So what is going on? The Medicare rebate freeze is still inflicting an icy bite on general practice.
Its teeth have been in place, save a few short breaths, since 2013, when the policy with all its political utility was employed by the Labor Government.
During that time you could count the rebate increases for a standard GP consult in terms of cents rather than dollars.
But this is the thing. Bulk-billing across general practice is claimed for 83% of GP services. This should not be happening if you accept the specialty is the victim of a funding crisis. Something should snap. Yet in the long history of Medicare, bulk-billing rates have never been higher.
The ‘why’ question is important. Yes, there is the personal. This is about GP incomes, given their dependency on the Medicare dollar for making a living.
There is also the medical care issue: whether GPs are doing the same with less, or more with less or less with less and, if it’s the last, what real-world effect is this having in terms of patient care.
Unfortunately, as will quickly become apparent, all these questions are hard to answer with much confidence.
The rise of care plan claims
In 2015, a Medical Journal of Australia article attempted to document the lost income inflicted by the various co-payment plans concocted by the soon-to-be-doomed Abbott Government.
On the issue of the Medicare freeze, the authors calculated that the average full-time urban GP would lose some $9600 in Medicare revenue in the first financial year, increasing with inflation to $29,500 by 2017/18, the date when the current government says the freeze will be thawed.
The sums involved here are significant. So the obvious answer as to why doctors have not been charging co-payments en masse to recoup these losses is that they have found the revenue from elsewhere. Health systems the world over are familiar with the health professional’s art of exploiting/identifying hidden demand. And in terms of Australian general practice, this usually means care plans.
The broad statistics show that care plan claims have been rising — and rising for some time. The Medicare bill for items 721, 723 and 732 in 2010 was $336 million. In 2015, it reached $711 million.
What’s been difficult — like all Medicare claims — is to untangle the various causes behind this rise. Cynics would say this is not a simple response to clinical need, even with the ever-growing weight of the chronic disease burden.
On the other hand, although anecdotes abound about the plans being churned out as though they were on a printing press in some practices, many elements of the profession would say this remains fringe behaviour.
Those obsessed with evidence-base, given the lack of any systematic review of their clinical use and the small scale of rorts identified by Medicare and the Professional Services Review, would probably remain agnostic.
Too many GPs?
Another explanation for high bulk-billing rates is the “too many” GPs argument. Or at least the argument is that there are too many GPs squeezed into particular geographic locations, namely, the big city areas where the schools are good, the career opportunities for spouses strong and you can get a decent soy latte.
Back in 2013, Dr Bob Birrell, a Monash University academic, published a controversial paper saying exactly this — to much condemnation from the GP groups.
The basis of his wider argument was that Australia should stop importing IMGs on 457 visas. He claimed this had resulted in the 16.7% hike in full-time equivalent GPs between 2006/07 and 2011/12, nearly double the growth rate of Australia’s population.
He went on to claim there was “no financial constraint on prospective patients in a bulk-billing situation”.
“[It] is up to the GP to decide whether extra services are appropriate for the patient.
“[When] GPs have to chase patients, the result is not good medicine. It is excessive service.”
This was rubbished by then RACGP president Dr Liz Marles.
“I have people come down from the Central Coast in NSW to my practice in Hornsby because GP books are closed,” she told Australian Doctor at the time.
“That is not suggesting to me we have too many GPs.
“The key point is that [Dr Birrell] has made no comment on changing morbidity in Australia — increasing rates of diabetes for instance or the ageing population.”
Dr Bob Birrell.
However, health economists agree that with the number of new GPs coming into the system (1500 new GP registrar places were filled last year compared with just 450 in 2003), price competition in general practice is likely to increase.
Dr Birrell says: “There’s no doubt in my mind that the growth in the number of GPs to patients has increased competition for patients and helps explain the low bulk-billing rates in the Howard era. The flow of registrars through the system will make the competitive situation worse. So will the movement of IMGs into metro areas as they finish their required years in areas of need.”
The rise of GP corporates
The other reason cited for the increase in bulk-billing rates is the rise of GP corporates: universal, bulk-billing corporate medicine based on easy access (in other words, the Primary Health Care model), where practices are happy to charge $37 for a 20-minute consult.
For critics of the corporate model, this has fixed the GP market price at low levels, at the level of Medicare bulk-billing rebates. This price is the level beyond which patients will often walk out the door to a rival ‘free’ clinic.
