I want to tell you about the evolution of medical pathology in Australia over the last 15 years - what it is, what was expected, what has happened and why ?
The over-riding and unpalatable point is that today's "practice" of pathology in Australia is based upon a corporate fraud in which the Health Insurance Commission ("HIC") and its banker, the Reserve Bank of Australia, play parts.
Both are so highly protected under Australian law that investigation of their officers' involvement in any crime cannot be done without their approval - and what Government instrument will initiate readily an investigation into its own suspect and sorry dealings ? Instead they, and those they assist, follow the traditional course of "shooting the messenger" and denial.
Lost is that crucial feature for professional freedom, immunity from commercial Equity. It has been over-ruled in many areas. This has widespread ramifications.
I will start with practical issues. References to the relevant section of the Health Insurance Act 1973 ("The Act") shall be by [s. ..].
A. What the patients and clinicians can see.
1/ The report is the rendered pathology service [s. 20A(4A)]. "Rendered" means that the service is provided for payment. The "pathology service" is not well defined. Ultimately this meaning shall require a Medical Board or court to make a determination (see later). However, the Undertakings (codes) make it clear that the service is to be rendered by an APP or on that APP's behalf, the APP being a medical practitioner, and the Medicare rebate is listed in the Medicare Benefits Schedule Book as a medical service. For Section 20A(4A) to operate, the APP rendering the service should be linked with the service (ie presented on the report) as the medical person taking responsibility for the report and elevating it from being a technical report to a medical report. The intention of the scheme was that the letters "APP" should be linked to the doctor's name to show that the doctor is a registered medical practitioner and that the doctor is accepting personal responsibility for the contents of the report (eg Dr IC Stethoscope APP). Multiple doctors and lack of APP should not be accepted - there can be non-medical doctors (theology, arts, engineering etc.) "Pathologist" is not necessarily medical - there are veterinary pathologists, plant pathologists and speech pathologists. "Supervising," "Director of Department" and "reported by" (etc.) do not necessarily indicate who the medical practitioner is who is accepting the responsibility.
Without the responsible medical practitioner (APP) being presented on the report means that the report is a technical report and those medical practitioners in clinical practice who act on the report accept the medical responsibility component, without (probably) any access to the laboratory to allow them to oversee the production of the report (they are not in the position to say "no" to the release or preparation of any report). Those involved in the production of such technical reports and who bill Medicare would seem to be involved in fraud. Clinicians should refuse to accept such medically non-attributed reports. Apparently, we must await litigations to sort out who is responsible (can anyone recall an APP being responsible for the late diagnosis in the Karen O'Shea case of misdiagnosed cervical cancer ?). Why is Medicare allowed to pay rebates for a medical component which is not being provided ? All that has been noted also applies to copies of reports, whether on paper or electronic (now often disregarded). Verbal reports should be in the name of the responsible doctor APP.
Where the name of a Specialist APP is involved, have you ever seen the specialist's other formal qualifications presented prominently (eg MB BS FRCPA APP) ? Show me a headed letter from a specialist in any other field, which does not have every qualification (relevant or not) displayed. I wonder if the laboratory proprietor(s) deliberately omit "APP" and qualifications so that s. 20A(4A) is not applicable, converting the APP into a laboratory lackey by stealth, apparently with medical professional acquiescence. For an APA (the proprietor, usually not medical now) to omit the name and APP status of the responsible doctor from the report would seem to be in contempt of Part 2 of the APA Undertaking, in addition to being an accessory to Medifraud.
2/ The bill. The Undertakings make quite clear that the bills and receipts should be for the medical practitioner who rendered the service (directly or indirectly by delegation), that is, the APP whose name+APP appeared on the report. For any other doctor(s) to bill as the rendering practitioner would seem to be dichotomous and/or fraudulent.
The preceding points should give concern that fundamental professional principles (eg personal responsibility), the Undertakings and laws seem to be disregarded in current pathology "practice." We now have to look for explanations - how, why and when the rot set in, and who can or should be doing anything about it.
B. Behind the scenes
1/ The intention of the APP-APA Scheme ("Scheme") was that a high percentage of clinicians would participate, and become APPs. After all, a Specialist Pathologist seems hardly necessary to oversee a "black box" spewing results on-line into a computer, or overseeing qualified technical staff performing technical work up to standards set by NATA. My view is that the Scheme cannot operate as intended unless a high percentage of clinicians participate. This is because the Specialist Pathologists (mainly laboratory-based) do not have the numbers and the interest to see the Scheme work properly as a tool for clinicians.
2/ The Implementation of the Scheme was defective : -
a) No-one seemed to explain the Scheme and how its options could work - the HIC advised doctors to seek legal advice (I am still to find a lawyer who can understand the Scheme). Medical bodies were not helpful.
b) At that time there was a 25% premium on the Schedule fee for Specialist Pathologists. Laboratories would not be interested in doctors who attracted less rebate
c) These Specialist-owned laboratories would not like to see their patient throughput diluted by referrals coming from self-determining APPs who were not in their group using the laboratory
d) No laboratory has provided spaces for the name of the self-determining APP &/or the referring doctor's choice of Specialist APP. Those bureaucrats vetting the format for referral slips are not concerned with this aspect.
e) I am unaware of any computer software provisions to accommodate large numbers of APPs - the maximum number I have encountered was 6 APPs. Accounting would be a major problem
f) Category 3 laboratories (no medical presence) were allowed to continue.
3/ The Glendon Fraud occurred September - November 1989 and galvanized thinking and interpretations thereafter, locking the officers of the HIC into a situation to be untenable in the long run. First, I shall relate the events as they were seen at the time, with the ramifications. Later I shall present the real course of events and how the Scheme became perverted.
a) Historical as seen. I "sold" my pathology practice in September 1988 to Glendon Diagnostics (Aust) Pty Ltd (now liquidated). The Contract of Sale was drawn up by Solicitor Stanley Myer Rosenberg, Director/Secretary of Glendon. My solicitor barely changed it. After a mild default with the Deposit, Glendon defaulted, claiming a dispute over patient numbers. With the National Australia Bank seemingly in control and dallying, I was kept on a Service Contract linked to the Sale Contract to oversee day-to-day testing, with the rendering pathologist Dr WP Harper APP. I reasoned that, to be a decision-maker in medicine, I would have to return to clinical medicine. Accordingly I started understudying a Consultant Physician/Oncologist. To provide for sites for clinical work, I applied for some Provider numbers on 23/6/1989. One was for the Glendon site. A week or so later I was handed the imprinter card for the site by the management, who had opened the mail (as usual)
On the 12/9/1989, Mr John O'Sullivan (Jr) came into my room to ask if my provider number was effective. He reported that Dr Harper's services had been terminated, and would I replace him ? I said "yes," but noted that my Service Contract was not adequate for the task (there was no provision for money to be handled or Glendon to be paid). He said he would look into that (but never did). My main duty then was to sign Medicare Claim forms. I then saw patient payments from patients coming addressed to "Chelmer Glendon" in response to an instruction slip in with bills. I suspected asset-stripping, and with the Bank still dallying, I instructed Medicare to redirect cheques payable to me to a remote post-office box and had the moneys put into trust (I was not a trustee). Chelmer-Glendon Pathology, a trading name of Ackland Cove Pty Ltd (now liquidated) came into operation on 6/11/1989 with Dr JS Menzies as the rendering APP. My contract was not assigned - I was left contracted to Glendon, soon to go into liquidation with the National Australia Bank having a claim for $1.75M against it. (Glendon never paid more than the deposit for my practice)
When Glendon noted the redirection of cheques, I requested a new contract that would be appropriate and an assurance that Glendon was the proprietor.
Glendon filed in the Supreme Court of Victoria 22/11/1989 to terminate my Service Contract and for the "return" of the moneys. The application was a high speed injunction without my involvement.. Moneys were to be frozen for a week. My lawyers seemed nonplussed by the situation, trying to grapple with the intricacies of the laws and Undertakings, and were non-committal until the day of the next hearing. On that morning my Barrister Mr G McGowan (not a QC) claimed that I had no standing in equity and had to lose. All lawyers nodded sagely that he was right; I was "pursuing a foible," and it was all my "own fault." Glendon offered to pay its own expenses if the matter was settled forthwith. Whilst I thought things were definitely wrong, I could not see what to do about the situation. So, reluctantly, and under duress, a cave-in settlement was signed. Lawyers chortled about how satisfactory the outcome was considering what I had done! There was no discussion at all about my Service Contract termination: it was undefended. No Settlement Contract was lodged with the Court, the Contract being confidential.
Because I felt certain that events were very wrong, I wrote to the Medical Board, concerned that the position into which I had been forced seemed to be "covering," (selling my name to a non-medical person for the latter to render medical-like services) and therefore unprofessional, and I called a meeting with the investigation branch of the HIC. Neither was helpful. Word went around that I had embezzled. Having been catapulted out of the laboratory scene, I turned to clinical medicine, later adding-in self-determined pathology with assistance from cooperative laboratories - always difficult, because all laboratory managements seemed to have unhealthy arrangements with clinic managements (non-medical to non-medical). In my spare time I continued to write to officialdom, trying to obtain answers to what appeared to me to be a fraud which needed investigations. I found brick walls everywhere, but slogged away with Freedom of Information and letters galore to everybody. That, and an application to the Administrative Appeals Tribunal eventually provided a reasonable picture of what really happened. That is now to be presented.
b) Now, the true story of a fraud with the involvement of officials.
This sets out that :
a. The Glendon to Ackland Cove "sale" was a scam and that all significant and relevant laws relating to pathology
laboratory conduct were breached - the Glendon fraud, a means to asset-strip the company.
b. The information should have been apparent to the HIC Officials from the moment I reported my concerns in
c. The Memorandum was issued to the addressee, Di Holland, FoI Officer on 1/6/1999. She (seemingly) was
too frightened of its contents to release it to me then, rather, wait until I had extracted the points one by one
from the Crown Law Officers representing the HIC at the Administrative Appeals Tribunal (AAT). Only
after that, did she release it, slipped in with other FoI application documents released subsequently - better late
than never ! This seems to highlight the damning nature of the Memorandum !
d. If she had released it when she should have, I would not have had to pay the $500 application fee to the AAT.
e. With the covering letter were some computer printouts which, if read correctly, indicate that Glendon's approval
was from 15/10/1988 - 14/10/1989, and my approval was from 1/5/1989 - infinity ?
Thus, the corruption in the laboratory
scene, involving officers of the HIC was, over time, to spread to involve the
Federal Health Department and the Reserve Bank of Australia, the National
Health and Medical Research Council, the Victorian Office of the Medical
Board; thence to corrupt (probably) the Victorian Governor-in-Counsel's list, the
Medical Board and its operation, the Victorian State Health Department and the
Victorian Civil and Administrative Appeals Tribunal ! What was to start as a
cover-up by the HIC, involving attempts to silence me and consolidate the
corrupted pathology scheme during the 1990s, proved inadequate and ineffective
- the documentation became available publicly to show that there was corruption
(see above); there was no more point in shooting the messenger after the
message had been delivered ! But the attacks were underway and could not be
stopped: they turned into a series of vicious, blood-thirsty, personal and
vindictive vendettas against me, which have been detailed here, elsewhere on
my website, or are in preparation. They would seem to be the most maintained
and destructive attacks by
bureaucrats (Federal and State), against a single medical practitioner in
Australian history, aiming to denigrate and eliminate someone whose sin was to
want to see crimes investigated. To date (4/2/2007), there still seems no sign that
the crimes are to be investigated - the public, especially the creditors and
patients, are the losers from the frauds and must also suffer from the
declining professional standards shown by a group of laboratory lackeys barely
able to justify being called medical practitioners and/or true professionals.
is a branch of jurisprudence, established by precedence. I noted earlier that it
places the rights of the business proprietor above all others at the site. That
means that the proprietor is an employer (in a general sense) of anyone linked
to the site, because (amongst other things) the proprietor can order the latter
off the site. Normally equity does not trouble medical practitioners because,
when they practise medicine, they cannot be seen to be employed with regard
to medicine since the proprietor (if non-medical) will be in trouble with
the law for medical impersonation (holding out) and, if the doctor is involved
knowingly, the latter could be seen to be "covering," (the selling of a
professional's name for others to practise using it) considered unprofessional
conduct. Thus, whilst the proprietor employs the medical practitioner in a
general sense, the latter employs the staff and equipment of the proprietor for
the specific purpose of medical practice.
