PSR Committees need to be mindful of whether records were contemporaneous.
And finally congratulations….
Professor Alan Cooper OAM, Deputy Director, Professional Services Review Panel, was awarded a Member of the Order of Australia (AM) for significant service to medicine as a dermatologist and researcher. Alan has been the head of the Department of Dermatology, Royal North Shore Hospital since 1999 and is the Clinical Professor, Northern Clinical School, Sydney Medical School, University of Sydney.
Dr Jennifer Kendrick, Member, Professional Services Review Panel, was awarded a Member of the Order of Australia (AM) for significant service to medicine, and to medical education and standards.
Jennifer is a council member of the Medical Council of New South Wales since 2015 and Director, Prevocational Education and Training, Hornsby Kuring-gai Hospital since 2018.