Issue 19 / 27 May 2013

ALL the argy-bargy from this month’s federal Budget about budget surpluses and deficits has made me wonder about the budget woes we doctors face.

It seems some doctors might also be struggling to achieve a budget surplus as Medicare rebates — frozen in the 2013 Budget until July 2014 — fall further behind inflation. Now the AMA schedule of fees — which is indexed fairly — is about double the Medicare Benefits Schedule.

Then there’s the Practice Incentives Program (PIP), which has not been indexed for years, and the immunisation incentives for GPs which have been axed.

Meanwhile, the costs of doing business continue to burgeon, with accreditation and insurance demands growing yearly, and energy bills, rents and wages rising at or above inflation.

The Rural Doctors Association of Australia (RDAA) has for some time expressed concern about the viability of practices in rural and remote areas and I am sure many urban colleagues share the worry.

In a bid to help rural practices, the RDAA wants a review of PIP funding and how GP registrars are employed. One suggestion is for the Regional Training Providers (RTPs) to employ the registrars.

While I can see why the RDAA wants a change of paradigm, I fear its proposal is naive. In hospitals, practice accreditation and assessment of education and training, we have already seen third party organisations burdening us with more forms and more demands for our time, but with little or no remuneration and a shift in responsibility from them to us.

If we let outside organisations into our private practices, we will soon see another layer of conditions and imposts. There is the danger that paying registrars will become contentious, as will workplace safety, rostering, liability for time off and fringe benefits.

Just as we are beginning to see with Medicare Locals and Local Health Networks, the RTPs will say “it’s our way or no way”. All we will achieve is an acceleration of supervisors no longer prepared to take on registrars.

So just what is a doctor worth?

Supervisors and medical educators are paid $100–$140 an hour to attend to the education of registrars. The same hourly rate applies for doctors coopted to most government committees. For supervising medical students, GP practices are paid $25 an hour ($100 per session).

In modern private practices, it is reasonable for each doctor to have a nurse and receptionist as a support.

A good practice nurse costs $30–$40 an hour, plus superannuation, leave entitlements and some education. The real cost to practices is therefore closer to $55 an hour. A good receptionist costs $25–$30 an hour plus benefits, so the real cost is closer to $35 an hour.

So paying a doctor $100–$140 an hour to supervise a registrar can leave $20–$40 an hour to the doctor after wage expenses alone, ignoring all the other expenses. Given that most of these organisations do not pay for reading time and travel time, the doctor is actually losing money.

As more and more registrars enter training, rather than being more centralised, we need to be more flexible, and to shift funding to the practices and registrars and away from the bureaucrats.

General Practice Education and Training (GPET) controls a large budget for the education and training of GPs. GPET could reallocate a percentage of its budget towards helping to pay the salaries of registrars, as well as allowing registrars to tailor their own college-approved education. We keep insisting that doctors are intelligent and responsible, so why not be treated in this way?

Why do we sell ourselves so cheaply? If current funding anomalies are not addressed and money continues to be poured into bureaucracies rather than where it is needed, salaried doctors and academics will be the only ones left who can afford to provide training, education and health policy.

Or we could just start charging patients, educational institutions and government what we’re really worth.

Dr Aniello Iannuzzi is a GP practising in Coonabarabran, NSW.


22 thoughts on “Aniello Iannuzzi: What are we worth?

  1. John Quintner says:

    For purposes of comparison, you might also like to take a look at the level of remuneration received by our colleagues who choose to work within systems of personal injury compensation. They are remunerated for their services at a much higher level of payment than that received by those of us who might actually treat the same patients and accept responsibility for their care.

  2. Michael McDowell says:

    Thank you for raising this important topic. When considering salaried doctors, the taxpayer burden of cost associated with non-salary infrastructure expenses is rarely quantified and represented in these discussions.

    I would guess that the per-clinical-service non-salary cost in public systems is several times higher than in private practice. If public salaried doctors had to ‘purchase’ this infrastructure from their wage at true market cost, the situation would be very different. Until the full cost landscape is included, we compare apples with oranges.

  3. Phillip Chalmers says:

    There is a legend in this country that it is a land of the fair go; that it is egalitarian and has no class consciousness or discrimination.
    Yet, we have a system where doctors are paid for their work at about half the rate that a relative value study established not long ago.
    So workers in a service deemed essential are actually being used as part of the welfare state to subsidise the health care of most of the population.
    At the same time as this population is guaranteed minimum wages, protected conditions, sick leave, annual leave and superannuation the doctors are accorded none of these basic Australian workers rights.
    How has this been allowed to happen and how can it be rectified?

