General Practice
Compliance Costs

Qualitative Project
- Topline Report -

Prepared For The: 

Research conducted for:
Productivity Commission
Research conducted by
Maria Vallis, Kim Kreuzer
Max Yann, Mark Zuker
Millward Brown Australia
245 St Kilda Road, St Kilda, Victoria, 3182
Ph: (03) 9537 2255 Fax: (03) 9534 4373
e-mail: kim.kreuzer@au.millwardbrown.com
ACN 000 029 630     ABN 86 000 029 630

September 2002
Job No: 83102336

TABLE OF CONTENTS

Page No.

1.	BACKGROUND AND RESEARCH OBJECTIVES	3
2.	KEY FINDINGS	4
2.1	Attitudes Towards Compliance with Government Programs	4
2.1.1 Implication for the Study	4
2.2	Compliance Tasks	5
2.2.1 Common Paperwork and Compliance Tasks	5
2.2.2 What are the Most Burdensome Tasks?	7
2.2.3 State or Commonwealth?	9
2.2.4 Implications for the Study	9
2.3	Overall Reactions to the GP Compliance Costs Study	10
2.3.1 Implications for the Study	11
2.4	Reactions to the Initial Letter to be Sent to GPs	12
2.4.1 Implications for the Study	13
2.5	Reactions to the Diary	13
2.5.1 Implications for the Study	14
2.6.	The Issue of Incentives	15
3.	CONCLUSIONS AND RECOMMENDATIONS	17
                                
1.	
	BACKGROUND AND RESEARCH OBJECTIVES

For some time Australian general practitioners have expressed concerns about the increasing burden on them arising from paperwork and other government requirements.  As such, the Commonwealth Government has asked the Productivity Commission to provide an independent assessment of GPs’ compliance costs associated with Commonwealth programs in particular, and to advise on ways to reduce these costs.  

The Productivity Commission has decided to undertake a survey of GPs, as part of its research program, and have commissioned Millward Brown to execute it.

In an effort to understand the most effective means of administering the survey, and to evaluate its viability, a preliminary stage of qualitative research was recommended by Millward Brown.  This also sought to gain some detailed insight into GPs’ perceptions of the costs associated with complying with Commonwealth Government policies and programs.  The information will further complement the information directly obtained from Commonwealth Government departments and agencies and government organisations.

Three focus group discussions were conducted across the 9th to the 11th of September, with a sample of vocationally registered GPs who had been practicing for atleast 2 years.  They each worked at least 18 hours per week, and practiced at a maximum of 2 practice locations.  A mix of those who operate as an ‘Individual Proprietorship (sole practice)’, a ‘Partnership’, an ‘Associateship’ or an ‘Incorporated Practice (corporate organisation) were recruited into the discussions. 

The discussions were held in three separate regions across Victoria, as follows: 
•	Group 1: Inner Metropolitan Melbourne in St Kilda.
•	Group 2: Outer Metropolitan Melbourne in Wantirna. 
•	Group 3: Rural Victoria in Bendigo.
 
2.		KEY FINDINGS

2.1	Attitudes Towards Compliance with Government Programs

The increasing burden arising from paperwork is an issue that concerns GPs.  It is difficult for them to estimate exactly how much of their working week involves dealing with paperwork and related tasks.  Estimates ranged from 5 hours per week, to 2 hours per day to around half of the working week.

The qualitative research did not identify any differences in attitude to compliance tasks and paperwork, nor any difference in the amount of paperwork, between different practice types or size.

The burden of paperwork is increased by the fact that GPs do not appear to delegate these tasks to anyone else in their practice.  While is it feasible that a competent practice manager or practice nurse could complete some of the tasks the ultimate responsibility lies with the GP him/herself.  In addition, the compliance tasks are seen as an integral part of treating patients – a task that they have full responsibility for.  For this reason, GPs tend to complete the paperwork and other compliance tasks themselves.

Much of the frustration GPs feel about paperwork and compliance tasks relates to:
•	Much of the paperwork they are required to do is unpaid.
•	A perception that their patients, and indeed the community in general, do not realise the amount of time they spend doing additional paperwork.

