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Unanswered questions on Maternity and Infant Care Scheme

A recent column in the Medical Independent by GP Dr Lucia Gannon warned of an erosion of the Maternity and Infant Care Scheme amid a growing trend of declined claims that meet its contractual terms. These concerns and experiences are shared by many GPs nationally, reports Catherine Reilly

“My secretary has confirmed that we are NOT getting payment for any extra antenatal visits (even if they are clearly identified, such as high blood pressure review). They are all being refused by PCRS [Primary Care Reimbursement Service].”

Yes, we have experienced this repeatedly. Claims denied for UTI, extra visits deemed necessary by obstetrics clinics referred to us, abdominal pain, hypertension, hyperemesis, post-partum abdominal pain, post-partum C section infection etc….”

“I have certainly noticed a number of additional visits marked as invalid and rejected. These are only claimed as pregnancy-related conditions, ie, a sore throat is obviously not covered, but somebody with bleeding/spotting, high blood pressure (risk of pre-eclampsia) and a number of other visits are supposed to be covered….”

These were among the responses from GPs when the Medical Independent (MI) asked if their practice was being refused claims for additional visits under the terms of the Maternity and Infant Care Scheme, which is a cornerstone of maternity care provision in Ireland.

Dr Lucia Gannon

MI’s enquiries followed publication of a concerning article by columnist Dr Lucia Gannon (‘Maternity and Infant Care Scheme under threat’, 4 October 2021, Medical Independent), where she described how her practice’s claims for additional payments had been consistently rejected since April.

“It does not make sense that there appears to be a move to undermine and hamper the delivery of this care by the PCRS,” wrote Dr Gannon. “Since April 2021, in our practice, claims for additional payments for hypertension, gestational diabetes, and urinary tract infections have been consistently rejected for payment and I am told that I am not the only GP who has had this experience.

MI’s enquiries have confirmed that GPs across the country have experienced a notable rise in rejected claims for additional visits, despite these consultations being covered under the Scheme’s provisions.

The Maternity and Infant Care Scheme, which is underpinned by legislation and contractual terms, provides for a programme of antenatal and postnatal visits.

Contracted GPs provide care for pregnant women and new-born babies from the time of diagnosis of pregnancy
until six weeks postnatal.

According to the HSE, the Scheme allows up to six routine antenatal visits with the expectant mother’s GP of choice for the first pregnancy and up to seven routine visits for subsequent pregnancies.

“This is in addition to the schedule of antenatal visits provided by the maternity hospitals, with further additional visits provided in hospital in the case of complicated pregnancies as required,” stated the Executive.

The Scheme also provides for two postnatal visits to the GP.

“In accordance with the rules governing the Scheme, expectant mothers with major conditions, eg, diabetes or hypertension, may have up to five additional visits to their nominated GP. Where claims are validated as [for example] related to hypertension and/or gestational diabetes, those claims are always paid. Care in respect of illnesses which are coincidental with, but not related to the pregnancy, does not form part of the Scheme.”

[While the HSE response correlated the additional visits with antenatal care, the contract does not appear to explicitly restrict such visits to the antenatal period].

In 2020 total payments to GPs by the PCRS amounted to over €780 million, of which more than €14 million related to
the Maternity and Infant Care Scheme. The fees payable to GPs under the Scheme are significantly less than standard private consultation fees.

A HSE spokesperson told MI that “PCRS has a legal responsibility to ensure that resources are used for the purpose for which they are intended”.

However, the experiences outlined in Dr Gannon’s column, and reported by GPs nationally, have involved rejected
claims that ordinarily meet the contractual terms for additional visits.

The consequences of eroding the parameters of the Scheme are far-reaching. As Dr Gannon outlined in her column:
“The World Health Organisation have designated the detection of asymptomatic bacteriuria in pregnant women
as one of the 10 most cost-effective screening interventions worldwide. Detecting an asymptomatic urinary tract infection can prevent perinatal death and septic shock in a mother.”

On social media, Consultant Obstetrician and Gynaecologist Dr Nóirín Russell described the content of the column as “deeply disturbing”. “Antenatal care reduces perinatal and maternal morbidity and mortality. Shared care between primary care and hospitals is critical.”