  4. Dr Chris Mckenzie says:

    Surely the teaching of future doctors is too important to be done as “an aside”, part time, etc. When the government wants to recognise this & pay me appropriately I wll dedicate a day to teach appropriately. It is too important to be done “on the run”, etc

  5. Gary Goland says:

    It is certainly valid to review where economic rewards fit for medical service to our community. The comparative points you make Aniello suggest there is not a fair reward for those engaging all of the health challenges presented. It seems like reward systems are almost upside down. Those calling the directions in health care, and not as directly engaged, are potentially reaping greater reward, and sadly, compromising resources available for where the procedures and interviews happen. In a growing and aging population, the pressure on the ground is going to expand. I avoid the political and economic catch-cry; growth. It is worthy to challenge where the money goes, but additionally, I suggest we should try with all our energy, to contain levels of medical service needed. To me this means seeing greater responsibility for containment of the many elements polluting our local living and working environments. This directly challenges our well being through compromising our immune systems and mental standing. Public health risk is so low on the ladder of health service importance, there is no accountability for how the system fails. This is undermining health system capacity, and well being, to the tune of $billions annually. We definitely do need to question where the rewards are going, as they are not providing adequate reciprocal value to our future.

  6. Patrick Hanrahan says:

    It is the concept of “double dipping” that allows the government to pay 100-140 dollars an hour. Government committees are full of hospital doctors, bureaucrats, academics etc who are receiving their salary as well as the hourly rate – same with pharmaceutical boards.There is also “triple dipping” where practitioners receive their full time salary, a sessional rate for off site clinics and then bulk bill medicare. And of course the everyday example of salaried practitioners bulk billing. These cause distortion of remuneration levels.

  7. Dr Robert Noll says:

    These comments are repeated decade after decade. If you are genuinely concerned about your remuneration stop talking about medicare rebates and start charging privately for your skills. Even my college (ACRRM) persist in referring to doctors and medicare rebates in the same sentence. They are patient rebates, which are between the patient and the government. How do you think the Health Minister manages to claim each one of us claims $360,000 per annum from medicare. Charge appropriately for your skills if you are genuinely disaffected.

  8. Gavin says:

    I would not do what I do ( the effort, the responsibility, the risk, the study) without clearing $100 per hour; in my circumstance that means a turnover of $ 325 per hour.

  9. Adam King says:

    I have run a solo rural clinic for 8 years where costs of nurse and receptionist plus rent and consumables cost more than 50% of billings. I mostly bulk bill as my patients are doing it tough. I chose to stay unaccredited as I don’t have the time for all the crap. And yes I am Australian born and trained Even so I earn a fair wage although much less than my colleagues in town but I go home happy and am respected by my patients. My family have nothing to want for and we lead a good life. Of course we all like making lots of money but the government has given it all away, built superclinics to compete against the little family doctor and are pushing out thousands of poorly trained students to fill their superclinics and swamp the workforce to bring down demand. Unfortunately I feel that doctors have become too self centered and base their wealth on their wallet size not on what they can contribute to their community, so maybe it’s fair to cut our wages make us keen to work and help people, and maybe if we were all salaried doctors in superclinics we wouldn’t complain

  10. Natalie Lindsay says:

    I am with Bob. Why as GPs are we continuing to devalue our skills and service by persisting with “bulk billing” and complaining about medicare rebates. Specialists value their worth and private bill patients who then receive a rebate from the government. GPs need to value their skills as clinicians and charge an appropriate private fee.

  11. Ulf Steinvorth says:

    Thanks Adam for some enlightening words.

    If we are doing it so tough, how come we make it into the top ten percent, more often than not into the top 5% of Australian income earners?
    If we want the public to fork out more money for our services we’ll have to be transparent about our real earnings – otherwise we’ll lose support and credibility, especially when crying poor while being the richest Australians.

  12. Neil Donovan says:

    Thankyou Aniello for making it real.
    It is great help try to have someone make sense of the economics of General Practice. Its pretty marginal.

    However I cannot agree with your thoughts about Registrars being employed by the RTP’s. I support the idea. This issues of payment, work safety, holidays and study are already contentious. So difficult that I am one supervisor who cannot take another registrar until it is sorted out. I reckon more Gp’s would become supervisors if we could just teach and not have the burden of employing registrars, negotiating wages and and carrying the risk.
    I think this idea is gaining momentum with Supervisors in our area.

