Issue 18 / 26 May 2014

CHILL out Chicken Littles — that’s my message to the public, welfare groups, politicians and doctors with respect to the $7 copayment for a GP consultation announced in the federal Budget.

I have not witnessed such an avalanche of expertise and prophesy since the soothsayers of the Y2K bug, SARS (severe acute respiratory syndrome) epidemic and Global Financial Crisis — or are they in fact the same soothsayers?

When I went to medical school I was taught to take a thorough history, then look, listen and feel before coming to a diagnosis.

The reaction to the copayment reminds me of how many younger doctors and emergency departments seem to practise these days — “Did I hear the word headache? Straight to the CT scanner.” Never mind if the patient with the headache was trying to solve the Rubik’s cube or had tonsillitis. Knee-jerk investigations and diagnoses have become way too common.

And so it is with the copayment idea and reactions.

Modern soothsayers hear the words “money” and “patient” in the same phrase and suddenly ejaculate the diagnoses of “unfair”, “deaths” and “unaffordable”.

Old dogs like me have seen these tricks before from the politicians and the soothsayers. When I take the copayment history, I see that Bob Hawke trialled it too. I see other countries like New Zealand have introduced copayments without the sky falling and that government spending on health in Australia has been growing faster than inflation.

When I look — keeping in mind that I live and work in one of the poorer areas of NSW — I see patients on welfare and low incomes every day who are already paying for pharmaceuticals, allied health services, complementary medicines and occasionally some quite bizarre devices and services they think are related to health.

When I look at the politicians and soothsayers opposing the copayment, I have found an uncanny resemblance to those calling for a carbon tax. Just as a price on carbon may make people respect and value the environment more, would not a price on GP visits make them value and respect their primary health care more?

When I listen to disadvantaged patients I have not heard as much hysteria as that of the soothsayers and non-government politicians.

For the 20 years I have worked in the public hospital system, I have listened to administrators constantly talk about the unsustainability of supplying services for free. More importantly, I have yet to listen to anyone who really understands the full extent of the copayments, rebate cuts and redirected funding of medical research.

The copayment is only one of about 70 changes to health funding and regulation in this Budget, so the last part of the examination is the “feel”.

I feel that the world will not collapse with a copayment. Just as Prime Minister Tony Abbott’s predictions when Opposition leader of the calamities of a carbon tax that did not eventuate, nor will Labor Opposition leader Bill Shorten’s dire prophesies for the copayment.

I feel that this debate will twist and turn for a few months more, as it passes through the Parliament, Department of Health and opinion polls. Let’s wait and see what the final outcome really is.

I feel a rebate cut will occur whether or not the copayment gets up. Accordingly, doctors should prepare for this in whatever way suits their practices and ethics.

I feel emergency departments and ambulance services will, out of necessity, have to address the longstanding problem of what to do with low triage category patients. If the states do not match the copayment, hospitals will choke with non-urgent cases.

I feel that the copayment will reduce trivial presentations to GPs, and will force GPs to be more accountable and thorough, which should lead to higher standards.

And I feel Joe Hockey should order the printing of a $7 note.
 

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


Poll

Has there been an overreaction in the medical and general communities to the introduction of a copayment for GP and diagnostic services?
  • No - this changes our health system (46%, 125 Votes)
  • Yes - hysteria (39%, 105 Votes)
  • Maybe - it's still not really clear (14%, 39 Votes)

Total Voters: 269

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18 thoughts on “Aniello Iannuzzi: Take a $7 history

  1. Peter Edwards says:

    I would like to hear debate about the pros and cons of reducing rebates for all services, not just front line services

  2. Patrick Coleman says:

    Some kind of co-payment (Emergency +/- GP?) was also introduced in Ireland about 20-30 years ago. Our health systems are not dissimilar. Perhaps someone should check what effect it had there?

  3. Ian Relf says:

    Main points – lets get real value.

    1. GP’s have improved health outcomes substantially -world best practice- so lets give them a  an effective pay cut of 20%. A sarcastic thankyou.

    2. It will take $4 to administer- so a large contributor to red tape- which is against Liberal ideology.

    3. There are much more effective ways to reduce healthcare spending by much larger margins.- ie practice eveidence based medicine for a start.

     

  4. Sagir Alibrahim says:

    I think the real question is: What’s the purpose of this new tax? If it was to ease the budget congestion then why it’s shifted to the 20 bil budget of Medical Research?

    Silly logic if you ask me

  5. Dr Kevin B. ORR says:

    Reducing trivial presentations will, unfortunately, lead to late presentations of more serious disease whose early symptoms can appear trivial.Then again, will the GP presented with a patient with a trivial early symptom of serious disease be able to recognise it – the GP who saw my granddaughter with meningitis did not! All right she is still alive, now with two children but serious deafness!

