Issue 19 / 30 May 2011

THE current Medicare rebate system penalises GPs working in areas of need because, despite often dealing with more complex presentations, they earn significantly less income and work with fewer resources than their colleagues in more affluent areas. Let me tell you why.

An area of need (AoN) is defined by the WA government as “a location in which there is a recognised lack of specific medical practitioners or where there are medical positions that remain unfilled even after recruitment efforts have taken place over a period of time”.

For 18 years I worked as a GP in an AoN in an outer metropolitan Perth suburb until 2007 when I took the opportunity to work part time at a Perth hospital. To maintain my general practice skills I also moved to part-time practice in an affluent inner city area. It was the first time I had worked outside an AoN.

I kept in contact with my former AoN practice, which now had just one woman GP, who was 67 years old, and seven men —  a significant gender imbalance.

After two years at the hospital I wanted to return to full-time general practice and initially practised in both the affluent area and the AoN. But the demand at the AoN practice was so great I decided to go back there full time.

It was at this point my salary dropped by about $30 000 a year after tax. I knew it would drop but had no idea it would be by so much.

The difference is simply private billing versus bulk-billing. No doubt some will say why don’t you bill then? It is because a lot of the people in an AoN are very poor, on pensions or health care cards. I do not want my patients going without healthy food, clothing, shoes and petrol to pay to see me.

The practice in the affluent area had an excellent standard of medicine and there was an abundance of part-time women doctors. No wonder.

Currently I only see women patients because of patient need and book 15-minute appointments. The problems are often complex and time-consuming in people with few support services and resources.

I have always worked in poor areas and I was happy. However, after having worked in an affluent area and been paid so much more it has been difficult to reconcile that difference.

A system that rewards doctors so extravagantly for working in affluent areas and does not recognise the difficulties or financial penalties of working in an AoN is extremely unjust.

Why don’t we all work in affluent areas and charge $65 a patient for a level B consultation? Well, that is precisely what is happening and why there are AoNs.

There is also the issue of employing overseas doctors in AoNs. If we employed carpenters or miners or hotel staff in similar ways there would be an outcry. Bringing people to Australia to work for less money in worse conditions would not be tolerated in mining or many other industries.

So here, in Australia, we have a two-tier system that is not getting better — it is getting worse. There are fewer services for the poor, they have less access to doctors, particularly women doctors, and the doctors they do have access to often come from different cultures compared with affluent areas.

I have given a great deal of thought to a possible solution.

One is more flexibility in the relocation grant, which is only available to those who apply before they relocate to an AoN. I was not aware of these grants before I moved. If I had, the payment would have gone some way to compensate me for the lower income.

The second is to increase the rebate for bulk-billing in an AoN.

Simply graduating more students is not going to address the problem of doctors working in AoNs being treated as second-class medical citizens and receiving a fraction of the income of doctors in better resourced areas.

And the sad thing is I will probably have to work in an affluent area 2 days a week to subsidise my AoN practice. So, once again, the people in that area will “lose” a female medical practitioner.

I will see men and children as well as women, with some faster, less stressful consultations, and at the same time boost my income. But somehow that doesn’t seem right.

Dr Tracey Palmer is a GP practising in WA.

Posted 30 May 2011

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3 thoughts on “Tracey Palmer: Counting the cost of location

  1. DamanL says:

    The tyranny of a grossly underfunded GP payment scheme (Medicare) is not something you should feel guilty about. The fact that politicians don’t see value in general practice (and soon all doctors if the incumbents continue) is the issue. There is a two-tier system, and it is not fair. Why should the tax I pay fund a cheap crappy system. I see patients who spend sigficant amounts on their drugs etc, all cost shifting from politicians, not doctors!!.
    I am specialist, I charge, I always thought I would work publicly, I would actually give up medicine if that were to be the only option.

  2. David De Leacy says:

    The Medicare system was introduced in 1974 by Labor in a serious attempt at the time to bring affordable high quality health care to all Australians. Subsequently it has been abused in equal part by politicians of all persuasions, by patients and even by the medical profession. First, patients have abused it as being something ‘free’ and now see it as a ‘right’ but one of little intrinsic value and have grossly overused and undervalued it and the doctors who have serviced it for decades. Second, politicians by deliberately walking away from funding it adequately and by being dishonest with the wider population about its true cost. They have hidden behind ‘spin/lies’ and neoloqisms e.g. so called productivity dividends – cuts since its inception. Finally by the medical profession for quietly allowing themselves to be nationalised over 40 years and hence allowing Canberra bureaucrats to happily (or not so happily) ‘sit’ alongside them and their patients in their consultation rooms. Surely something as simple as an indexed Medicare levy, a mandatory co-payment with exemptions only to strictly defined non-welfare recipients for all medical services and a root and branch review of the ‘item number’ system of payment would be somewhere to start. Far too brave an approach for any of the current lot of politicians I fear, even the medical lobby ones. We can all thank the rise in the 1980s/1990s of economic rationalism for the triumph of the Harvard School of Business over the Harvard of Medicine. Now all health care debate budget spin at any parliamentary level is about treasury dollars and not about health care outcomes. What a mess this country is now in with Labor politicians actively hawking a dumbed down fractured primary health care system staffed by nurse practitioners and doctors’ assistants as some sort of great leap forward. “Never mind the quality feel the width.” This approach is nothing but a gross admission of neglect and stupid failed policies over decades.

  3. Greg Hockings says:

    I completely agree with the posts of DamanL and David De Leacy. Remember the Relative Value Study, which showed that general practitioners and consultative (non-proceedural) specialists were underfunded by Medicare by around 50%? Thethen treasurer, Peter Costello, refused to implement the findings becuase they would have impacted the bottom line in his budget, even though he couldn’t fault the methodology.
    We need the AMA to fight vigorously for the right to charge a co-payment and still bulk-bill the balance, as well as a substantial increase in Medicare rebates for consultative medicine by general practitioners in patients with complex problems. Without a co-payment the profession will continue to be undervalued and taken for granted. The public hospital system should be able to provide adequate care to those who genuinely can’t afford a small co-payment.

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