One of the most troubling aspects of the piece was the lack of accountability, with decisions attributed by the HSE to faceless medical officers in the PCRS, with whom GPs or practice managers are generally not permitted to communicate.

Centralisation

The Maternity and Infant Care Scheme was centralised within the PCRS from July 2019. Prior to centralisation, it was operated at local level. “With the advent of centralisation, PCRS has ensured that all claims for additional visits are reviewed, if appropriate, by medical officers (doctors) employed by PCRS,” according to a HSE spokesperson.

Some GPs say the increased rejection of claims followed the Scheme’s centralisation, while others reported that the issue first came to their notice earlier this year. On social media, a GP remarked that the situation had been ongoing for years, but with “less consistency”.

A Cork GP, who did not wish to be named, said their practice was not being paid for the additional visits since around springtime.

They recently submitted  another  claim  for a gestational diabetes consultation, which  was  not  approved.  The patient had  been  instructed  by  the  hospital  to  attend  their GP.

According to the GP, the situation was very frustrating for the practice manager, but was “typical HSE behaviour”.

“Lots of GPs won’t cause a fuss and just get on with things and they know that.”

According to information from a practice  manager in the  southwest,  when  the  Scheme was  operated  locally,  each  HSE  office had their own criteria for determining  payments  for  additional  visits.  When the process was centralised, no new criteria was issued.

Their understanding, from conversations with HSE staff, was that claims required a potential reading for hypertension while “diabetes is not sufficient, it has to be gestational diabetes”.

The practice manager believed all claims for additional visits were assessed by a medical officer, but  there  was  no  information  as  to  the  identity  of  these  persons,  or  any accountability regarding their decision.

Dr Stephen Murphy, GP in Ashbourne, Co Meath,  confirmed that the PCRS was refusing claims for additional visits that had been approved in the past. The reasons provided for the refusals were vague and included “lack of clinical information”.

“Hospitals are telling  patients  to  attend  GPs, but are unaware of how we are funded for antenatal services. Same with HSE – ‘go to your GP’ but then [they] refuse to re-imburse,” he added.

Another GP, based in Dublin, remarked that practices were so busy they may not have noted this issue.

“The problem is that it’s very difficult to  query  specific  claims  with  PCRS,” they commented. “We get a payment breakdown each month which will list payments/non-payments. A lot of practices are so snowed under that they maybe only check every few months, but the process for appealing is so laborious and usually ends up with no payment being made regardless that it almost defeats the purpose.”

According to this Dublin GP, it appeared the non-payments had “skyrocketed” since the process became electronic and submissions  were  handled  centrally  by  the  PCRS,  rather than local HSE health offices.

A practice manager in north Leinster noted that their claims for additional visits had  recently  been  ‘on  hold’  for  a  period,  whereas  usually  they  were  processed  reasonably  quickly.  They  speculated  that  this  could be due to under-staffing in the PCRS.

Dr  Laura  Cullen,  GP  in  Bantry,  Co  Cork,  told MI that Dr Gannon’s article was “absolutely excellent” and “very, very accurate in its representation” of the situation. After an exhausting  19  months  for  GPs,  “there  are  only  so  many  fights  you  can  take  on”  and  GPs  were  grateful  to  Dr  Gannon  for  bringing this issue to wider attention in the medical community and public.

Dr  Cullen,  who  specialises  in  women’s  and  sexual  health,  works  in  a  practice  that  typically has a significant cohort of patients requiring ante- and post-natal care.

She  confirmed  that  the  practice  has  not  been paid for most additional visits under  the  Maternity  and  Infant  Care  Scheme  since  the  claims  process  was  digitalised. 

While the practice has endeavoured not to charge patients for the additional visits, not all practices would be in the same position.

Additionally,  tolerance  of  non-payment  of  claims  has  repercussions  for  the  sustainability  of  general  practice  over  the  longer  term.  Dr  Cullen  said  the  situation  could  also  be  confusing  for  patients  whose  additional  visits  were  previously  covered,  in  accordance  with  the  terms  of  the  Scheme,  and now were being rejected.

Dr Cullen expanded on the importance of these consultations for pregnant patients.  Some  women  with  high  blood  pressure  in  pregnancy,  for  example,  may  be appropriately managed in general practice without the need for hospital referral. She said while high blood pressure in pregnancy may be benign, “it can also be something more serious, which can become pre-eclampsia.”