When I visited some laboratories in California in about 1991, I did not see any Pathologists. I was told that the Pathologists attended for an obligatory session each week. I presume their absence is, to some considerable degree, because of the problem with equity. As the degree of delegation increases and the direct medical involvement decreases, the harder it may become to establish that the medical role of elevating a technical report to a medical report is the practice of medicine, which implies direct contact with patient consultations and procedures. I presume that this has been a problem in California at least, meaning that the Pathologists have to base themselves separately from the laboratory site in order to perform their medical roles. I believe planners for the Australian Scheme included advice from America and, since the logical place for a Pathologist to be based is in the laboratory (the Pathologist's tool of trade), the Scheme has gone to great lengths with Undertakings and laws to overcome the problems inherent in Equity and its ramifications, ensuring (all being well) that the APPs are free-ranging professionals. When this is realized, much of the Scheme becomes clear to understand. What the planners did not anticipate however, were the extreme lengths the non-medical forces would apply to overturn the Scheme for their own advantage, and the weak link the HIC officers and the rest of the bureaucracy proved to be in administering the Scheme. With Equity now being applied generally contrary to the intention of the Scheme, its Undertakings and laws, the Scheme has collapsed into a rather meaningless, ill understood idealism. (The close similarity between the Scheme as intended and the "extended-hours" clinics can be seen by those who look.)
Before the Scheme arrived, doctors controlled laboratories and were subject to Medical Boards. Now, (largely) non-medical organizations control pathology, conduct themselves and issue reports by employing doctors, often in unprofessional arrangements; the proprietors not clearly answerable to Medical Boards. This has not been a medical sell-out, it has been a give-away of medical professionalism !
5/ Juggling Jurisdictions and Jostling.
The Australian convention is that, when there is a conflict between Federal and
State jurisdictions, the Federal arrangements prevail. In case you have not
realized it, the basic aim of the pathology Scheme is to ensure that the APPs,
as free-ranging professionals, may use the laboratory facilities (behind the
walls of the laboratory) and release reports with medical standing and
attribution - tasks which cannot be done by non-medical people. This means, that
as far as medical duties are concerned, the APPs can practise as
any other doctor would in (say) a private hospital and render individual
accounts. Such doctors then come under the jurisdiction of the relevant state
Medical Boards with respect to the medical duties revealed to the external
public. If duties are interfered-with, to result in an unprofessional outcome
(seen outside the walls of the laboratory) then it is up to the State Medical
Boards to make such determinations and refer specific concerns to the HIC for
examination of the breaches or offenses within the APP-APA Scheme (behind the
walls), in order to see that the Scheme works correctly. The HIC is not
empowered to set professional conduct with respect to the public, and the
results are intended for the use by the public.
There is a big difference between a professional acting as a free-ranging employer of facilities and staff with regard to specific duties of a medical nature and as an employee. I recall commenting to a Cytologist about the seeming absence of a responsible Pathologist in the case of Karen O'Shea's late diagnosis (see earlier). The retort was that the Pathologist could not be responsible, having not seen the slide ! So, like the three wise monkeys, the less an APP sees, hears or says, the less responsibility ! When metamorphosis is complete, the APP turning into a mushroom, then responsibility asymptotes to zero ! My own observations confirm this effect, with an FNA thyroid reported as normal breast as one example. I call these APP employees laboratory lackeys.
I have drawn my concerns to the attention of the Victorian Medical Board on four occasions:
The First was in December 1989, just after the Supreme Court fiasco. I made a reasonably long submission detailing what had happened and my inability to comprehend the events. I asked if the Board determined that I was an employee, then what were the APP & APA roles ? I also sent a copy to the Federal Minister for Health (received 14/12/1989) whence it was sent to the HIC (received 18/12/1989). The Board also sent a copy to the Minister. Only the former has appeared under FoI. None of the correspondence from and to the Board has appeared, but the copy I sent to the Minister has some legible hand-written notes in the margins, possibly by two anonymous officials. Two notes are of particular interest :
a. Next to a point from my Settlement Contract "Glendon was an APA and entitled to receive the funds held in trust." was written "Yes - No, only if APP agrees" and,
b. Beside another point "If the Board determines that I was - - an employee (with respect to pathology services) then would Glendon have been acting as an incorporated medical practice, and I was merely a trustee for Glendon with respect to the payments ?" was written "Benefits could only be paid to Glendon with Traill's approval." So two bureaucrats at least, knew how the Scheme should operate, that my payments stream should be controlled by me: that Equity should not apply. But they were not to let on - the cover-up had started !
Whilst the actual reply to the Board has not been produced, FoI found an internal memorandum from Richard Karling, Benefits Control Branch (17/1/1990) to Mr Peter Winchester, Eligibility and Benefits Branch, which is of sufficient importance in understanding HIC conduct, that I will present it in toto (bar my address then):
"CORRESPONDENCE FROM VICTORIAN MEDICAL BOARD RE DR MA TRAILL
'I refer to the correspondence forwarded to the Minister's office from the Victorian Medical Board regarding a submission to that Board by Dr Malcolm A Traill. This correspondence has been forwarded to the Commission for response.
'As I have discussed with you, I consider that the Board is not entitled to any response concerning Dr Traill nor Glendon diagnostics given the legislative restraints placed on the Commission by virtue of s. 130 of the Health Insurance Act 1973.
'Accordingly, I consider that the response to the Victorian Medical Board should be couched in the following words; I refer to the submission dated 6 December 1989 by Dr Malcolm A Traill of - - to your Board concerning his employment with Glendon Diagnostics (Aust) P/L.
'As you are aware, this submission was forwarded to the Minister for Community Services and Health in order that his department's advice would assist you in responding to Dr Traill's submission.
'As the Health Insurance Commission is responsible for the administration of the Medicare program, the Minister has referred this matter to this office for reply.
'As you are aware, Dr Traill's submission relates to his employment with Glendon Diagnostics (Aust) Pty Ltd in the provision of health care in the faculty of pathology.
'Accordingly, given the legislative restrictions placed on the Commission by section 130 of the Health Insurance Act 1973, which provides inter alia;
'A person shall not, directly or indirectly except in the performance of his duties, or in the exercise of his powers or functions, under this Act, and while he is, or after he ceases to be, an officer, make a record of, divulge or communicate to any person, any information with respect to the affairs of another person acquired by him in the performance of his duties, or in the exercise of his powers or functions under this Act.
'I am not able to provide you with the
details you seek in order to respond to Dr Traill's submission. However, should
Dr Traill wish to correspond directly with the Commission, his submission would
receive favourable consideration. Yours etc. Forwarded for your information and
(I had sent the HIC a copy also, and been to the Investigation Branch in Melbourne, so I had already communicated.) I would have thought that :
a. Communicating with the Board on matters such as clarification of jurisdictions, medical roles and definitions of what may be the criteria for a "pathology service" would come within the meaning of "performance of his duties" in s. 130.
b. Even without revealing protected information from within the Commission, there was enough shared and common knowledge within my correspondence for definitive comments and discussions to be possible.
c. Notwithstanding caution on either of the above, the HIC officials could still have responded in generalities, not specific to me.
d. No-one from the HIC, the Board or the Health Department contacted me to tell me that there were concerns over confidentiality, and could I give authorization for (certain of) my protected information to be discussed with the Board ?
I assume that the Board received a letter along the lines given above: in which case, the Board was snubbed - was treated with contempt. In this way, the HIC had assumed a dominant position over the Boards of Australia - those that guide the practice of medicine. What arrogance ! Little wonder that everything was screwed-up from then on.
The Board ultimately sent me a letter, saying that it considered that it was not in a position to tell. It had been turned into a mushroom.
The Second occasion was in 1994, when I
raised the issue of "medical impersonation" (to hold out) by non-medical APAs,
who were providing reports meant to carry medical responsibility and
authorization, by means of employing Pathologists. The Board did not believe
that the matters raised came within its jurisdiction.
The Third time was in 1998 when I expressed concern that APPs in general, seemed not to be accepting their professional responsibilities by being associated with the release, by the APAs, of medically unattributed reports, which led to other aberrations. The Board summarized my allegations as "1. Failure to accept professional responsibilities, 2. Accessories and deception and, 3. Participation in incompetitive (sic) market practices. Having conducted an investigation the Board does not believe that there are grounds to proceed further."
The Fourth occasion was in 1999. Here, I had narrowed down my concerns to the medical status and definition of "pathology service," as is used in s. 20A(4A) of the Federal Act. I noted that "In order for Section 20A(4A) to be fully operative or relevant, there seems to be required from the Board, a list of minimum requirements to define at the State level, what rendered pathology services must be to be fully 'medical.' In particular, there is a need to define what is different between a rendered pathology service and a rendered technical service as far as the Board is concerned." The response form the Board (17/11/1999) states "I refer to your letter dated 14 October 1999, seeking a ruling from the Medical Practitioners Board of Victoria on the meaning of certain sections of the Health Insurance Act 1973 (C'th). The matters you raise appear to relate to your relationship with the Health Insurance Commission and as such do not fall within the jurisdiction of the Board." I would beg to suggest that the issues primarily do not relate to my relationship with the HIC and did not involve interpretation of the Act, but were fundamental to defining what constituted a pathology service in Victoria to be relevant for the Act to function (ie what are the components of a pathology service for it to be considered a medical service - a service that could not be performed by unregistered persons). The HIC is not a Medical Board - only a State Medical board can do this.
In no instance does the Board appear to have given indication that it had concerns that it would like to take up with the HIC, nor were there any specific reasons given for its replies. The HIC cannot give opinions - "The Commission will not provide legal advice or any other opinions to support private litigation." (Richard Baker, HIC 19/11/1990) and, as we have seen, the Medical Board of Victoria cannot clarify any issue relating to a medical practitioner's role in pathology. So we have a situation close to anarchy. I still believe that the rendered pathology service is the pathology report, after all, it is the report written by a doctor on headed paper and credentials which is the medical service for a medical report for an insurance company, not any aspect of the history gathering, examination and reference reviews which may go into the report.
We have to ponder on why the Board, with its jurisdiction to protect the public and see an orderly conduct of medical practice, has been so impotent - being unable to say "something is wrong, HIC fix it !" Apart from my own account of the Supreme Court fiasco, I do know that Mr Geoff Gillett of the HIC Tuggeranong claimed to have been involved - (10/4/1992) "I do not believe that "covering" is relevant or that there were other State requirements which had any bearing on the APA/APP arrangements. This matter has been discussed with the Victorian Medical Registration Board." (That was all.) I have sought written correspondence between the HIC and the Board under FoI without success to date. With Geoff Gillett's now known involvement in the Glendon Fraud, I have every reason to believe that he provided the Board with an untrue account of events and interpretations, meaning that the Board has been convinced by him (as others have been by Ralph Watzlaff) that APPs must be employees of APAs in all respects and that the Federal APP/APA Scheme takes APPs out of the Board's jurisdiction; no doubt quoting Court "Orders" (that did not happen).
The HIC, to cover its involvement with crime and the resultant false Court "Orders", seems to have embarked upon a misinformation campaign. A follow-on from the "Orders" was the elimination of the provision for APPs to Self Determine their pathology tests. For an APA to pay an employed APP to order tests would be illegal [s 129AA & 129AAA]. Clearly, an APP's place was in a laboratory. The medical bridge between the clinical areas and the laboratory had been destroyed, with the non-medical financial bridge between clinic and laboratory managements still occult. Non-medical laboratory representatives sailed forth to sing the virtues of the laboratories, instead of APPs performing sessional consultations in clinics (to be discussed later) and establishing a practice and association based upon medical merit.
With removal of the rebate premium for Specialists in 1991, there was a new disincentive introduced for non-Specialist APPs in 1992 - the Patient Episode Initiation fee, to cover collections and transportation costs to a remote laboratory. Since thinking now was that the only place for an APP was in a laboratory, and a GP laboratory had to be in the clinic, I expect that the HIC concluded simply that any GP-based laboratories would not justify such an item number, so it became exclusive to Specialist Pathologists who were now restricted to major APAs. (Because of the problems with s. 129AA & 129AAA, self determining would seem limited to those medical practitioners who were both APP and APA.) This was to virtually guarantee that non-Specialist Pathologists would be excluded from the major laboratories.
Also introduced in the 1991-1992 changes was an addition to the "Outline of Arrangements" regulations in the Medicare Benefits Schedule Book - Item (v) in PA.1.3. which reads "(v) No benefit will be payable for services provided by an Approved Pathology Practitioner on behalf of an Approved Pathology Authority if they are not performed in the laboratories of that particular Approved Pathology Authority." This is the Equity interpretation and the reverse of that provided-for in Section 20A(4A). (I note also the use of "will" - the vague form in law.) This does not prevent the correct operation, but seems to permit dual methods of providing pathology services.
