The Price of Pain By Mrs Vera West
Here is a Four Corners program well worth viewing, "Pain Factory," dealing with the problem of chronic pain in Australia. This is a problem facing around three million people in Australia, and I am one of them. Back pain, which I have, is the leading cause of disability both in this country, and across the world, and the main cause of loss of productivity.
Dealing with back, and spinal issues is a multi-billion-dollar business. Four corners found out from its investigations that there was much shonky business going on with private health insurance billing of patients undergoing spinal surgery between November 2017 and May 2023. They reported:
"77 per cent were billed for more complex services than provided;
10 per cent were billed for longer services than provided; and
7 per cent were billed for spinal fusions for chronic lower back pain without a diagnosis, in breach of a Medicare rule."
The program left me with the feeling that the medical profession seems more concerned with profits from the misery of we back pain suffers, than addressing the cause of our sufferings. Watching the program had the impact upon me of giving me back spasms, probably a psychological reaction.
https://iview.abc.net.au/show/four-corners/series/2024/video/NC2403H008S00
"Trudi King is always in pain.
"The only relief you get is when you go to sleep," the 60-year-old says.
In 2021, she had spinal fusion surgery at a private hospital in Sydney after struggling with back pain for four years.
"All I wanted was to live a pain-free life," she says.
When she woke up, she couldn't feel her feet.
"I was terrified … no one really told me what was going on," she says.
Trudi had a second surgery the next day. There were serious complications and she was in a coma for almost three weeks.
When she finally got home, she had to use a wheelchair.
As for the pain, it's now even worse.
Trudi is one of more than three million Australians grappling with the relentless agony of chronic pain. Back pain is the leading cause of disability and lost productivity in Australia and globally.
It has spawned a multi-billion-dollar industry offering treatments including spinal surgeries and medical devices — the majority done in the private sector.
For the past six months, Four Corners has been investigating the trail of misery it has left behind. For some it's meant more pain, paralysis, and even death.
Spinal fusion costs tens of thousands of dollars. Trudi's experience cost her health fund a fortune.
What she now knows, after the investigation by Four Corners, is that not only did her surgery cause her harm, but some of her medical bills raise concern.
An analysis of Trudi's records by medical billing expert Margaret Faux found questionable billing from anaesthetists involved in her surgery.
Dr Faux, the founder of medical technology company Synapse, did not have access to Trudi's full medical records, but analysed her private health insurance and Medicare bills for the time she was in hospital, including the period she was in a coma.
"There are red flags because during that same period, a number of doctors came into the intensive care unit," she says.
"The services that they billed are services that require the doctor to have a discussion with the patient; not their relatives, not their colleagues — with the patient — because you have to explain treatment to the patient.
"I do not understand how it is possible to have a discussion with an unconscious patient who is in a coma."
It's not an isolated case.
Four Corners has obtained the private health insurance billing records of more than 23,000 patients who underwent spinal surgery in Australia between November 2017 and May 2023.
Across the full data set, the analysis found:
77 per cent were billed for more complex services than provided
10 per cent were billed for longer services than provided; and
7 per cent were billed for spinal fusions for chronic lower back pain without a diagnosis, in breach of a Medicare rule
The de-identified data was supplied by six private health funds, representing 25 per cent of the private health fund industry.
The records were sent for analysis to Dr Faux and a team at Synapse, as well as a team at Kirontech, a UK-based health fraud investigation company that used its specialist detection software.
They cross-checked the analysis and wrote a report. Together, they found more than 20 per cent of the bills they assessed raised questions.
The experts state in their report there is a strong suggestion of "a serious fraud, waste and abuse problem requiring urgent attention".
The terms "fraud, waste and abuse" are used widely in the industry and can cover conduct ranging from errors, to overservicing, to fraud.
Rachel David, CEO of Private Healthcare Australia, says if the findings were applied to the whole industry for spinal surgery, it would signal a huge draining of the health system by some medical professionals.
"We're talking about half a billion dollars."
The team analysing the data ran complex algorithms to exclude the possibility of other medical explanations, but without each patients' medical records it's impossible to be conclusive.
Most of the questionable billing came from anaesthetists and surgeons.
Kirontech's chief medical advisor Dr Simon Peck – who is also a former anaesthetist – says the findings are alarming.
"We've looked at data from all around the world, and I would say the indicators of misbilling … is at the top end of the scale," Dr Peck says.
"Medical bills are paid on the basis of trust … After a while, when people realise that they're not being checked up on, they start … to push the boundaries."
The system is hitting the patient twice, Dr Faux says.
"We are exploiting them clinically by offering them treatments and procedures that … can be harmful, and then a second time financially."
Last year, an Independent Review of Medicare Integrity and Compliance, commissioned by Health Minister Mark Butler, found "legislation, governance, systems, processes and tools are currently not fit for purpose and, without significant attention, will result in significant levels of fraud".
The review made several recommendations to be implemented to strengthen the Medicare system."
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