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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.
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.
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.