Presumably, to counter the increasing confusion about roles, and my recurring concerns, the HIC started producing notes and sample APP-APA contracts about early 1994, and issued them annually for a while, being written by some anonymous author(s). The first may have been a photocopy of an actual contract, with identities obliterated. It states "1. The basis of my employment is as an associated . . . . providing services to and on behalf of . . . Pathology.' - and '4. Remuneration has been agreed upon between the APA . . . and myself in respect of provision of these services to the APA." (my emphasis.) This clearly follows the (now official) equity line. Understanding the financial stream is not easy ! Later, there are two examples, the first being for APP employment by a public hospital. It acknowledges the right to private practice, and "All private practice revenue accrues to the hospital and is split between a facility fee and a special purposes fund." The Special Purposes Funds would amount to perquisites and do not clarify the monetary stream. Whether "private practice" in this context is really that is questionable. The second, presumably for the private sector states " - - the pathology services rendered in the laboratory may be rendered by or on behalf of Dr . . . - - - . . . . . will provide at its cost the use of the laboratory, staff, equipment and other facilities, goods or services necessary for Dr . . . to render pathology services in the laboratory. The remuneration to Dr . . . for these services being rendered by him or on his behalf will be paid at an hourly rate for the time worked and works in the following manner . . . . . All claims for Medicare benefits relating to services rendered by or on behalf of Dr . . . at a laboratory operated by . . . will be payable in full to . . . there being no sharing of claims between the aforementioned two parties." Again, to whom the services are being rendered is unclear, but presumed to be the APA. The money stream is as confusing as usual. The APP seems to be out of it, and with respect to the rendered services, definitely an employee.
No other options were presented. These examples, and the Glendon Fraud, would seem to run contrary to the HIC's stated position of not providing legal advice, opinions or interpretations ! Examples provided by the RCPA or AMA would have seemed far more appropriate, but where are they ? (Professor David Davies, President of the RCPA wrote, 16/7/2001 "Although the College is the relevant national body concerned with training and certification in pathology, and through its various statements from time to time issues advice to its members on certain aspects of practice. It does not however have any statutory power to make any determination about conditions of medical practice. These are addressed by the State and Territory Medical boards while matters concerning payment of rebates are determined by the Health Insurance Commission - ." The College had a Code of Ethics, so it should be able to express opinions on how pathology should be practised. The Board appears to me to have failed in its duty.
When I took my concerns to the Medical Indemnity Protection Society, Professor Ross Webster (after some dialogue) stated 8/5/1992 " - may I emphasize that billing by pathologists under Medicare regulations has nothing to do with patient care. The function of MIPS is to indemnify medical practitioners against patient claims, and to assist them as appropriate when they have problems with statutory bodies in relation to patient care." And 3/6/1992 " - the matters you raise are industrial ones and do not come under the ambit of a medical indemnity organization." (He was also Chairman of the Medico Legal Joint Standing Committee under the Law Institute of Victoria, representing the AMA. The Standing Committee echoed the comments above, as did the Lay Observer.) I presume "industrial" means civil and not necessarily medical, meaning that the nature of the pathology service was not understood. I was concerned that medical defence organizations may look favourably upon APAs becoming primary targets in litigation, as in the Karen O'Shea case (without recognizing that the clinicians who act upon defective non-medical reports may have increased exposure). Accordingly, I raised concerns with the AMA that Professor Webster may be in a conflict of interest situation. This produced a less than friendly denial and a rebuke from the AMA, but no interest in seeking background information or reasons for my concerns. In the final analysis, I suffered as a result of the HIC's actions in supporting organized crime, in such a way as to disturb patients' rights and to increase the exposure of clinicians involved in patient care. I believe that the Medical Board and MIPS should have provided assistance.
6/ Medical Pathology
is the study and understanding of diseases. It is
inherent in almost all areas of medical practice, is a basic science taught in
medical school, is re-taught as part of the training for most postgraduate
studies and continuing professional development and basic to any research work,
clinical or laboratory. Clinical Pathology is selection and use of
destructive testing to diagnose, assess and monitor the conditions of patients
in the clinical setting. Laboratory Pathology (or simply "Pathology" in
usual speech) refers to the destructive testing done by laboratories, with the
production of a report, which often includes a reference range for the item(s)
tested, expressing a medical-based opinion of the relevance of the test
result relative to the population from which the patient was drawn. Whilst there
are some subspecialties where registered medical practitioners express specific
written opinions (Histopathology and Cytology) much of the rest involves "black
box" technology and/or testing by Medical Scientists with "potted"
(computer-generated) interpretations and having overall quality control
exercised by the National Association of Testing Authorities (NATA).
For years, clinicians have complained that they have been largely excluded from recognition and reward with respect to their relevance and capabilities in Clinical and Laboratory pathology. In the absence of any recognition there have been (of course) the occult payments, often management to management ("kick-backs" - which are a form of dichotomy and secret commissions) despite all other attempts to eradicate them. The Scheme set out to deal with all these problems. So now I will examine the intent of the Scheme - what might have been !
The Scheme set out to enable a clinician to order tests, as basic tests could be done by clinic staff in a side room under the clinician's supervision, but here performed in a remote laboratory, using staff, equipment, facilities and clerical back-up provided by the proprietor; the remote proprietor (APA) issuing bills in the name of the clinician and receipting patient payments in the name of the clinician, just as the clinic management would have done for the in-house tests. This seems simple, until someone tells you that there is a legal problem called Equity, a word that you probably would not have heard about until you read all that I have written. The architects of the Scheme then, had to overcome the problems created by Equity, to ensure :
a) Complete professional freedom of the
APP (the clinician in the laboratory role) - leaving the clinician/APP in the
b) Ensuring that APP responsibility and payment streams are clear
c) Thorough vetting of both APP and APA for suitability with respect to the handling of protected information [s.130], medical confidentiality and handling the public's money
d) Inclusion of measures to eliminate over-servicing and fraud.
To achieve this was not simple, involving a complex set of laws, Undertakings with the Minister, and regulations which, to most doctors seem incomprehensible. Most lawyers, who cannot be bothered to read and understand the Scheme, assume Equity operates (because they have been taught to understand Equity and not its removal), missing the whole point of the Scheme.
The clinician would be expected to have clinic staff collect and process specimens and process the incoming reports. For this, the clinician can pay the management as part of the in-house service arrangements. Such payments have nothing to do with the laboratory - the clinician obtaining an extra income from the laboratory site for services rendered from that site. Kick-backs should be eliminated.
The requirement for the clinician personally to supervise the remote laboratory staff is very important, because it gives the clinician the right to enter the laboratory and say "no." It may be seen as a problem, but it isn't - the APP-APA agreement contract must have in it the requirement that the APA shall provide a locum tenens APP at all reasonable times when the clinician APP is absent. Most laboratories have Histopathologists &/or Cytologists in on a regular sessional basis and one or another can be the locum tenens, ensuring a medical presence.
Then there is the situation, particularly in the country, where nurses initiating tests may be desirable. Under the Scheme, nurses acting for a self-determining clinician can initiate tests on the clinician's behalf, no signature being required.
Such arrangements would mix in well with tests done in the clinic - basic or more advanced point of contact testing. The specimen could have one test in the clinic and then be sent off to the remote laboratory - all testing being done in the name of the clinician, one billed from the clinic, the rest billed from the remote laboratory, each in the clinician's name.
Since Licensed Collection Centres are islands of the APA. Country APPs could attend the Collection Centres from time to time to ensure that collecting standards and transportation issues are up to standard.
The Specialist Pathologists will, as is usual in most areas of private practice medicine, have to justify their existence. Some, such as Histopathologists and Cytologists will have their own in-house specialty to look after, with referrals, either to one or other by the referring doctors' nominations, or handed over in some orderly fashion by the laboratory management. The others may well seek clinical positions, attending the laboratory in a rostered way to fulfil the requirements of accreditation. If released, to be free ranging professionals, I expect they would seek sessional arrangements in large clinics, to attract referrals to themselves to build up a practice and income. They would have to show that they are in the position to accept responsibility for difficult cases - those that the non-Specialists would not be prepared to undertake. They should consult and investigate within the knowledge of their sub specializations. Training should be along clinically relevant lines.
Competition will be between non-Specialist APPs and Specialist APPs. Thus, a Licensed Collection Centre in a small country town under the present arrangements has a virtual monopoly. Under the Scheme, every doctor contracted to the APA can be seen to be providing a service based at the site, each practitioner free to charge an individualized fee. I would expect to see a lot of movement between clinics by Specialist Pathologists endeavouring to offer Specialist services with individualized features and generate practices based upon medical merit. The ACCC should not permit the current arrangements - but try telling them !
Since the nature of the APP-APA contract will, to some degree, be influenced by costs the clinician generates for the laboratory, there should be pressures on clinicians to restrict testing to the minimum. For example, clinicians who order as routine 24 basic biochemistry tests generate some 18 tests which are not covered by a Medicare rebate, meaning that either the patient must pay extra or the laboratory "wears" it. Such doctors may turn-off patients or not obtain such favourable APP-APA contracts.
There may have been concern in earlier times that the Scheme would "open the flood gates" for over-servicing. I believe that this no longer applies - there are features such as coning and methods of monitoring individual profiles which should discourage this. I also believe that when one knows that what one orders is seen to be generating an income for oneself, one tends to be more circumspect.
Idealist and Dreamer !,
do I hear you cry. Not at all. I have practised as a self-determining
clinical pathologist for over 12 years since 1990, and no bureaucrat has
told me that what I was doing was wrong. I did have the advantage of being a
recognized Specialist, meaning that coning did not apply and the patient episode
initiation fee for the specimen's trip to the laboratory was covered. One major
laboratory terminated my contract because I was not fitting into its standard
employment arrangements, and another tried to turn me into an employee (with
respect to rendered pathology services) but dropped the issue when I pointed out
that for me to be paid to order tests would be illegal. They begrudgingly
accepted the arrangement as some bizarre one-off aberration. And then there were
the ongoing "arrangements" that clinic managements had with the managements of
the laboratories . . . How I was regarded by the clinic and laboratory
managements depended very much upon which laboratory had the "Contract" to
service the clinic. (These "contracts" were rarely discussed with me or,
presumably, the other doctors, but they obviously existed. There was an
expectation for all doctors to use the laboratory "chosen" by the non-medical
clinic management.) When my laboratory was not the successful tenderer
for the current "contract," clinic management would patronizingly note that they
could not force me to use the other laboratory, but I was not one of the team.
There were other handicaps such as my specimens being sent to the other
laboratory "by mistake," management not telephoning the laboratory for a pick-up
etc. The arrangement would be tolerated, even when I issued request pads with me
the recipient for the referral, although the pads inevitably and politely were
removed, usually without comment. If doctors in the clinic started referring
patients/specimens to me, that was insurrection, which had to be stamped out
! On one occasion, I was given instant dismissal from the clinic. My
laboratory management regarded me favourably, with me being regarded as a "foot
in the door" and hope for a change of heart of the clinic management. When my
laboratory obtained the "contract" the clinic management and doctors commented
that it was good to have feed-back from the laboratory, although issuing
referral pads in my name again was not popular with clinic management. The
laboratory did not seem to want me - not only was it (presumably) paying the
clinic management a fee, but it would receive less under my contract than it
would otherwise. One laboratory rep. reportedly said "what's in it for XYZ ?"
(the name of the doctor who ran the laboratory) shortly before I was catapulted
out of the clinic because of the pathology arrangements. The correct form of
practice is almost incompatible with the HIC's version.
I believe that, with my experience, I am one of the few who has seen the Scheme working as it was intended and I have experienced first hand most of the major distortions and corruptions which can occur. I shall be happy to comment on contracts planned or current for a small fee - but remember, I am not a lawyer.
should be relatively simple :
a) The patient episode initiation fee rebate must be made available for transporting specimens to major laboratories, irrespective of the postgraduate status of the APP involved
b) The HIC needs to stop lying about the Scheme - after all, we now know that its officers were involved in protected organized crime, so they can stop the charade of a cover-up. Those who want to tell lies should resign and stand for Parliament
c) The APAs need to be given clear warning that they are expected to provide request slips on which referring clinicians may indicate a chosen Specialist APP, that APAs must issue reports in the names of any APPs who wish to use the laboratory as self determining APPs, that bills must be issued in each relevant APP's name, and receipts must be likewise issued in the name of each relevant APP. This may require major computer software changes, including a pricing structure for each APP. The technology is there and, if the Scheme had been followed from 1987, the software should have been available long ago
d) The AMA should instruct the medical profession generally on how the Scheme can work and encourage as many doctors to use it as possible, and also negotiate with laboratories that show reluctance to cooperate (eg any who refuse to enter into contracts with non-Specialists). The Scheme will not work if left to Specialist Pathologists - they do no have the weight.
e) The annual APP fee of $500 is too high for a Scheme which should be encouraged. The fee should be less, say $200. Remember that the HIC has been using the $500 fee to maintain a perverted Scheme - doctors should demand better value for money.