  13. maggie mahar says:

    You assume a doctor needs to hire a nurse and a receptionist–i.e. that he is a solo practioner.
    In the U.S. we have finally figured out that the solo practice model is extraordiniarly wasteful and inefficient. Increasingly U.S. physicians work, on salary, for large organizations like Kaiser Permanente, the Mayo Clinic, or the new accountable care organizations beginning to spring out all over the country. In rural areas, they will be joining “virtual” large organization, linked by HIT.
    In this way,they enjoy the economies of scale of large organizations– a back office serves hundreds of doctors, not one. Health IT becomes affordable.
    Doctors work on salary. They are not expected to run a business: they are expected to do what they have been trained to do– practice medicine.
    When they share information with each other, and work together as a team (with nurse practioners and physicians assistants) patents receive better, evidence-based care.
    As the developed world gets a handle on health care spending (breaking the curve of health care inflation) specialists’ incomes will, no doubt, fall. For those who went into medicine expecting to earn more than 98% of their fellow citizens, this will be a disappointment.
    But we realize that we can no longer afford to over-pay for medical devices, pills, hospitals–and many specialists.

  14. stevegipps says:

    Why bother paying RACGP or AMA annual fees if they can’t effectively influence public decisions for our basic fees!
    The government just screws us over and over again.
    Are there any teeth at all in these bodies to represent us or should we all go form a new industrial union eh!

  15. Rebecca says:

    Vote with your feet! I chose to step away from Medicare and now work as a General Practitioner seeing a wide variety of cases. I am an employee on a salary with superannuation, sick pay and paid holiday leave. No more ” will this be bulk-billed?”, no more unpaid hours of following-up results, paperwork and unpaid training.

  16. Neil Donovan says:

    Dear Brock
    I am intruiged, I would love to know more about this gig.
    Can you tell us more about it.
    Do you work for the HIC as an investigator.? Agpal?

  17. Vijay Panchanathan says:

    Kindly allow me to allude to a case I know only too well. This lad trained overseas as a GP, came to Oz to do a Ph.D in basic research and left academia after 6 years in search of job security. He has passed Pt I of the AMC exams but cannot get a job as an intern anywhere in Oz. Now 2 years later has yet to be allocated a place to take Pt II of the AMC exams. He now works in a bakery run by his mate and is resigned to the fact that he might never get to practise medicine here. All this, while you lot are worried about how much $ you do/do not get, etc. We all recognise that “the” system has to change, but will that ever happen in our lifetime?

  18. David MacFarlane says:

    Sadly the medical profession is infested with people who see sickness as an opportunity to line their pockets. This is especially obvious in the “Private ” sector where people are routinely tricked into forking out huge gap payments to ordinary operators who have tickets on themselves.

    Medical Practitioners are not struggling, they are not “Aussie Battlers”, they are not hard done by, and they need to stop whinging about money.

  19. ann says:

    Everything that Adam said is correct. Unless you live in Mt Druitt or some other rundown unsafe area and recieve a measly pension caring for a loved one with Schizophrenia or Downs Syndrome etc you really need to get some perspective and stop your discontent and whinging. There are too many Doctors that don’t deliver and still get paid. A new system should be doctors getting paid off patients’ satisfaction. It is unnecessary for a sole doctor to have a Receptionist plus a practice Nurse and they are better off with a nurse who is willing to do dual roles. Also, of course, doctors shouldn’t be bulkbilling the well off – it’s unnecessary.

  20. john smith says:

    An an anaesthetist on 500K/year I still think I’m underpaid. A GP on 120K is not just grossly underpaid but enslaved. In today’s wages and considering the high level of intellectual capital and the labour component of the work we do, the rebates are a joke. There is a concept such as Fair Market Value and since the TPA and the ACCC are out to get doctors, and that both acknowledge medicare to be a price fixing scandal, perhaps a class action is required against the government to force fair market value reimbursement. This is one for the AMA, but of course there is no union as spineless and inept as the AMA. The concept of universal healthcare is also deeply flawed…if you’re poor and you walk into a milkshop and take a carton of milk, then you are stealing and will be thrown in jail regardless of how poor you are….yet every man and his dogs thinks they are entitled to receive your services at below market value, effectively stealing a portion of wages. I have many patients who are advised of fees and then ring up after recieving services to refuse payment. Of course theft of services is not treated the same as theft of goods….we consider theft of high value services to be a civil issue for VCAT, yet the $2 milk carton will land you in jail.

  21. Helen Robertson says:

    I’m with Adam. I work hard in a rural town but as my taxable income puts me in the top 1% of Australian incomes I don’t think I have grounds for complaint; I bulk bill as it’s a disadvantaged area but the effect of that is offset by a generous lease arrangement with the local hospital. I do a lot of on-call but it’s not surprising that high incomes are associated with long working hours.  

  22. Helen Robertson says:

    Unlike “Anonymous” , I’m wary of schemes to be paid on “patient satisfaction” . Not providing someone with the drug of their choice may leave them unsatisfied but I might still have done a good job on wider considerations.

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