Professional Services Review: the audit process we have to have

Our health system places great responsibility on doctors to act in the best interests of patients, and in the interests of the system itself. Laws and regulation apart, the system functions well primarily because practitioners act ethically and fairly. In return, society accords doctors considerable trust, respect and financial reward. There is no question that any abuses of this trust that occur need to be stopped.

The Professional Services Review (PSR) scheme was established in 1994 to safeguard the integrity of Medicare and the Pharmaceutical Benefits Scheme by providing, according to the PSR website, “an effective peer review mechanism to deal quickly and fairly with concerns about inappropriate practice” (http://www.psr.gov.au/aboutpsr/history.asp).

One of last year’s most controversial topics was that of the role and behaviour of the PSR. Despite a recent Pricewaterhouse Coopers draft report recommending substantial changes to the PSR, significant issues remain to be discussed (The Australian 2011; 28 Dec). In this issue we feature lively opinion pieces by two key players — Tony Webber (doi: 10.5694/mja11.11431), recently retired director of the PSR, and Scott Masters (doi: 10.5694/mja11.11560), a vocal critic of the PSR and a doctor who has himself been investigated by the PSR. Ray Moynihan (doi: 10.5694/mja11.11524) adds fuel to the fire, looking at the difficulties the PSR faces when investigating large medical corporations, an issue which was flagged by Webber at the 2011 Senate inquiry into the PSR scheme.

“Quickly and fairly” are at the heart of the current dispute. Critics say that there is a lack of due process, and that it often takes years for the PSR to complete its investigations, resulting in enormous stress and financial loss for the practitioner involved.

I think we should applaud Webber for his willingness to tell us an insider’s view. Whether one agrees with him or not, there is always a personal cost to the “whistleblower”. He is frustrated by the lack of audit and oversight of the huge public expenditure on health, and by Medicare’s failure to adapt to the pursuit of profit in medicine. He highlights the poor sense in a system that remunerates doctors for completing paperwork for a convoluted referral system instead of enabling them to refer directly to allied health providers. He notes that rebates for Medicare Benefits Schedule (MBS) items need to be constantly reviewed in the context of improved efficiencies and the adoption of new technologies.

Webber is scathing of the design of the “safety net”, which he feels is open to easy exploitation by avaricious practitioners, and of cost-shifting by state health entities, in violation of the Council of Australian Governments National Health Care Agreements.

Masters, on the other hand, argues that Medicare’s screening procedures for identifying doctors who will be reviewed by the PSR are blunt instruments that are unable to differentiate the bad from the busy. There is certainly support for this view, especially among doctors who work in poorly resourced settings. He articulates the problem of vaguely defined MBS item numbers that increase the vulnerability of practitioners to unknowingly misuse them. He is angry at what he sees as the lack of transparency in PSR processes and heavy-handedness of the organisation.

The PSR is part of the audit process in our health system, which should reassure taxpayers that their money has been well spent. It is, in reality, a “defence” for honest and ethical doctors. The current debate is about process. A clear definition is needed of what data will be examined, along with the development and application of a transparent, respectful and efficient process of review.