7/ The Review of Commonwealth Legislation for
pathology Arrangements under Medicare. A
brief mention of recent history seems appropriate. After I obtained the
Recht facsimile under FoI in late 1999, I went on a wider search, with more
searches under FoI and, when there seemed a reluctance to produce, an appeal to
the Administrative Appeals Tribunal (cost $500). This resulted in flurry of
legal activity involving the Crown Law Department, with the winkling of more
information in January 2000. The advertisements for the Review appeared on
4/3/2000. The sequence of events may not be mere coincidence ! (Under FoI
received February 2005, there seemed a lot of consternation in the HIC about
2000 because many files went missing !)(Prior to the Administrative Appeals
Tribunal hearing I felt that the Medical Board should be interested in the
issues, because it dealt with how pathology should be practised. I telephoned
the Board and suggested such to the male to whom I had been connected. He
conferred in the background with others, and returned to say that the Board felt
no need to attend. So the mole had been tipped off - see later.)
I made a submission to this Review. It was shown briefly on the Government's website - until it was censored off ! Under FoI (see above) there ensued a burst of emails shortly after my letter, advising of the site, was published in the Medical Observer 13/10/2000. Drawn into the open were the names of the old guard, Ralph Watzlaff, Peter Brandt and Geoff. Probyn, plus others – Shaun Gath, Robert Orato, Clinton McKenzie, Helen Bryant, Alan Keith Mark Elliott and Helen Stokes. Not one raised a concern that there may be some basis for my allegations, or whether the allegations had been or should be investigated. Their only concern was to have my submission removed (cover-up). By failing to enquire about investigation meant that they all condoned what happened ! My name remained but, as far as I can tell, the Review subsequently made no specific reference to anything I contributed. We would hardly expect the bureaucrats to call for an inquiry on how they screwed-up pathology in1989 and later. The enquiry would most likely seek (fish for) how much the stake holders had realized what had happened over the years, with an opportunity to consolidate the perverted arrangements that have evolved and "band-aid" over the main problem areas - presented as fine tuning.
The output from the Review comprises three substantive components; a Background - July 2002 ("B"), a Draft Report - July 2002 ("DR") and the Final Report, December 2002 ("FR"). B goes through areas of concern with expurgated, selected and edited submissions from the interested parties (except mine). The DR presents brief summaries of the issues of concern selected by the Steering Committee, together with the Draft Recommendations. FR omits the summaries and is quite vague, light-on for specific problems and suggested specific solutions. It reminds me of the Oracle of Delphi - covering all options, so that any subsequent action may be claimed to be covered by the FR. In order to analyze the FR's Recommendations requires collating all three documents, together with the Act, old and new Medicare Benefits Schedule Books and old and new Undertakings, which is time consuming. To analyze the Recommendations in full would be beyond the scope of this analysis. I shall stick to some key issues in order that the reader can see my concerns.
Participants included Mr Ralph Watzlaff and Associate Professor R Conyers, which cause me particular concern and would seem to make the findings and recommendations of dubious value for the medical profession. (see previous).
From what I have written earlier, you may ask - what is in the Recommendations for clinicians ? The answer is probably a loss.
I am unable to identify evidence that the Committee understood the intention of the Scheme as it was originally intended - certainly, there is not presented any brief summary of how it should have operated for clinicians. There is evidence that the intention was not understood. None of the contributors' reported concerns expurgated, selected and edited, seemed to evince basic understanding of the intention :
i. Throughout, APAs were
presented as having the pathology practices and performing tests for the public
(instead of the APP rendering pathology services), with APPs somehow accepting
an element of responsibility in a strange and inexplicable way, with a quote
omission [B p64 clause 319] from Part 2 of the APA Undertaking "The Authority
undertakes - - - unless - - - rendered by an approved APP or under the personal
supervision of an APP - - - who exercises a reasonable level of personal
control over the rendering of the service, and who accepts personal
responsibility for the rendering of the service; - - - ." (The omitted
section is highlighted.) This omitted section provides, within the Undertakings,
a Civil Code which liberates the APP from Equity for a specific function: ss.
20A(4A) augments this freedom for the Crown because of the added special
responsibilities taken-on by the HIC in looking-after the Public's money when
administering Medicare bulk-billing. Then the
slide [B p71 clause 363] "The changing structure of the pathology industry
has led to an overall decrease in the total number of APAs and an increase in
the APAs that are company owned. Developments in the industry have also led to
changing roles and responsibilities for APAs and APPs. Evidence suggests that
the APA undertaking in its current form is not achieving its original purpose."
The Recommendations were then [FR p 6 clause 10] "The Approved Pathology
Practitioner undertaking should be revised and streamlined with overall
responsibility for services transferred to the Approved Pathology Authority."
This would virtually complete the consolidation of the Equity issue
- seal into place changes that have evolved because the HIC has condoned
perversion of the Scheme in order to protect itself from investigation.
Seemingly not considered in the ramifications of the Recommendation are :
This recommendation does not seem to have been well thought through.
ii. Section 20A is referred-to only
twice, in the footnotes to pages B 45 and B 64. Since, throughout the
Review, references seem almost invariably to subsections, the absence of
subsection reference is noteworthy. The former reference was in connection with
an analysis of the APP Undertaking with respect to Accounts, receipts and
assignment of Medicare benefit. "224. As part of the undertaking, the APP
agrees not to issue an account or receipt for fees, or make an assignment of
Medicare benefit,(89) or knowingly allow anyone else to issue these
on their (sic) behalf unless: (quotes points from clause 7A [Part 5] of the
Undertaking)." Astonishingly, the footnote states "89 The purpose
of this aspect of the undertaking is to establish that, notwithstanding section
20A of the Act, the APA is to issue accounts, not the APP - see clause 7a of the
APP undertaking. Further, subsection 16A(3)(b) establishes that an APP can refer
a request to another APP." I see nothing in the wording of the undertakings
to mean that an APP cannot issue accounts - it would have logistical problems of
course, and would need to be provided-for in the APP-APA contract. I believe
this quoted legal interpretation is simply wrong. Section 20A seems
mentioned only in order to be dismissed, and the relevant subsection (if any) is
unclear. When an APA issues accounts it is doing so on behalf of the APP(s)
who have rendered pathology services to the public (ie all accounts).
The second mention is in the footnotes of B page 64, justifying "320. The authority undertakes that where a service has been rendered by or on behalf of an employed practitioner or partner, the authority will not cause or permit the following to take place except by or on behalf of that employed practitioner or partner:(35)
Again, which subsection of s. 20A is relevant (if any) ?
There seems to be no reference to or acknowledgement that subsection 20A(4A) exists ! The Steering Committee, which has been empowered to review the laws relating to pathology and was advised by three Legal Officers and Mr Ralph Watzlaff, has overlooked it ! It has not been examined for intention, effectiveness or ineffectiveness, whether it should be repealed or not, or whether it should or should not be modified. Even more surprising is the absence of Section 20A from the listing of relevant "Legislation for the regulation of pathology services in Australia" in the Appendix 3, (DR p 37) ! Subsection 20(4A) is the unmentionable law !
By omitting any reference to subSection 20A(4A) and why it was enacted, the Steering Committee has not complied with its terms of reference, which read: "1. The Pathology Legislation Review Committee is to : - B. Clarify the objectives of the legislation; - ." (DR p 34, Appendix)
iii. The definition of Pathologist. It seems that, when the Scheme was introduced, there was no definition in the Act. There was a two tier rebate system, with a Specialist SP rate and an OP rate (for others). Eligibility to attract the SP rate relied upon "recognized pathologist" status as defined by Section 61, to be "a specialist in the specialty of pathology." (PX.1, 2, 3) of the early Medicare Benefits Schedule Book ("MBSB"). The early APP undertaking (eg 1990) have in Part 5, Clause 7) b) ii) "the service was either
1) a pathologist-determinable service which I have determined to be necessary for my patient; or
2) rendered pursuant to an unambiguous request or confirmation of request validly made to me for the rendering of the service and which is capable of interpretation - - - ;"
Here the term "pathologist," not being
qualified by "recognized" means a non-Specialist pathologist (eg a GP with APP),
and those self-determining clinicians in that position came under 7) b) 11) 1).
So what did the bureaucrats do ? They introduced a law [Section 23DNA,
subsection 23DNA(4)] on a not easily identified date, which defined a
Pathologist as a Specialist. This law relates to the rather peripheral matter
of the status of those supervising in Approved Pathology Laboratories,
as opposed to those accepting responsibility for the rendered
pathology service. The Committee notes (B p 48 Clause 241) "The only
definition of a pathologist in the legislation is in connection with supervisory
requirements for various categories of APLs. In this context, it is defined as
'a medical practitioner who, by reason of a determination under section 61, is
recognized for the purposes of this Act as a specialist in the specialty of
pathology.' While it appears somewhat circuitous , the definition of an APP and
pathologist are consistent across the legislation. The confusion about the legal
definition centres on the assumption that all APPs have been through an agreed
formal postgraduate training program in pathology." So that makes it about
as clear as Yarra water. But the notes in the later MBSB still refer to "Specialist
pathologist," (PO.9) and the APP undertaking has not changed. Those
referring to the MBSB would believe that nothing has changed, but the
Steering Committee applies the s. 23DNA definition, so that only Specialist
Pathologists can apply Clause 7) b) ii) 1), [ B p 28 Clause127]: "Exceptions
to the need for a written request apply to pathologist-determinable services.
These may be performed by Specialist pathologists who are also treating
practitioners (eg haematologists) or by non-treating pathologists who perform
additional tests - - -
." Apparently all those few self-determining
non-specialist pathologist/clinicians must write out unambiguous requests
for themselves, and staff acting under their direction in the
clinic cannot initiate tests on their behalf - so the Committee then
Recommends that (FR p 6 Clause 7) "The current restrictions on the
eligibility to request pathology services should be reviewed to examine the
merits of extending requesting rights to nurses and/or health workers in
designated remote communities where this would improve access to services."
The Steering Committee seems to see little wrong with this maladministration and
perversion of the original Scheme, merely Recommending (FR p 7, Clause 11) "A
review of the current qualification requirements and the approval process for
Approved Pathology Practitioners should be undertaken to address the following
- clearer definition of a specialist, based on completion of a postgraduate program conducted by the Royal college of Pathologists of Australasia or its equivalent;
- distinction between Fellows of the Royal College of Pathologists of Australasia and other medical practitioners who perform pathology services; etc." Consideration should be for both those who render services and those who supervise. I would have thought that s. 61 and s. 3D would have been adequate to define Specialist Pathologists, but not sufficient to frustrate or exclude non-specialist APPs. There appears a leaning towards excluding non-Specialist APPs from the Scheme.
My own view is that the term "pathologist" should not be inconsistent with the terminologies for the other major recognized specialties - a graduate in medicine can be called a physician and surgeon; if an APP, then can be called a pathologist and become eligible to be an Associate (or similar) of the RCPA, to participate in Continuing Professional Development. To pretend that one needs a postgraduate Fellowship in order to supervise and/or accept responsibility for the results spewed on-line by a "black box" is ridiculous. The intellectual attributes of Pathologists relating to such tests is in the selection and application of the tests in the clinic. Clinicians who accept responsibility for testing that has been delegated become sensitive to results with bizarre clinical relevance - the final arbiter for quality control. APPs are in the position to order re-runs, withdraw and change inconsistent reports in their names. Such Clinical Pathologists may be Specialist or non-Specialist. A Specialist Clinical Pathologist can be referred-to as a Specialist Physician, a term I have found more easily understood than Clinical Pathologist.
Assessment: You may recall that security of protected information, protection of the public's money and the implementation of Subsection 20A(4A) were significant HIC failures in the Glendon Fraud, and are also points which have received minimal attention in the Report. I believe that the avoidance of the unmentionable law is most convincing evidence that the Steering Committee had a secret agenda - that, in fact, the Review was to find out how much was known and a smoke screen to cover maladministration and crime, and was rigged, and certainly not in clinicians' favour. If an expensive Review can be rigged, what else in the public eye can be rigged ?