    KBO

  6. Tracy Soh says:

    I’m not against the concept of copayments in general, but I feel that the structure of the copayments put forward in the budget disproportionately affects patients who can least afford it, is counterproductive to the public health measures that we should be trying to promote, and is overly bureaucratic and onerous for GPs.

    I now work for a drug & alcohol clinic, but 15+ years ago I was working in a small group GP practice that stopped bulkbilling altogether – they charged nominal gap to concessional patients (< $5 but I can’t remember now what the actual amount was) and a reasonable gap for everyone else. Business dropped for around 6 months then picked up again. We had more time with our patients, and patients who attended were clearer in their reasons for attending and more appreciative of our time. Socioeconomically, this practice was situated in an area which had low unemployment and was reasonably affluent. In the context of that practice, a copayment worked.

    The budget copayment is a different beast. For patients who are financially disadvantaged, GPs are simultaneously being given 2 very conflicting messages – charge the exact Government endorsed copayment of $7 and we will reward you with the “low gap” incentive payment, but of course you can continue to bulkbill your disadvantaged patients at the cost to the practice of not just the copayment but also the incentive payment. The Federal Government is cynically shifting the payment blame game on to GPs for patient gaps, as few practices could afford to continue bulkbilling all concessional patients, but it will be the GP who chooses not to bulkbill.

    As for immunisation and chronic disease management… I feel that this copayment disincentivises quality care.

  7. John Boyd says:

    Firstly, let us note that Australia has about the highest overall level of co-payment for national health medical services in the world. The real purpose of this new co-payment is to condition people to the eventual destruction of Medicare; to move to a US-style private insurance based system, which is grossly inequitable and economically inefficient. The US spends nearly 20% of GDP on health services, compared to about 9% in Australia, and many other countries with similar national programs. To regard such expenditure as simply part of the normal economic activity of the nation, is like saying that a major hurricane is good for the economy. Health expenditure is more like the maintenance cost of a large enterprise, that is it is a cost that reduces resources available for the productive units of the enterprise.

  8. University of New South Wales says:

    I’m unconvinced by the comparisons made between the carbon tax and GP co-payment, and I think I understand enough about both, thank you. This argument assumes that people don’t value and respect their primary healthcare. I assume people go to their GP because they or their children are unwell, or they are concerned for their health and continued wellbeing. Secondly, the introduction of a carbon price was a tax on polluters not people, the purpose being to reduce emissions, not to change values (but it is fantastic if this changes in the process).

  9. Horst Herb says:

    Well, yes, take a proper history (and that would include a world view review of health systems, not just the USA/UK and NZ as usual), and take RECENT evidence into account. You might find that as a rule of thumb, public systems without co-payments yield better outcomes than other systems, that NZ recently has at least partially abandoned co-payments based on very good evidence that they harm at least a sub-population, and similar things.

    Selective listening is not helpful when taking a history.

  10. Anthony Zehetner says:

    I thought GP would welcome copayments with open arms considering that the Medicare rebate is so poor. I do think that we should get rid of a culture of entitlement in this country and that copayments are a good practice. Maybe the government should have started it as a token $2 for the first year and then increased it to $7.

    Some patients do not object to the copayment but rather that the money is going to research that they do not agree with, eg some animal rights campaigners.

    I also feel that we should get rid of “turnstile” medicine and patients will (and rightly should) expect a degree of value and thoroughness for their dollar, even though $7 doesn’t go very far. It may also rationalise expenditure on medical investigations and prevent unnecessary ordering and spending. So in all a good thing!

  11. Department of Health Victoria Clinicians Health Channel says:

    Thank god! At last an author with a rational perspective without the shameful fear-mongering that we here from the AMA.

  12. Fiona McGovern says:

    1. I am very concerned about the effects that the co-payment will have on those who can least afford it. Working in an Aboriginal Medical Service, I have seen great improvements in the health of many in the community with the introduction of “Close the Gap” and widespread bulkbilling of pathology and Xray services. We need to encourage people to look after their health, not punish them with added costs. I can remember when sick children would not get antibiotics until the next “pay” and people with diabetes wouldnt go for pathology tests.

    2. The $7 co-payment will not translate into extra income for GP’s. In the best case scenario, if you charge the co-payment, the fee derived witll increase by $2. In the worst case scenario, if you waive the $7, the actual fee will be about $14.90 lower than at present (in rural areas with the bulk-billing incentive fee, approx $13 less in city areas).  For all patients who are billed privately, they will effectively be paying $5 more to maintain the current fee. 

    3. Medical research is of great importance, but we already know that diabetic people will be healthier if they have better sugars and lower blood pressure and people with heart disease will do better with statins and anti-platelet medications. Therefore it seems counterproductive to be looking for new treatments if people are not using established therapies because they can’t afford them.

  13. Dr No says:

    If you have spent 20 years working in the public hospital system, then you have no idea what it is like working in the private General Pactice secctor.