2.1.1	Implication for the Study
•	There is clearly a need to accurately measure compliance costs in general practice.  •	The majority of the data obtained in the study will come directly from GPs.  There will be few practices in which diaries will need to be completed by other personnel.
2.2	Compliance Tasks

2.2.1	Common Paperwork and Compliance Tasks

Spontaneously, GPs list many paperwork and compliance tasks that they complete on a daily, weekly or less frequent basis.  
•	Medical reports
•	WorkCare reports
•	TAC reports
•	Life insurance reports (re: pre-existing medical conditions)
•	Pre-employment reports
•	Superannuation reports
•	CommCare
•	Reports for the DHS
•	Disability Services
•	Three Plus Asthma Program
•	Immunisation notification
•	Pathology requests
•	Enhanced Primary Care program
•	Infectious Disease notifications
•	PBS authorisations
•	Care plans
•	Centrelink reports
•	Passport certifications
•	Taxi driver licence applications
•	Disabled parking applications
•	School asthma plans
•	Medico-legal reports
•	Death Certificates
•	Doctors Bag
•	Narcotic registers
•	Medical certificates
•	PIP
•	Private health fund reports
•	Veterans Affairs reports

The list on the previous page includes all of the paperwork, forms and compliance tasks spontaneously mentioned in the 3 focus groups, in their own language.  When the GPs were provided with a list of all of the Commonwealth Policies and Programs, many were surprised at the length of the list.  On closer examination it became clear that some tasks are more common than others and also that they used different terms and language to describe them.  GPs refer to the forms or task rather than the policy or program name.  The forms and tasks themselves were referred to in different ways to their official names.

GPs make little or no distinction between the types of paperwork tasks.  From their perspective it is all paperwork and it is all a necessary part of their work, however onerous and time consuming.  

Estimating how much time these tasks takes in an average day or week is very difficult.  This is due to the fact that the tasks are seen as almost inextricably linked with the consultation.  And, most GPs try to do these tasks while they are with the patient, rather than later on in their own time.

“Every consultation would have at least one of those things.”
“It’s hidden a bit in normal consultation time.”
“Unless you have a patient that comes in with a basic cold and you do nothing and send them away there’s going to be some paperwork.  And not many patients come in with just one thing.”
“It’s part of running a practice and offering a service to the patient.”

2.2.2	What are the Most Burdensome Tasks?

There was no agreement as to which were the most burdensome task and to an extent this did not seem to be the most important issue.  No one particular task is singled out (with the exception of Centrelink forms which are discussed below).  Rather, it is the sum total of the paperwork and compliance task burdens that GPs lamented.  They also feel that attempting to reduce the burden of paperwork would be a very difficult exercise.  As discussed, the tasks are seen as a part of the consultation and part of their job.

There is a perception that many of the compliance tasks, paperwork and forms are required to be completed on the GPs own time rather than charged for as part of a consultation.  There is also a great deal of confusion as to which tasks can and can’t be charged for and under what circumstances.  

“If you do something medical in that consultation….and you’ve done the Centrelink form….it’s not illegal to do that.  I’m sure that no-one comes in and just has a Centrelink form and then walks out.  I’m sure you do other things as well.”

If any particular task did stand out as frustrating it was the Centrelink forms.  The main issues GPs identified with regards to Centrelink were: 
•	Time constraints in which the forms are often required.
•	The frequency with which some of the Centrelink forms are required to be completed for the same individual.
•	The repetitive nature of the questions.
•	The fact that GPs are not often able to charge a Medicare Consultation Code for their time completing these forms.

“A lot of the forms we do fill out are Centrelink forms.  We seem to be filling them out repeatedly, yet for some of the questions that they specifically ask in these forms ‘Is the disability permanent?’  - you tick ‘yes’.  Yet three months later you’ve got the same form again for the same patient, which really contradicts the purpose of the form.”

Similarly, forms relating to Sickness Benefits and the Carer’s Allowance are also described as having “strange” questions.

The GPs in the research do acknowledge that their profession involves long hours and large amounts of paperwork.  This therefore turns their focus on ensuring that they are remunerated for as much of their time as possible.  In the case of compliance tasks such as Centrelink forms they describe two alternatives:
1.	Charge the patient for a private consultation.
2.	Conduct a ‘real’ consultation (eg. take blood pressure) and charge for a standard consultation.

The latter option is generally more acceptable to patients while the former is more difficult to explain.

There was a strong feeling that there is little that could be done to reduce compliance costs in General Practice.  As previously discussed, rather than reducing the load which GPs see as a necessary part of their work, there is a strong call for their time to be remunerated.

“Mind you, paperwork is part of our job.  I don’t think that at the end of the day it matters if I’m talking to a patient, looking at a kid’s chest, or I’m doing paperwork.  I’m still there and I’m doing work.  My personal beef is that it’s unpaid.”