Those tangled in the rigging, for reference are; Mr D Borthwick, then Dr L Morauta, Mr J Jepsen and Ms C Cobbold. (B p 149 Appendix 3)
iv. Point of Care Testing ("PoCT") Because clinicians largely have been denied involvement in laboratory pathology through the machinations of those bureaucrats who prefer to help their mates in crime, there is a natural interest by clinicians in embracing this newer technology. Some points emerge :
Not content to let a flawed Review fade into oblivion, the HIC contracted the legal firm Phillips Fox to review the findings. Many years ago, when I moved into my private practice laboratory, I became disgusted with the state of the kick-back industry. A prominent player was Data Laboratories (or a name very similar), which had as its driving force a Dr Merv. Jacobson reasonably prominent on television for representing a General Practitioner lobby group – until there was a realization that he had never practised in primary care ! Data Laboratories subsequently featured in at least one current affairs program dealing with rorts in pathology. I had used Phillips Fox and Mazel for minor legal matters, but became so outraged by the goings-on that I encountered that I telephoned my lawyer in the firm and told him of my concerns. After a while, he pointed out that his firm had Data Laboratories as a client, and that there would be a conflict of interest ! I did not trouble the firm after that. Of course there has been a slight name change – but can a leopard really change its spots ? In its Summary Issues and Options Paper of 25/1/2005 there was specific note that “The Department of Health and Ageing (the Department) called for proposals for the Review. Following a competitive tender process Phillips Fox Lawyers were appointed to undertake the Review.” Perhaps the firm’s previous association justified a public statement to put the skeptics at ease ! Needless to say, the Reviewers did not seem to understand the intention of the original scheme: they could not see the point of laws which did not seem directly related to over-servicing (the laws were there to see that the system worked – eg that laboratory nurses did not participate in clinic functions.) There was no mention of Subsection 20A(4A) of the Health Insurance Act 1973 (as expected). The basis was flawed, their output was flawed: more of the same. I made a submission, but the die is cast.
8/ The HIC's Grand Vision for Pathology & the RCPA. I have noted earlier that a natural conclusion from the Equity interpretation is that (Specialist) Pathologists, being fully employed by the APA/APL, have no place outside the laboratory - are condemned to be laboratory lackeys. You may feel that this is absurd, but Mr R Baker (HIC, Tuggeranong 16/6/1995) sent around a "Special Codes to Aid Pathology Billing" sheet, which had "[Code] 029 Spec. Path(Cons) - Temp Code." The "Temp" seemed ominous to me then and, since there is no other consulting code for Specialist Pathologists, I wondered if the HIC was waiting for me to depart the scene and then scrapping Code 029. Then, in the more recent Review of Legislation (see earlier; B p 67 Clause 339) "In the future, the majority of pathologists can expect to be salaried employees, without equity working within a public or private laboratory enterprise. Under the current undertakings required by the Act, however, they will be expected to assert effective control over the provision of services and to be legally responsible for claims against Medicare.54" - - "54Commonwealth Department of Health and Aged Care (2000) Analysis of the Pathology Industry Structure in Australia. Final Report, Commercial in Confidence, p9." This is a bit woolly. So, there is some confidential report, expecting (Specialist) Pathologists to be salaried to APAs, who may ("will" has the vague meaning) assert some control (as employees) over the provision of services by the APA and to be responsible (as employees) for signing the Medicare Claim form. Some future ! Remember that in the Undertakings the services are "rendered by or on behalf of the APP." (I have seen 2 bills for pathology from one big organization coming from different States of Australia at about the same time with the same APP Doctor's name on them ! We are reaching the stage where each large laboratory over different States may need only one Specialist Pathologist - for the bills ! Now for my experiences :
I shall digress briefly here to report that in 2002, I encountered a
patient* who claimed knowledge of the matters following-on from here, and alleged
that the Chairman of the PSR Committee, a Consultant Physician, Dr Richard King,
received $1.2M cash in a bag drop (ie a bribe, said to come from
the Glendon Fraud interests - friends of Mr Burdett and others.) (The patient
also alleged that some of my patients were paid to complain to Statutory bodies
about me, with Associate Professors paid to act as advocates for the patients.)
This, so the allegations went, was to discredit me and hopefully have me
deregistered, so that my Specialist Clinical Practice (Code 029) could be
cancelled, and pathologists (and others) excluded from practising clinical
pathology forever. It is all about power and money, and a few $M
here and there out of petty cash is a small price to pay to seize full
non-Medical control of Pathology. The HIC and those crime groups it has been
supporting must have received advice from former USA President Richard Nixon,
who was reported to have exhorted his staff to "'get' the enemy" and that "its
legal if I say its legal." *[Note
added 19/10/2009] Mr Charlie Gakis; see
Whilst I am not in the position to affirm or deny the accuracy of these allegations, they do provide a strong stimulus to look more closely and critically at what has been taking place. Certainly, if the process were not corrupt, then it would be quite out of character, given the HIC history as related earlier and later in this, my musings.
The Committee then, was provided with the information (fact) that I was a FRCPA (only), and was empowered to assess my "clinical input." I would have thought that "clinical input" would put emphasis upon diagnosis and treatment. Not so ! The Committee largely disregarded these (probably because these issues could be defended by reference to post graduate training) and concentrated instead upon clerical, protocol and costing issues - the relationship of these to "clinical input" would seem somewhat tenuous :
Clerical: Important failings in the Committee's eyes were (i) Failure to take a full and extensive history from a patient at first contact. This history taking expectation was greatly in excess of what later official guidelines were to expect. (ii) Putting "==>Path" instead of writing out all tests ordered into the file. The Committee did not ask for, nor did it see, the Pathology Books which each clinic had, and into which the clinic staff entered all tests ordered, the laboratory involved, the initials of the couriers , and the checking-off of all reports against the tests ordered. (Bureaucrats love making extra clerical work for doctors when much can be delegated !) (iii) Having a shorthand that the Committee deemed was not clear to other doctors. In developing it, I had considered this potential problem, so wrote-out significant findings, diagnoses and prescription details (a few standard abbreviations, such as OM excepted). This could put in a small space what many doctors did not bother to record ! No doctor had ever complained over 12 years!
Protocol: Here, the Committee floated an "ideal" that all patients seen by me for the first time should thereafter become my ongoing patients and I should follow them all up. As put, it sounded very fine. However, this "ideal" did not seem to be very well researched and thought through. In particular, it did not take into consideration :
(i) What the patients want. I do not know how many readers have practised in a primary care setting. Those who have should know that patients do not like a "hard sell." On the odd occasion when I have encountered a patient with a particular problem which interested me, my enthusiasm to proselytise was rarely shared by the patient, who could not grasp that I was an acknowledged world authority (according to me) in whatever the problem was. Such patients become defensive and see no reason to change from Drs X, Y or Z, who have given valued and trustworthy service over the years to the patients and their families !
(ii) Medical Ethics. When I started working in primary care clinics in about 1990, I spoke to a solo practitioner whose opinions I respected. I asked how he liked the "24 Hour" clinic that had opened nearby. He said "Its great!" I asked "why?" He said "because they look after my patients after hours." This struck me as a very ethical arrangement and one that should be respected. These sentiments are also given in the AMA Code of Ethics items 1.1 k and 1.1 n. Accordingly, in my dealings with patients seen for the first time (chiefly) after hours, I made a point of not trying to "pinch" them and to respect the relationship they had with their usual doctors, who may be nearby or in the same clinic. When the Committee asked me about following-up patients I had seen in such clinics, I had the answer from my own ethical deliberations. I always gave patients the option to return. I did note that I only sought to have them return to see me if there was a clear medical reason to do so.
The Committee was not impressed by this and made no attempt to seek out why. In examining the mere 8 patients' files, and finding "lack of follow-up" it used ethical policy to extrapolate criticism throughout my practice. Using lack of follow-up of some patients plus the policy, when used as a measure of "clinical input" meant the Tribunal could extrapolate this failure found in the small number, and every other defect "in respect of each and every service that he rendered." Since the Full Bench of the Federal Court has supported the Committee's policy that I should try to make every new patient seen out of normal hours my ongoing patient, means that Medical Ethics should be reworked, given that legal precedence has priority over ethical considerations. The AMA Code of Ethics needs to be re-written, eg:
1.1 k The patient should be encouraged actively to forsake any previous medical attendant and ensure continuing follow-up with the most recent doctor (eg yourself).
1.1 n Recognize that an established relationship between doctor and patient has, in law, only a limited and temporary value in current times. (Suggested examples only)
(iii) Temporal and Location Convenience. Out of hours, many patients drive considerable distances. They may be most reluctant to repeat this when they feel better.
(iv) Over-servicing Concerns. Follow-up for many patient attendances may not be necessary. The unnecessary review of essentially well patients to confirm that they are better, when the clinic is overworked and crowded, is essentially over-servicing and wasteful of resources.
(v) The Role of a Specialist Consulting Pathologist (general). I believe that it is not the role of a Specialist Consulting Pathologist to "pinch" other doctor's patients. I believe that the role for such Specialist doctors, when in primary care, is to assess, diagnose and commence appropriate treatment for the matter at hand, only seeking following-up when it involves ongoing pathology testing. The Specialist with a reputation as a "patient pincher" is hardly likely to receive referrals from other doctors.
Another issue was the signing of blank DB1 Claim forms, to be used by clinic staff when preparing the Medicare submissions. (Tell me what this has to do with "clinical input?) The trick here was to misquote the Declaration, stating " - the DB1 form included a declaration to be made by the practitioner who rendered the service that all in the information in the claim was true - ." The actual Declaration states "To the best of my knowledge and belief all information in this claim is true." (My emphasis.) If one normally conducts oneself along honest lines, I see no problem in signing such a form in advance and having the knowledge and belief that the delegated staff were trustworthy and will perform their duties honestly. To do so seemed universal, and in the pathology laboratory scene, the idea of checking every patient's assignment form is next to physically impossible. They were flying a kite.
Costing. In the expectation that the rigged referral process was to eliminate clinical pathology forever, there is no surprise that the costings that involved pathology were all screwed-up. The Committee (not being my peers) was unable to comprehend the Patient Episode Initiation (PEI) numbers and payments. The laboratory-based Item 73901 was regarded as a "venipuncture/specimen collection fee" which, of course it is not. (For those who do not know, it is to pay for the laboratory courier taking a specimen from the reception desk area [or similar] in the clinic, transporting it to the laboratory and returning with the results. In normal primary care clinics there is still no specimen collection item number - it is included in the clinical attendance costing. The Committee argued that, if there was a specimen collected for pathology by me and little was written in the file against the date, then the PEI fee paid to me by the laboratory covered the venipuncture and form-filling activities and there would be no consultation of the length to satisfy Level B (Item 23). In reaching this conclusion, the Committee ignored the wording, which describes the "Professional attendance - " and the second part "OR a professional attendance of less than 20 minutes duration involving components of a service of which item 36, [etc.] applies." The relevant part of Item 36 being " - arrange any necessary investigations and implementing a management plan - ." I believe that the Committee concluded, in order to pursue its own scheme, that the laboratory paid me as an employee - which is illegal !
Consistent with the known rigged nature of the referral process, there was of course, the inevitable running-down of clinical pathology - it should not be seen to exist and had to be stamped out. The Committee dedicated a whole section and more to doing this - some two and a half pages! (Remember that the terms "General Practitioner" and "Specialist Physician" are not defined Categorizations and are in the nature of opinions.) The relentless aim was to show that a Specialist Pathologist had no place in the clinic, and if I did happen to receive Medicare payments through Claims as a Specialist, there had to be something definitely wrong. I shall present the Section and its follow-on in full :
"III. Dr Traill as a general practitioner and specialist pathologist
22. At the outset Dr Traill claimed that the Committee was not made up of his peers. The Committee considered that it should address this assertion.
23. Dr Traill claims to be a "specialist physician." He bases this view on the fact that he is a 'specialist' by virtue of the fact that he is a pathologist, and he is a 'physician' by the fact that he has a bachelor of Medicine and Bachelor of Surgery (MB BS) qualification. However, he has had no "specialist physician" training or qualification and his only hospital training was that of a junior resident medical officer for one year at Footscray Hospital.
24. He claims to have "picked up" training by being involved with clinics at the Repatriation General Hospital, Heidelberg, while acting as a specialist pathologist. However, the Committee found no evidence to support Dr Traill's assertion that his training rendered him equivalent to a specialist oncologist, a specialist hepatologist or a specialist neurologist.
25. The Committee noted that Dr Traill confused his role as general practitioner with that of a specialist pathologist. Dr Traill had provided 142 specialist referred consultation items during the Referral Period. In a significant majority of these services, the patients who had been seen by Dr Traill (in his role as a GP) and referred by him to other specialists and consultants, were then sent appropriately by these specialists and consultants back to Dr Traill as the referring doctor with requests that tests be ordered for follow-up of these patients as part of the general management of these patients.