“So you do need to keep a closer eye; you need to see them at increased frequency.”  Dr Cullen added this was one of many examples where patients would need closer observation during pregnancy.

Dr Cullen confirmed she has heard “multiple GPs” discussing the issue of non-payment of  claims  for  these  additional  visits.  To  the  best  of  her  knowledge,  the  “great  majority”  were  not  being  paid  in  this  regard. 

She  was  unaware of the outcomes for the small number  of  GPs  who  still  submitted  paper-based  claims under the Scheme (a process that involves  the  claims  being  submitted  after  the  end  of  the  pregnancy,  as  opposed  to  after  each visit through the online system).

According  to  Dr  Cullen,  the  online  system  is  “much  more  seamless”,  but  the  current  difficulties  are  “going  to  disincentivise  people from engaging with advancements if they feel like their income is being undercut. We  are  very  appreciative  of  the  technological  advancements,  but  if  you  are  undercutting people, that just acts as a disincentive.”

She  added  that  her  practice  manager  has  queried the situation with the PCRS, but has not been furnished with further information or  provided  access  to  a  person  with  whom  she can query the situation in more detail.

Responses

Dr Cliona Murphy, Chair of the RCPI Institute  of  Obstetricians  and  Gynaecologists,  informed MI  she had  been unaware of  the  matter prior to the recent coverage. She described shared care as the “cornerstone” of maternity services.

Dr Murphy stated: “From the obstetrician’s perspective our GP colleagues provide invaluable  continuity  of  care,  give  flu  and  pertussis boosters in pregnancy, monitor for signs of pre-eclampsia, among other issues.

“Crucially they know the personal and social circumstances and the other children which ensures holistic care.”

An ICGP spokesperson said it would not be making a comment to the media, as the terms and conditions of the Maternity and Infant  Care  Scheme  were  an  “IMO  matter  and don’t relate to the training and education role of the College”.

This  newspaper  sought  comment  from  the  IMO, but none was received by press time.

MI  asked  the  Department  of  Health  if  it  was  aware  of  any  policy  change  in  regard  the  Maternity  and  Infant  Care  Scheme,  or  if it had requested any change to the access criteria. “This should be directed to the HSE,” according to a spokesperson.

The  HSE  stated  that  “where  uncertainty  arises  in  relation  to  a  claim  submitted  for additional visits, GPs are requested to  provide  information  to  ensure  the  additional  visits  are  in  line  with  the  rules  of  the  scheme.  Furthermore,  in  the  case  of  claims  initially  rejected  for  payment,  GPs  may  provide  additional  information  to  support  these  claims,  and  in  those  circumstances,  the  initially  rejected  claim  would be reviewed.”

Following  the  first  24  months  of  centralisation  of  the  Scheme,  the  PCRS  was  “engaging” with the National Women and  Infants  Health  Programme,  according to the HSE.

“PCRS medical officers engage with relevant  clinical  experts  to  assure  themselves that any internal validation procedures  are  appropriate  and  in  line  with  clinical practice guidelines.”

The emergence of difficulties for GPs  receiving  payment under the contractual terms of  the  Scheme  has  come  at  an  incongruous time for Minister for Health Stephen Donnelly, whose Department has recently issued a string of press releases on various women’s health initiatives.

As well as their concerns around the impact  on  antenatal  care,  many  GPs  say  the  issue  points  to  a  broader  dysfunction  in  the  relationship  with  the  PCRS,  which  they  fear  will  further  hamper  recruitment  and  retention.  The  ICGP,  which  has  been  increasing trainee numbers, recently highlighted  that  Ireland  has  29  per  cent  fewer  GPs per head than the UK.

Killarney GP Dr Gary Stack told MI: “My concern is that it is practice management that  really  puts  off  many  young  GPs  –  as  well  as  out  of  hours  –  and  the  complexity  of  the  GMS  system  is  smoothing  the  way  for the corporates to take over practices.”

Another experienced GP, in the southeast, reflected: “The PCRS interpret payment requirements in whatever way they choose and this is never to the benefit of the GP. I am unaware of any neutral arbiter to whom any appeal can be made in the event of non-payment of fees.”

The PCRS was, according to one Dublin GP,  engaged in a “game of attrition” with GPs.

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