2.2.3	State or Commonwealth?

When GPs consider their load of compliance tasks in terms of whether it was a Commonwealth, State, Local or private matter and considered the Commonwealth compliance tasks (the terms of reference of the study) many realise that this is only a small proportion of the total paperwork burden.

There is also some confusion as to which programs are State and which are Commonwealth.  While GPs could quickly identify most when asked to review the list presented, there was contention surrounding a few.  

However, the important finding from the qualitative research is that this makes no difference to the GP.  The fact that one task is part of a Commonwealth program and another is part of a State funded program and that others are a regular part of the consultation is of no relevance to them – it is simply paperwork.

2.2.4	Implications for the Study

•	The terms of reference of the study must be clearly defined to GPs.  The term “compliance tasks” has little meaning to GPs – this is not their language.  To facilitate quantitative data collection on relevant tasks a list of the tasks of interest will be essential.
•	A comprehensive list of policies and programs of interest should be included.  Many GPs will be de-motivated to complete the study if they feel the terms of the reference are too narrow for the study findings to have a real impact on their paperwork burden.
•	The language used by GPs to describe some of the tasks and forms may be different to the technically correct terms to describe them.  This must be carefully considered in conducting the quantitative research to make the task easy for the GPs and make sure that reliable data is collected.
•	There is a degree of scepticism as to whether reducing the load of Commonwealth Compliance is possible, and if it is, how much impact this would have on their overall workload.  This will have implications for likelihood to participate.

2.3	Overall Reactions to the GP Compliance Costs Study

There was some scepticism among GPs when the idea of the study was introduced.

The GPs in Bendigo were the most positive towards the idea of the study, and felt that their participation would have a positive impact on their workload in the long term.

In Melbourne, the very idea of the task of recording time spent on compliance tasks seemed an onerous addition to their workload.  Their first question about the study was how much they would be paid to participate.

“I think it would be interesting, but I think the task itself and what you’ve got to do, it would be daunting.  And if it was a really busy day you might not do it.”

“To get the doctors you would have to tell them straight off that it (would) take one minute to tick the box.”

“When you’re running late, [the diary] is the last thing you’d think of – every minute counts!”

“I can understand that no one is going to be able to cut down the amount of paperwork we do unless they realistically know what we’re doing.”

“The only way you can help us is to make sure we are reimbursed.”

The main issue that creates a barrier to participation is a lack of confidence that the results of any such study would be implemented.  Many cited as an example the Relative Values study that they perceive has not been actioned (or not to their satisfaction).  In addition, the fact that the study’s terms of reference are Commonwealth policies and programs seems to lessen the value of the study and the potential value to them of its findings.

“The Commonwealth Government acts on their own.  The State acts on their own.  Local council acts on their own.  So you’re doing this and it’s a lovely idea but its not going to give you a really good view of what we’re doing, because the Commonwealth [tasks represent only a minimal amount of the paperwork].”

“It’s interesting because the ones that cause us the most hassle are actually the State ones and the local government stuff.”

It should be noted that many GP’s feel that the best outcome of a study into compliance costs for them would be to remunerate them for the time they spend on such paperwork.  But at the same time, they realise this is a highly unlikely outcome.

It is also significant to note that there was low awareness in the focus groups of the role of the Productivity Commission.  When this information was provided as well as the information that the results of the study would be published and tabled in Parliament some of the scepticism abated. 

2.3.1	Implications for the Study

•	The purpose of the study and its intended outcomes must be clear and honest.  It is potentially an over promise to suggest that a focus only on Commonwealth Compliance tasks will result in a major reduction in overall compliance costs in General Practice.
•	The objective of the study must be made very clear, as should the role of the Productivity Commission and its independence.
•	The information that the results of the study would be made public and tabled in Parliament helps lend credibility to the study and could act as a motivator to participation.
•	An incentive will greatly increase the participation rates, particularly of the busier GPs.  Indeed, many expect this would be the only benefit to them of participating.

2.4	Reactions to the Initial Letter to be Sent to GPs

GPs receive a large amount of mail daily that they must sort through.  This includes all sorts of material of varying quality.  Much of it is thrown away with little more a cursory glance.  

This clearly has significant implications for the quantitative study.  The letter informing GPs of the study must:
•	Look official and important.
•	Be personally addressed.
•	Be signed by a relevant official and carry endorsement of relevant peak bodies.

However, selecting an appropriate signatory will not be an easy task and this was a controversial issue in the focus groups.  GPs themselves describe their profession as “fragmented” and they have varying degrees of loyalty and regard for their own professional bodies.  