26. Dr Traill considered that such requests from the specialists to whom he had referred the patient constituted a specialist referral which entitled him to then bill Medicare for specialist referral consultations rather than general practitioner consultations. However, these were not "specialist referrals" to Dr Traill and the Committee is of the opinion that it was highly likely the specialists and consultants who wrote the letters would be surprised that their communications had been interpreted by Dr Traill as such. Had these consultations being itemized as general practitioner consultations rather that specialist consultations they would have added to the number of Level B consultations rendered by Dr Traill during the Referral Period. As it is these consultations do not currently form part of the referral as they are inappropriately categorized as specialist consultations.
27. Dr Traill seemed unable or unwilling to accept that a letter from a specialist was usual when a patient was returned to the care of their(sic) general practitioner. He persisted in his view that when he saw such a patient regarding the ordering of pathology or the discussion of results of pathology tests he was acting as a specialist pathologist. During the hearing, he was asked: 'You feel that when Dr [X] refers back to you after you have referred to him, that when he refers the patient back to you to do some follow-up that you are acting as a specialist?' Dr Traill answered: 'I believe he was - he was not doing it himself. He was asking me to do it.'
28. The Committee considers that such letters did not constitute a referral to Dr Traill for specialist services. For example, a female patient (RJ) taking Warfarin (an anticoagulant drug):
* Dr Traill had received a letter from another doctor concerning her condition. Dr Traill saw the patient at Kingsbury usually twice a month to manage her Warfarin. He considered the letter constituted a referral to him as a specialist and that he was to monitor her weight loss.
*Dr Traill billed this patient MBS item number 105 (specialist referred consultation - each attendance subsequent to the first in a single course of treatment) on 16 occasions and an item 23 on 3 occasions between 6 July 1995 and 14 March 1996.
*The Committee asked why Dr Traill thought that a pathologist was a more appropriate person to refer the patient to than a consultant physician . He stated: 'well I checked her for thyroid for starters.' This statement reflected Dr Traill's inability to answer a direct question, and his failure sometimes to understand his different roles.
*The Committee considers that the management of Ms RJ's condition and Warfarin usage was properly the role of of Dr Traill in his capacity of general practitioner and that it was inappropriate for him to bill item 105s for the consultations on 5/10/95, 12/10/95, 9/11/95, 16/11/95. 11/1/96, 15/2/96 and 7/3/96.
29. Dr Traill also believed that a note in a patient's file at one of the Premier Care Centres saying 'Dr Traill to explain' or 'see Dr Traill' amounted to a referral. He stated in relation to this : 'well why not? He [the other doctor] couldn't explain it . . if he can't do it himself and sends it to me its a referral.'
30. Occasionally a patient from another general practitioner in the clinic was discussed or asked to be seen by Dr Traill. In those medical records examined where this occurred, there was never a referral letter in evidence nor a particular reason given, but merely a simple note on the patient's medical record such as 'discuss with Dr Traill.' or 'see Dr Traill.' For a valid referral to have taken place the referring practitioner must have considered the need for a referral, conveyed any information that the referring practitioner considered necessary, and the referral must have been given in writing, signed by the referring practitioner and dated. Nevertheless, Dr Traill undertook to see these patient as a specialist and billed Medicare for a specialist referral consultation. While these consultations are not the subject of the Referral the Committee views with them with concern. Most of these consultations should have been billed as general practitioner consultations. Had they been so billed they would have added to the number of Level B services rendered by Dr Traill during the Referral Period. By categorizing them as "specialist consultations" Dr Traill has effectively claimed a higher rebate for what was essentially a general practitioner service.
31. For example, Dr Traill was asked by another GP to look into the condition of a patient (DW) with a vitamin B12 deficiency via a note on the patient's record stating 'see Dr Traill.' Dr Traill accepted this as a specialist referral and on 19 March 1996 charged MBS item 104 (specialist referred consultation - initial attendance in a single course of treatment) for a consultation with Mrs W. He maintained that looking into a vitamin B12 deficiency was a appropriate for an item 104. He stated: 'well if I asked the local surgeon to look at a dressing for me, he can charge a 104 for it too. I am a specialist, I am entitled to claim to give opinions on that.'
32. The Committee considered that Dr Traill's conduct in billing for such services as specialist referred services rather that as general practitioner consultations would be unacceptable to the general body of medical practitioners in general practice. In particular, the committee concluded that in respect of the seven item 105 consultations billed to Medicare in respect of Ms RJ on 5/10/95, 12/10/95, 9/11/95, 16/11/95, 11/1/96, 15/2/96 and 7/3/96, and the item 104 consultation rendered to Ms DW on 19 March 1996, Dr Traill's conduct would be unacceptable to the general body of medical practitioners in general medical practice.
33. The Committee's consideration of Dr Traill's conduct in regard to this particular practice however has been considered entirely separately to the major concerns expressed by the HIC, that is the high volume of Level B services provided during the referral period."
"64. Dr Traill asserted to the Committee that he felt that because of the particular conditions under which he worked, the normal concepts and standards of general medical practitioners cannot reasonably apply to his situation or be used as a valid comparison.
65. He stated that during the hearing: 'I don't accept that the Committee in fact represents my peers...in a number of respects and in particular about the qualification side of it. As far as I can see the only common factors that you and I have together is that we've all got medical registration and we're all the same gender.'
66. As Dr Traill practised as a vocationally registered general practitioner, the Committee comprised the Chair who is a medical practitioner (a Consultant Physician) and two vocationally registered general practitioners as required by section 95 of the Act.
67. Dr Traill's statement above is another example of his inability to separate in his own mind his possession of specialist medical qualifications in pathology and his actual practice as a general practitioner."
To comment on the above :
(i) There is no specific "Specialist physician" training that I know of (it is not an official categorization). (ii) Specialist oncologist, specialist hepatologist or a specialist neurologist are not official categorizations, are undefined, not necessarily "medical" and subject to opinion. I am a Specialist clinical pathologist with particular interests. (iii) I am not a bit confused about my roles as a clinical pathologist and a laboratory pathologist. (iv) Referrals require the clinical information (as provided in a letter or on the patient's file), be in writing (by letter or on the clinic's file), signed and dated. (v) If another practitioner requests, in writing, a Specialist Consulting Pathologist to perform activities consistent with that Specialty, I regard such a request as a referral. (vi) The clinical roles of Specialist consulting Pathologists are different from those of Consulting Physicians (and not as expensive)! (vii) A note on the clinic's file signed and dated constitutes a valid referral - the reasons should be apparent from the file. Section 95 is Categorization-specific and I shall look at its application at the start of the Committee stage next. The Chairman indicates that he is aware of how Section 95 should operate.
The Director of the PSR needed to apply Section 95 to set up his Committee - subSection 95(1) (a) & (b) provide for a Chairperson and 2 Panel members (none involved Categorization). The subSection 95(4) at the relevant time stated "If the practitioner was at that time a specialist in relation to a particular specialty, the other panel members referred to in paragraph (1)(b) must also be specialists in relation to that specialty." The subSection 95(5) stated much the same , but replaced "specialist(s)" with "general practitioner(s)."
In the Instrument to set up the Committee, Dr Holmes advised appointing the Chairperson "under paragraph 95(1)(a) of the Act." He appointed " - Panel member(s) under paragraph 95(1)(b) of the Act - [Drs X & Y] - vocationally registered general practitioner(s)." I am not certain what can be made of his reference to "paragraph" instead of "Section," but he certainly did not refer to subSections 95(4) or 95(5). So he fudged the legals ! My specialist status was bypassed.
Elsewhere, the reference of Section 95 is imprecise. Strangely, at the commencement of the Committee's Report, also in paragraph 66. of the Report, in the Tribunal's and the Federal Court's summaries, nowhere are the particular subSections specified ! Given the stated structure of the Committee, subSection 95(5) would seem to have been implied when, for my Categorization (Specialist, 029), subSection 95(4) was applicable. This point is of interest because, given the allegation of bribery, the performance of lawyers also goes under the microscope. Later I shall look at the exit end of the Committee's process and review the process.
So there you have it - 16 paragraphs, largely irrelevant and with attitude ! Sixteen out of 74 - about 22% dedicated to heaping abusive, derogatory and pejorative claims against my clinical post-graduate Classification and without a determination that my Specialty has no legal status in the clinics - just carping. (The lady doth protest too much methinks.) In the old days, medical ethics regarded as unacceptable, doctors slinging off about specialists. I find this degree of diatribe hardly called-for - even if I did not have Code 029. The Committee was Ultra vires*. The allegation that there had been bribery to pursue and complete the clinical pathology eradication campaign has considerable attractions. *acting above its powers
The Tribunal cheer squad added its bit " - we have no doubt that, in rendering services during the referral period at ... and ..., the applicant was practising not as a specialist pathologist but as a vocationally registered general practitioner. It follows that the test to be applied in determining whether the applicant had engaged in inappropriate practice is whether his conduct would be unacceptable to the general body of general practitioners." Again, there is no determination that I have no legal right to be a Specialist in a clinical setting - it was left to general practitioners to apply tests - and they were not my peers.
After this I sought advice from my College (RCPA) :
A letter from the College President, Professor David Davies (16/7/2001) noted that "If a Pathologist is unconditionally registered as a medical practitioner in any State or Territory of the Commonwealth of Australia, he or she can provide a medical consultation to a patient as an unreferred service. While the fee to be charged to the patient for that service can be anything which is agreed between the practitioner and the patient, as far as rebates are concerned it is my understanding that because the service is unreferred a specialist consultation rate cannot apply, and furthermore because the practitioner is not a vocationally registered general practitioner the rebates depending upon the circumstances are likely to be those falling between item numbers 52 and 698." I read this to mean that a Specialist in a relevant* field is still a specialist irrespective of what is charged. It is the rebate which may vary by Specialist referral, VR or not. (* A Specialist Microbiologist may have difficulty claiming relevant specialist knowledge when treating a patient with gout.)
Feeling vindicated that my post-graduate training does not switch off every time a see a patient as a doctor of first contact, I sent a fiery letter to my lawyer Mr John Petts/Hugh MacLaren of Tress Cocks & Maddox (Melbourne) requesting that all legal matters be halted until the matter of Categorization be settled (note that I still had not obtained this from FoI). This produced a legal opinion 13/3/2002 from Mr Matthew Smith, Barrister (Sydney).
The response was chilly, producing a "powerful argument against" what I had proposed :
(i) Subsections 95(4) and (5) of the Health Insurance Act 1973 (Cth) as they then stood did not require a medical practitioner to be classified to only one speciality across all his practice.
(ii) The references in these subsections to "at the time" show that a classification is needed only of a specialty in which he "was practising when he or she rendered the referred services" (c.f. s 95(2)), ie when rendering the particular service.
(iii) In Dr Traill's case the Committee has found as a matter of fact (and the Tribunal has agreed) that when rendering the item B services which were referred by the HIC, Dr Traill was in practice as a vocationally registered general practitioner.
(iv) If so, [the] Committee was therefore validly appointed to report on those services.
(v) The finding as to Dr Traill's specialty when rendering the referred services is a finding which now cannot be challenged in an appeal limited to questions of law."
Mr Smith mentions the subSections 95(4)&(5) for the first and only time ! What he is trying to say, using prolix legalese, is that my Pathology Specialization should be invalid outside the laboratory. To date nobody, not the Committee nor the Tribunal, has presented a determination to this effect. He has referred to a finding as a matter of fact that I was a Vocationally Registered General Practitioner in the clinics. I am not aware of any finding along these lines. I believe that the assertion was an opinion devoid of primary supporting documentation and begged the question. I believe Mr Smith did not do his homework well and the opinion was fudged. In the circumstances, I let the appeal idea lapse, and we prepared for the Federal Court.
So now, I shall look at the exit end of the Committee process, because there is Section 82 to negotiate. It, like Section 95, is Categorization-specific. Interestingly, the Committee Hearing was 1/10/1997. The Act was amended on 6/11/1997. The Committee produced its "Draft Report" on 28/8/1998 and its final Report on 26/11/1998. The Section states "82 (1) A practitioner engages in inappropriate practice if the practitioner's conduct in connection with the rendering or initiating services is such that a Committee could reasonably conclude that:
(a) if the practitioner rendered or initiated the referred services as a general practitioner--the conduct would be unacceptable to the general body of general practitioners; or
(b) if the practitioner - - - as a specialist (other than a consultant physician) in a particular specialty--the conduct would be unacceptable to the general body of specialists in that specialty.; or - - - ."