Just how sensitive patient behaviour can be to GP price signals remains an academically open question in Australia. But one of the more interesting experiments began in 2009, when the late Dr Ed Bateman, the Primary Health Care boss who had turned Medicare into gold, decided to allow GPs at some of his larger practices, mainly in NSW and the ACT, to charge gap fees.
He said it was partly a response to the frustrations of Primary’s doctors and partly a toe in the water to see if company revenue would rise.
The co-payment ranged from $30-$40 for non-concession card holders. It lasted three years, but the plug was finally pulled. Primary said it was not that patients fled, but patients numbers did not rise in line with expectations. So the initiative got ditched.
It is worth pointing out that Primary is again flirting with the idea of co-payments. But Australian Doctor has been told it won’t be at the company’s 60 large-scale clinics. These will remain universal bulk-billers. It will be at the smaller clinics where, you suspect, competition for patients is not going to be so keen.
The one question that the specialty, at least at an individual level, is aware of is the impact of the government paying a $37 rebate for 20 minutes of GP consultation time.
What do you get for your money if there is limited opportunity to cross-subsidise the business of general practice through care plans, Practice Incentive Program payments, mental health items or after-hours work?
But this is the question, despite its fundamental importance, that beyond the experiences of individual practices, health economists and health policymakers have struggled to answer. This is where the hole — at least in public policy terms — is darkest.
Dr George Quittner (pictured left), a Sydney GP and a well-known ideological opponent of Medicare, says the effect of record bulk-billing rates is disastrous.
“The cheap doctors are the most expensive. I charge double the rebate to do a Pap smear. Around 99% are normal, so there is no need to call the patient back to discuss it. This costs taxpayers one consultation.
“Bulk-billing doctors almost always call the patient back for all pathology results — so it costs the taxpayer two consultations. I make phone calls and respond to emails daily as part of my ‘expensive’ service. Any communication of any kind with a bulk-billing doctor requires personal attendance by the patient. This is a commercial imperative … but nevertheless is a total waste of more taxpayer dollars.
“[Bulk-billing doctors] are victims of a system that has crushed all self-respect for the GP. If they do not do it, the guy next door will and they may lose a patient.”
This account may be extreme, fighting talk for those GPs bulk-billing through necessity, those in the low socioeconomic areas where charging co-payments is not an option.
But groups like the AMA and the RACGP make their argument to governments that quality care will be eroded with funding cuts.
The issue goes to the heart of every GP fighting to practise the medicine their extensive education and training prepared them for.
The problem is that it has been a struggle to give a clear vision to the wider world — particularly to the politicians — of what general practice would do for Australian healthcare if it were funded to deliver the highest quality care.
Dr Linda Mann, a Sydney practice owner, says the widespread expectation and practice of bulk-billing breeds a certain psychology in younger doctors.
“I encourage them to charge what their skills and talents are worth. I worry because I sometimes think they don’t understand their value, what it is they are doing … certainly not like your average specialist in other fields,” Dr Mann says.
There is also the wider politics. The profession argues funding for general practice is far from adequate. But it is worth pointing out the obvious — the only time in recent memory a Federal Government increased rebates for GP consultations was in 2003 when bulk-billing was at an all-time low, at some 68% of GP services. Then prime minister John Howard had an election looming, so against his ideological instincts he increased rebates to 100% of the scheduled fee. It cost some $750 million over its first four years.
And once bulk-billing rates reached their record high? Medicare rebates were frozen — as they remain to this day. Bulk-billing rates are more than just a number.
What the AMA says
“The Australian public largely expects that GPs will bulk-bill them, and history shows that it takes a lot to push GPs to the point where they will charge patients an out-of-pocket expense. GPs are at the front line, and are known for their compassion and efforts to put the interests of their patients first.
“GPs work in an environment where the community loves them, but does not want to put a value on the high-quality care that they deliver. For many GPs, the fear is that patients will simply move to another practice if they charge a gap.
“GPs have also worked hard to deliver high-quality care in a constrained funding environment, with more and more GPs working in larger practice models.
“We have also seen the expanded role of practice nurses and other efforts to improve efficiency within practices.
“In practices where patients are charged a gap, this has grown significantly over the last 10 years, more than doubling. This is often used to cross-subsidise other patients.
“There is no simple solution that explains the high rate of bulk-billing in general practice. With the freeze on rebates and more and more patients suffering from complex and chronic disease, the real challenge for policymakers is to think about the future sustainability of general practice.
“General practice is seen as being the answer to all the health system’s woes but, unless we see additional investment, we know it will only be a matter of time before many practices will struggle to make ends meet.”
Dr Brian Morton, chair of the AMA council of general practice.