“I think you do need to have the General Practice bodies endorsing anything that’s to do with General Practice, whether we belong to those bodies or not.  I think that increases credibility, and it needs to be all of them.”

Mixed responses were expressed in relation to the Productivity Commission or Millward Brown being potential signatories.  Given the amount of mail GPs described receiving and sorting, a letter endorsed and signed solely by these organisations may be tossed away along with many other requests for participation in surveys by other research companies, pharmaceutical companies, universities and the list goes on.  The Minister of Health and Ageing, Kay Patterson, a clearly recognised character, similarly received a mixed response.

2.4.1	Implications for the Study

•	The letter informing GPs of the study should carry the endorsement of multiple organisations to maximise appeal and credibility.
•	The letter should clearly state that GPs would have the option to receive a copy of the resulting report.

2.5	Reactions to the Diary

The sample diary instrument itself was well received by the GPs in the focus groups.  On closer inspection of what the task required, many questions were raised.

Initial or follow up activity

There was some confusion about the definition of a “follow up”.  This also seemed irrelevant to GPs and they did not understand why this extra level of information was required.  If this information is required a very clear and common example will be required to ensure the correct information is obtained.

Time

The metropolitan GPs were very concerned about having to estimate how much time each task took.  As discussed previously, GPs are completing these tasks during the consultation as often as they can.  This makes it difficult to estimate how much time particular tasks within a consultation take.

“It’s all woven into the consultation…”
“Its very difficult to sort it out”
“You’re doing other things as well.”

Activity

As discussed earlier in this report, GPs list a wide variety of paperwork, forms and compliance tasks.  A list of policies/ programs/ forms will be required to facilitate accurate data capture.

Consultation Code

The need to provide a consultation code also concerned GPs.  As it is inappropriate to charge a Medicare schedule fee for some of the paperwork and compliance tasks it seemed inappropriate to include this in the diary and raised the suspicions of some as to the real purpose of the study.  

2.5.1	Implications for the Study

•	Overall, GPs reactions to the diary were positive.  It was perceived to be a simple form to fill out.  Clear, common and relevant examples of the information required should be provided to facilitate accurate data collection.

•	The requirement in the diary collection tool to indicate the Consultation Code causes confusion and concern.  We would recommend reconsidering the need to collect this information.
o	The confusion arises from the fact that GPs understand some tasks should not be charged for.
o	The concern is that they are being audited in some way.
o	It would appear that some GPs might be reluctant to complete this field in the diary completely honestly.

2.6.	The Issue of Incentives

Some of the GPs in the research expressed concern that they feel undervalued.  Undervalued by both the community and by the Government.  GPs main complaint is that they do not feel that they are paid for all of their time and work.  Many described taking steps and changing their behaviour to rectify this.  For example, charging an hourly rate for providing medical or legal reports.  Increasingly, this means GPs will be reluctant to give their time, opinions and experience for free.

Similarly, requests for participation in surveys from Universities, private organisation and Government that are not accompanied by a realistic reimbursement for their time are unlikely to be met positively.  

The mood of GPs on this issue creates the concern that it will potentially reflect negatively on the Government and the Commission, given the nature of the study, if GPs are expected to participate without any reimbursement for their time.  It sends a signal that their time is not valued and could be interpreted by GPs as a lack of understanding of their situation and concerns.

When GPs considered the requirements of the study (diary and 20 minute telephone survey) it was difficult for them to estimate the time involved in participation.  However, their expectation is that the reimbursement would be at least commensurate with their hourly rate.  

3.	
  CONCLUSIONS AND RECOMMENDATIONS

The qualitative research clearly supports the need for further investigation into the cost of compliance in General Practice.  Paperwork and compliance tasks do create a burden on the day-to-day work of GPs.

However, the response in the focus groups to the idea of the study was quite skeptical and this may impact participation rates.  GPs seemed skeptical that:
•	Paperwork and compliance tasks can be reduced significantly, as they perceive them to be an integral part of their work.
•	The results of the study would be acted upon.

In order to maximize participation in the study:
•	The letter must be compelling as well as honest with regards the study objectives and what can be achieved.  The letter should also inform GPs of the ways in which the results would be published.
•	Endorsed by the peak medical bodies.
•	The diary should be simplified as far as possible to make the task easy for GPs.  The diary should also be accompanied by a comprehensive list of the tasks and forms that GPs complete in complying with Government policies and programs.
•	Offer an incentive as a way of both encouraging participation and recognising the contribution of GPs in the study and their time contribution in participating.