One would think that this would pose a big problem for the Committee, in particular its Chairperson. Not so ! This obstruction was bypassed by not making a Finding of inappropriate practice !! (s 106S) Instead, the Committee made a Finding of unacceptable practice which, as you can see from Section 82 (and also the following relevant Sections of the Act, Sections 106H, 106K,106T and 106TA), was not the wording to enable matters to proceed against me. Fortunately for the Committee and the PSR/HIC, the Determining Officer who received the Findings (and the confidential body of the Report) was the very understanding and helpful Dr Louise Morauta, previously mentioned in connection with the rigged Review of Commonwealth Legislation for Pathology Arrangement under Medicare ! She was happy to regard "unacceptable" to mean "inappropriate" and therefore open the Confidential Body of the Report and proceed. In effect it was she who made the Finding of Inappropriate practice ! So the exit from the Committee process was fudged ! When I questioned this with the replacement Determining Officer, Mr Ian McRae, he stated simply "I am satisfied that a finding by the Committee of conduct 'unacceptable to the general body of general practitioners' satisfies the definition on 'inappropriate practice' in section 82 of the Act !" Now, he is making the Finding ! He must be a Federal Court Judge ! But other Sections required the word "inappropriate." So he fudged other thing also. A brief discussion on meanings in the Macquarie Dictionary may be pertinent here :
"Inappropriate" means "not right for the occasion." So there is a right (or wrong) and an occasion.
"Unacceptable" means "that cannot be accepted (receive with approval or favour)." Here, there is implied an observer's assessment (rather than a factual right/wrong) in relation to a threshold, below which the matter is unacceptable.
The two words do not have the same meaning. To defend "inappropriate" one can refer to standard texts, journals, experts etc. When "unacceptable" is used one has to know the criteria used for the threshold. If it is set close to "perfect" than almost all doctors will be found wanting, and such a finding is almost impossible to defend. My belief is that this technique was used deliberately with me.
This point seems important in assessing my legal advisors :
Mr John Petts. When I received the Final Determination, I sought a legal advisor. I had read about the Dr Stephan Yung case and how it had been contested successfully. So, I rang Tress Cocks & Maddox, and I was told that Mr Petts was their man in Melbourne for this sort of matter. I spoke to him and sent him copies of the paperwork to read, planning to see him later. He was to apply for a review by the closing date. After sending me a draft application on 10/11/2000 to peruse, on 13/11/2000 he referred to me a considered copy of the actual application for review sent to the Minister for Health and Aged Care. Of the 31 grounds listed, seven stand out in retrospect: "3. Dr Traill was not given any adequate opportunity to comment on or respond to the issues raised by Dr Olszewski in an interview conducted on 17 October 1995." Remember that I wrote to Dr O. after the meeting, but the letter was intercepted by Mr Burdett. He dispatched it to the "NFA" file. "14. The Committee failed to identify which of the referred services it found to have been rendered inappropriately." See my earlier comments. The word "inappropriate" and its application features in some five grounds. "31. The Committee erred in applying S82(1)(a) as it failed to have regard to Dr Traill's particular specialty." Here Mr Petts clearly accepts my specialist status. After the application went off, the bureaucrats would have then known who my lawyer was. When I spoke to him next he was very negative, saying "You didn't do yourself any favours in the Hearing," (to become a familiar phrase). When I did meet him I raised the issue of the use of the word "unacceptable" instead of "inappropriate" because I had read that this was a successful point in the Yung appeal. He scoffed at this, saying to the effect, "that would not be accepted by a judge." So, now you see them, then you don't. Like a conjuring act and without consultation with me, the points disappeared and, throughout the entire Tribunal and Federal Court scenes, the "inappropriate" issue was never raised ! Another feature I found strange, was that throughout the entire talk-fest processes, I only spent about 1 hour at the start alone with him ! I did see him with Mr Matthew Smith, but the latter talked over me when I wanted to speak. I had tried to discuss my concerns about the HIC and crime, as outlined earlier here, with Mr Petts, but he always cut me off - he never heard anything of it ! (Some years ago a QC prepared a list of features expected of a competent lawyer. I remember one point - knowing that the client has no other lawyer, a competent lawyer would be expected to show interest in all legal concerns of a client.) I can tabulate my concerns:
(i) Failure to present (or mention) the flaws in the referral process, the Committee setting-up and the Committee exit
(ii) Failure to criticize the "Draft" Report. He never asked why there had been no reply to the "Draft." There were a number of reasons: a) The "Draft" was not headed as such, not signed nor dated - it seemed to have no legal standing as a document. b) One cannot address a "Draft" in an adversarial situation - drafts are usually used by groups with a common general objective to seek consensus. In an adversarial situation, to respond to a draft tells the other side how to modify the final report better for their objectives - it is like the old legal maxim "Oh that my adversary shall write me a letter !" c) The "Draft" used the word "unacceptable" in the Findings, suitable for s 106S. One could hardly write back and say "Hey fellas you have used the wrong word !" d) To write back addressing the "Draft" would imply that the word "unacceptable" had been accepted to mean the same as "inappropriate." e) To defend allegations couched as "unacceptable" is very difficult. Even if the matter of concern was actually "appropriate," a Committee could state, to the effect, that the standard found still did not come up to the Committee's expectations - whatever they may be - and who is to know what they are? It is left vague ! (You may note that in the quoted parts that were dealing with matters irrelevant to "clinical input" the word "inappropriate" is used !) f) There was no evidence that a letter of mine to the Committee after the Hearing attracted the slightest notice - there was no indication that the Committee would take any favourable notice of any response to the "Draft." g) Reading the body of the Report left little doubt in my mind that the Committee had certainly made up its mind - it was hostile - I would be offering a defence to a body which was not then impartial. I took the "Draft" to a local suburban solicitor, Mr Andrew Burgess of Henderson & Ball. After listening to me elaborating on the above points, he wrote a letter seeking an extension in time and a copy of the transcript. When the response came extending the time, he forwarded this to me with a note to the effect that he "awaits further instructions." To me, response to the "Draft" was next to impossible – an insoluble dilemma. Mr Burgess, having not provided me with any form of legal opinion (on a matter which would seem serious), he let the matter rest and also did not bill me ! I am not certain what to make of all this - was he really unlike most money-hungry, work-creating lawyers, or did he believe that I could/should not respond; or perhaps he may have been "got-at." (By writing, he had declared his identity without real involvement or commitment and could have been influenced.) I wonder.
In the Federal Court appeal, the perceived bias at the time of the "Draft" received the briefest mention from my barrister, to the effect that " - but by then the Committee members had made up their minds." - Pithy, but hardly a well developed and logically presented argument in context ! Despite this, the Federal Court judges must have been hit on a very sensitive nerve, because they had this to say :
"144. On the material before the Tribunal, there is nothing to suggest that the provision of the draft report was anything other than a genuine invitation to Dr Traill to make submissions or comments on any findings included in the draft. Nor is there anything in the material before the Tribunal that would lead a detached observer to think that the Committee had prejudged the matter, thereby preventing the earlier procedural flaws from being cured. In particular, there is nothing to suggest that the Committee, by the time it had provided its draft report to Dr Traill, had made up its mind, or had put itself in such a position that a fair-minded person would reasonably have believed that it would not genuinely consider any further submissions from him: see generally [Court Cases]." Once again, the lady doth protest too much methinks. Just look at the earlier quotes I have included. Could the judges really be serious ? This was the Australian Inquisition, where a reasonable defence to an impartial judicial body was denied ! How the AMA allowed the legislative framework for this is beyond me.
(iii) He never asked me why I made those comments which "did you no favours." I had reasons for many.
(iv) He never queried the difference between, nor the application of "unacceptable" and "inappropriate."
(v) He always seemed "off side."
(vi) Every time I tried to tell him about the Glendon Fraud etc. he would cut me off. Nothing of historical type was ever said.
(vii) Every time I wrote to him with my thoughts, he would write back saying "you do not understand the process - new evidence cannot be tendered."
(vii) Throughout the process, he was adamant that I was a "general practitioner" and that view was exteriorized and "confirmed" by Matthew Smith (see earlier).
(viii) Whilst in the Tribunal appeal stage, there came to light the the amazing fact that the photocopies of the patients' files presented to the Tribunal contained no Pathology reports and other investigations. I believe that, after the Committee Hearing, the files were photocopied and sent back to the clinics within days. By omitting photocopying my pathology reports effectively removed a significant part of my practice as a clinical (self-determining) pathologist ! This meant that, when the Committee came to prepare and write its report it had no pathology reports to which to refer. No wonder that there were criticisms of me writing "==>Path," and the desire that all tests be written out - because, with no reports, they had no idea what was ordered, done and what any add-ons could be. I was criticized for seeing a patient on Warfarin too often. The Committee could not tell how unstable his Prothrombin INR was (he was an alcoholic with abnormal LFTs). The Committee and the Tribunal both criticized me for not entering into the file the Warfarin dose adjustments. This information, of course, was written on the relevant, and absent, Pathology reports (which supplied the patient's 'phone number for convenience) ! Similarly, when I treated patients with Hepatitis C, the Committee had no idea what the Liver Function Tests were - whether the patients improved or not ! Having surfaced at the Tribunal stage, Mr Petts and the Barrister made nothing of this - not a whisper of protest: but then, I was being separated in my clinical role from the general encompassing role of Clinical Pathologist and Mr Petts seemed to be assisting. This issue did not seem to be mentioned at the Federal Court either.
In the fudging chain from Mr Burdett, through Dr Holmes, Dr King, Dr Morauta and Mr McRae, the only non-public servant was Dr King. He and my lawyers would form the weak links in the grand plan. The allegation of bribery regarding Dr King would seem consistent - as an outsider contractor he could not necessarily be relied upon, not being in the club. The passiveness (?negligence) of Mr Burgess and the negligence of Mr Petts would also be in accord with the possibility that they too had been "got-at." From all this, I have come to the considered opinion, reluctantly, that Mr Petts was "one of them;" that he had been persuaded to steer me through appeals with the intention of losing (at my expense), either because of a monitory consideration, or possibly by a "trade-off" in cases.
You may recall that earlier (8/5/2002) I had my official Categorizations appended to the original PSR Referral under FoI. In the letter from the FoI Officer (Ms Lisa White) she states that "A copy of this annotation has been forwarded to The Director, Professional Services Review for his information and dissemination." (My emphasis). Apparently, he did not disseminate this annotation to anyone. There is no evidence that the subsequent Federal Court received a copy, and there is no evidence that it was attached to documentation which was sent to the Medical Practitioners Board of Victoria. This means that the Federal Court was allowed to proceed with superseded and outdated referral information. Documents received under FoI in February 2005 showed that the lawyers, Minter Ellison, knew of the annotation. The Federal Court was deceived, and Minter Ellison did not assist the Court (as lawyers are employed by courts to do). (In an HIC monthly report for September 2002, the entry states “PSR and its legal advisers were aware of some of the issues in relation to FoI matters due to involvement regarding annotations.” When Kathryn Johnson of the HIC notified the FoI officer, Lisa White 31/5/2002 that “. . the Traill matter proceeded in the Federal Court earlier this week without any FoI issues being raised.” The response was “Thanks Kathryn, I can sleep easy now.” ! The inevitable referral of the PSR outcome to the Medical Practitioners Board likewise had no annotation. Dr Holmes has now fudged the legals with Section 95 and fudged the dissemination of documentation. He would seem to have quite a bit to answer. Strangely, within about one month of presenting my updated Musings in December 2004, which included the preceding two sentences, Dr Holmes announced his retirement from the PSR in the Medical Throw-aways ! When the Medical Practitioners Board took up the PSR Report matter at a Formal Hearing in May 2004, I provided their lawyers, Minter Ellison, with a copy of the annotation and a copy of this document (Musings updated 13/1/2004). On legal advice, I pleaded (in effect) guilty, after all, I could not deny that the PSR had made an adverse Finding (even if the wrong word was used), which still should have not allowed anyone to read the body of the Report. I felt that a lot could be said about the lack of seriousness of the rigged issues and to present the flaws as extenuating factors. However, my legal Counsel, Mr David Grace and Andrew Smith, were adamant that I must not argue - I should show remorse - remorse for being shafted ! There would seem to be minimal passing reference to the annotation ! The Board subsequently stated :
" Dr Traill recognized that he had placed himself in a position of conflict of roles as pathologist and as general practitioner. He was operating at all times as a general practitioner and should have maintained that distinction, except on those rare occasions when he genuinely did act as a specialist pathologist.
 Counsel pointed out that from 1989 to September 2002 Dr Traill had been practising as a general practitioner, by using the classification codes that are the subject of that Health Insurance Commission letter, Exhibit 1. He was practising as a specialist pathologist under item 029, classification code 029, He was on the vocational register practising under item 130, and as a medical practitioner under item or code 104."(Exhibit 2, a current copy of my Musings, was never listed nor mentioned) That seemed all to be said. So, we know that they really understood it ! Now, that made it all clear ! As far as I am concerned, I have never recognized that I had a conflict of roles, as all the preceding writing attests. As far as I can tell, Mal’s Musings was never mentioned, referred-to or given an Exhibit number !
Another gem that emerged was the comment :
" Counsel Assisting* said that Dr Traill's conduct in contesting these issues to such an extent indicated a lack of insight into the seriousness of his professional conduct that should be taken into account by the Panel. - "
*from Minter Ellison. This, then made me realize that throughout the Tribunal, Federal Court and Medical Practitioners Board stages, Minter Ellison (the legal firm) has been involved, advising and representing the Federal Government side and the Victorian Medical Board ! In effect, Minter Ellison was in a position to dictate to the Medical Practitioners Board, as an adviser with influence, what the Federal groups wanted: and Minter Ellison would certainly not have wanted to lose its contracts with the Federal Departments ! The Board effectively would become subservient to the Federal wishes and dictated by Minter Ellison. Evidence could be brought to the attention of the Board's Panel to influence it; evidence which had not been tabled, and tabled documents could be overlooked (as happened). None of my lawyers noted this ! Mr John Smith (Deputy CEO MPB 17/12/2004) commented that the Board had been using Minter Ellison about 3 years - coincidentally, about the same time I went throughout the appeal processes in the Federal area ! Further enquiry revealed that Minter Ellison was appointed by the Board on 26/6/2002, with the annotation being release 8/5/2002, a PSR report to the MPB on 15/5/2002, the Federal Court appeal started 27/5/2002 (till 28/5/2002) the MPB calling me in (28/5/2002) to answer the allegations, with a letter from John Smith 24/6/2002 “I can confirm that the Formal Hearing into the matter of Mrs X will proceed and is being prepared by Minter Ellison.” – a bit eager, being two days before the firm was appointed !! (Mrs X was a patient who sued me, claiming that I had not provided the optimal treatment, which she had, in fact, refused and another was administered. I was the first defendant, with a third defendant, Marketform Ltd, an Australian agent for Lloyds of London, being the third defendant. They were represented by . . Minter Ellison ! So, Minter Ellison was both for and against me !! Ironically, Maurice Blackman Cashman, the firm representing Mrs X in Melbourne, was also representing another patient [Mrs Y] in Sydney, seeking damages from earlier doctors, claiming that the same treatment I had given Mrs X was the only treatment that did Mrs Y any good ! I wonder if lawyers ever meet up at parties ? I suspect that the Melbourne events were a legal rort involving UMP, which had appointed Mr John Petts to assist me [but who dumped on me], and which, at the time, was receiving Federal assistance.) What were the circumstances surrounding the Board starting to use Minter Ellison ? Dear Reader, can you really believe that, of all the legal firms in Melbourne, Minter Ellison’s appointment at that time was purely by chance ? Could the Board have been offered a special deal, in part (or more) subsidized by subtle (or less than subtle) fee loadings in the Federal domain ? Who would know ? How could anyone find out ? Under FoI (received February 2005) there is documentation showing that the HIC had contact with Jane Salveson, the day-to-day representative of Minter Ellison with the MPB. The HIC (eg Mr Watzlaff) could advise Minter Ellison on how the pathology scheme was "supposed to operate in practice," (see a lot earlier) and Minter Ellison could relay this version to the Medical Practitioners Board, when the Board sought any opinion ! Who on the Board would question the interpretation ? Who, outside the Board, would know what the opinions were and how practitioners or the public would be affected ? (I regard myself as a member of the public. With regard to pathology practice, I believe that I have not been protected by the Board in the slightest way.) Minter Ellison obviously did not advise the Medical Practitioners Board that there could be an ethical and Professional Standards issue here involving themselves. A complaint was lodged with the Professional Standards of the Law Institute of Victoria, with the response from Mr Thomas Moore, 15/12/2004, being " . . no evidence has been provided as to Minter Ellison's motives in this regard and it is purely speculative on your part. It is for MPB to determine whether or not they are satisfied with the advice being provided by Minter Ellison . ." How would the MPB know of influence ? I thought that the whole point of ethics in this context is to avoid the possibility of improper influence; to ensure transparency. The Ombudsman was approached. After some time Ms Kate Hamond 1/4/2005, claimed “. . you have produced no evidence that Minter Ellison have acted improperly, or that they have gained or used any confidential information from representing various parties in the several proceedings in which you have been involved. . . Further, the issues you raised regarding alleging Minter Ellison failed in their duty to the Federal Court are allegations that should have been made in and tested before the Court.” So it was my responsibility to see that the Crown had its paperwork in order ! Justice at its best ! (There must be a special school for Ombudsmen, where they are taught how to write, explaining how they are unable to assist.) That the Federal Court outcome was flawed, means that everything which flows from it is likewise flawed. Naturally, all this started me thinking about the failure of the MPB to handle my concerns (x4) on pathology practice, why the MPB seemed be badly informed following my appearance before it in May 2004, why reporting of the finding in the MPB Bulletin seemed to reflect the Crown’s aims, rather than the Board’s Findings, and the very suspect nature and timing of the appointment of Minter Ellison. I find it very difficult not to believe that the appointment was rushed, particularly, following the annotation, so that the firm would be in place when the matter reached the Board. To manage a rush job like that can only mean one thing – there is a mole in the office of the Medical Practitioners Board. That person would have to be very senior and have been there a long time. That a bribe or two would be involved would seem virtually a certainty. The continuing unhealthy and invidious association of Minter Ellison and the Medical Practitioners Board will taint past and future proceedings. I believe that the Minter Ellison association with the MPB is egregiously scandalous.
Summary: Over the years, the HIC has made strenuous efforts through the Courts to discredit me, probable attempts to have me deregistered and have the Specialization Code 029 deleted. There have been numerous attempts outside and in Courts to strangle my practice as a Specialist Consulting Pathologist, consistent with the desire to stamp out Clinical Pathology altogether. My penalty from the PSR process was one of the most severe - more than that for Jack Freeman - but then, he was only involved in some $250,000 Medifraud (that they could prove) etc. My penalty was designed by Dr Morauta to have me lose my clinic patient base, and then ease me back into the laboratory scene where, presumably, I would stay until I retired ! I believe that, in the long run, if pathologists wish to remain clinically relevant, they must remain in clinical pathology, and train in that direction. Continuing Professional Development must include basic clinical knowledge (eg as run for GPs), in order that Specialist pathologists remain relevant, especially in the non-morbid anatomy specialties. I can see a FRCPA having a standing like a Diploma of Laboratory Science (Pathology). The short term is bleak. The profession generally, has failed to capitalize on the Scheme to ensure a significant percentage of non-Specialist Pathologists (GPs, Dermatologists, Surgeons, Gynaecologists, Physicians etc.) participate in clinical pathology and take responsibility for testing within their own limits. It is the profession generally which seems to have failed to recognize the gradual attrition of the Scheme in order to please organized crime groups especially friendly with officers of the HIC. For medical pathology and clinical pathology to have any future, there need to be 4 clear statements from Government answering :
1. What is the long term plan for clinical pathology ?
2. What is to be done with the officers in the HIC who have been
involved with organized crime ?
3. What mechanisms must be put in place to allow observers of
institutionalized crime in the highly protected HIC to have
the crimes investigated ?
4. How is the mess to be cleaned up ?
Those medical graduates who have an interest in the scientific side of medicine should consider their position carefully.
We have seen how Mr Burdett was involved in organized crime, has rigged categorizations and seemingly masterminded a personal harassment campaign to further the interests of those outside the Commission, yet been supported from the level of the Governor General down and, I believe, even having some assistance from State bureaucrats. Once again, there should be serious doubts cast on the role, veracity and credentials of the HIC in any prosecutions against doctors.
At the end of the day, do not forget that HIC officials were involved in organized crime - crimes that have been covered-up and which cannot be investigated because the HIC will not allow it. Criminal elements are still on the loose, unrestricted by the bureaucracy and the laws of the land. If you think I am paranoid, let's have the crimes investigated so that we can see the true picture.
9/ Pay Group Link. This strange term seems to have been coined by the
HIC and refers to changes in the doctor's name &/or address on the Medicare
cheques and associated protected information differing from the name &/or
address of the site for the relevant attendances. It occurs in two main forms :
a) Doctor address change. If I direct the HIC to change the address on the Medicare cheques, me payee, it will be done, as will the cancellation of that directive later. (Refer back to the Glendon fraud, where a Solicitor, acting for a bunch of crooks disturbed in the middle of a fraud, directed my cheques back to an address I did not attend any longer - the cheques, and protected information could have been sent anywhere !) This application is simple, convenient and I have no problems with it (provided the HIC takes my directives as it should, and refuses the directives from others !).
b) Payments to a third party. If I direct the HIC to make my payment cheques payable to a third party (at any address), the HIC returns the letter, noting that the third party must also sign (I have tested this) and will enclose a special form for both me and the third party to fill in, which warns "Please Note: Health Insurance Commission policy concerning pay groups is that where a pay group to a third party is terminated by a practitioner, the third party will be advised." (I have tested this also, the HIC ignoring my directive not to inform the third party). Early in the 1990s, there was no such warning. It may have appeared after I registered my concerns. Strangely, this nasty little trick dreamt-up by the HIC, came to my attention because I was not pay grouped linked ! I had moved to a clinic in the ACT close to the HIC's crystal palace. Management opened all the mail and banked my cheques by conversion (this was a widespread practice in those days). One day, Professor Ian McGoldrick came to town and seemed to be becoming involved in the clinic management. For my own reasons, I did not want him having access to my payment stream, so I directed the HIC to change the address for cheques etc. to my home in Victoria. Within hours, the management was informed and, after some unpleasant talks and negotiations, I was catapulted out of the clinic, with management holding my payments. It took lawyers and a negotiator for me to obtain my money. The HIC did nothing of consequence to help, noting that they "thought" that all doctors in that clinic were pay group linked to the management ! Mr Geoff Gillett did apologize (hollow words), but the damage had been done. So, within about 18 months, I had my payments streams tinkered-with twice by the HIC, Mr Gillett involved on both occasions. The first was certainly not an accident, the second, when I consider the protocols which I would expect to be in place to administer pay group links, is difficult to believe for it to be an accident.
We now need to look more closely at this obnoxious trick with doctors' payment streams for medical services when third parties are involved. In correspondence with the HIC and others I was informed that pay group link is not covered by the Health Insurance Act - it is an "in-house" arrangement created by the HIC. I wonder if the legal ramifications really have been considered by the bureaucrats. You remember that the HIC rejects my directive to make cheques payable to a third party, and responds by directing me and the third party to sign, and then one becomes liable to the HIC's actions in the event of the other party cancelling. This is not lay commerce; we are dealing with my payment stream for medical services. The third party has muzzled into this stream, and without the vetting process for proprietors as seen in the Pathology Scheme (and I can think of some pretty crooked managements). Because the HIC "calls the shots" it become an employer (in the general sense and also relating to medical services). I and the management become employees, with the management becoming an agent for the HIC with respect to the public's moneys and protected information, and having use of the moneys until disbursement, as a consideration. This means that I come under the Commonwealth Jurisdiction, and out of the Jurisdiction of the State Medical Board ! The HIC, in return, could carry responsibility in accepting as an employee, a manager of poor character, who mishandles the public's money and protected information, and become liable for medical indemnity claims. This latter should be popular with the Medical Defence Organizations !
I find it strange that the Medical Board finds the conduct of a small number of doctors working within a Federal Scheme that is supposed to provide professional freedom, to be outside its jurisdiction, when a far larger number of doctors in an "in-house" Federal Scheme without Parliamentary mandate, which does impose upon professional freedom remains unquestioned at the State level !
My own view is that the HIC has no right to impose such an arrangement upon a doctor's payment stream for medical services. Having such a trick advantage for the clinic management makes the latter less inclined to seek proper employment contracts (which have nothing to do with the HIC). I can understand that the clinic managers would want to have some sort of a bond from the doctors they employ (in a general sense), but without Parliamentary mandate, the HIC would seem to have no justification to enter into this field and distort jurisdictions and powers. For Geoff Gillett to state that the HIC wants to treat both parties equally is a gross simplification - medical practice and clinic management are not equal ! The primary responsibilities for the HIC are to look after the public's money, pay medical rebates and discharge debts for medical services, not protecting clinic proprietors or laboratory managements. In my experience, the HIC has failed both responsibilities. Gillett's involvement in organized crime makes me suspect that he, and others, have responded to powerful non-medical lobbying. I would be surprised if the HIC can claim support from any medical professional body for what it has done.
10/ Rigging Justice - State and Federal: Eliminating nuisances - See elsewhere in my website, eg :
The VCAT Experience
The Dark Side
More to follow in other Chapters
This site (http://home.iprimus.com.au/matraill) is have sections moved to www.malsmusings.info . If you wish to know more at this stage, you can contact me at firstname.lastname@example.org
Malcolm Adams Traill
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