    GP’s already subsidise the Medicare system and have been doing so increasingly for the past 25 – 30 years as the medicare rebate to bulk billing GP’s effectively reduces their income in real time and in real terms, while practice overheads have incxreased the cost of living in domestic and business sector. The cost of running a general practice is not reflected in the current rate of bulk billing remuneration.

    The government’s proposal of a GP co-payment will further reduce the bulk billing medicare remuneration to the GP from around $37 to $30 for a bulkbilling consultation for a standard consultation. The patient may be asked to pay a fee, but  the GP is funding this fee by receiving a reduced fee for service as the co-payment goes directly to the givernment’s coffers. The GP becomes a tax collector for the government..

    How many other sectors of the community would / could accept such a reduction in their essential service delivery.  Perhaps we should be asking energy providers, and communication providers to reduce their cost structure in the same way that the givernment is asking GP’s to accept a reduction in their income.

    there should be a contribution from those who can afford to pay for health service delivery. But unfortunately the general public has the idea that their health services SHOULD be free. . Specialists do not bulk bill, and patients attending specialists know that they will have to pay for this service. Yet the same mindset for contributing to services from a GP is somehiw different. WHY, I ask?  

  14. James Cook University says:

    Couldnt agree more with Aniello. If the concern is for those who are socioeconomically disadvantaged, the capping of the Medicare co-payment means that concession cardholders will only pay (up to) $70 more per annum than they currently do for health care. This capped figure includes co-payments for pathology and radiology. Thus the debate hinges on whether a max of $70 will lead to an increase in preventable hospital admissions amongst this subpopulation. How likely is this outcome? Some argue this outcome passionately with 100% certainty. But, this doesn’t make any sense, as concession cardholders’ budgets per annum can vary by a greater amount than this per annum. There is also the incorrect assumption that every primary care clinical consultation initiated by a patient, or by a doctor (eg reviews, repeat prescriptions, etc) are necessary without which the patient would suffer a serious catastrophe. There are arguments that the quality of care delivered may substantially increase as clinical decisions become more targeted, and unnecessary over-investigation is reduced (good evidence that this type of practice is prevalent). This is not a debate about the effect of price signals per se. Price does affect demand. Numerous studies have shown that co-payments reduce demand for health services- some have shown this reduces both necessary and unnecessary health care. However, generalizability of these findings to an Australian co-payment of $7 is arguable. As argued above, this co-payment effect is important for quality and sustainability of our health system, and the issue is really about affordability, value for money, and safety nets. The $7 co-payment seems to provide the right mix as compared with other OECD countries.  

  15. Sue Ieraci says:

    Aniello, the carbon tax analogy is interesting. I thought that creating a price signal might force all of us to reconsider the energy we use. On the contrary, though, we all continue to increase our energy use – from airconditioning to computers humming all day long – and only the elderly seem to turn off all the lights and sit under a rug in front of the bar heater, or use a fan in summer. I wonder if the same will happen with the co-payment price-signal – those with the means will continue demanding more and more, while the impoverished elderly will continue to sit in bed under the quilt, and not go to the GP.

  16. Philip Dawson says:

    Whats missing from the debate is what Medicare is-its a compulsory exclusive Governement run insurance scheme, paid for by a levy on taxable income. Like the compulsory superannuation the government runs, but in that case allows us choice of private funds to put the money in. Medicare allows no choice, private health funds are prohibited from offering insurance for medical consultations pathology and radiology. So we have a Government run monopoly reducing the benfits paid while keeping the fees the same. if it was a private insurance company offering a scheme like this what would you do? The only fair thing to offer is to allow the private funds to insure for either the “gap” as they can for doctors visits in private hospitals, or indeed to allow patients to insure for consultations and opt out of medicare. Medicare could be means tested. all those below the “poverty line” 9 which is a lot more than just those on health care cards) would remain eligible, eveyone else would pay the ful levy if they didnt take out private hospital insirance, as they currently do for the hsopital component of medicare, or pay a reduced levy if they do take out insurance. Thequestion has also been asked abot wh all tisexa research funding at a time ofbudget cisis? Wy not wai till we are back in the black Indeed why not negotiatemore funding from pharmaceutical compnies, te trade offcul be les epensie drug regisation prcesses here eg not having to repeat safety and effcac studiestat hav alreadybeen done overeas?

  17. Graham Row says:

    Last century, at the time of the Hawke co-payments I decided to charge a co-payment.  Julie (not her real name) was crippled with arthritis, divorced, socially and financially disadvantaged.  As I explained the need for a co-payment a tear appeared in her eye and I felt dreadful.  “How much will it be?” “Ten dollars” I said.  At that she pulled a ten dollar note from her purse and slapped it on the desk.  “Jeez you had me worried for a moment !”  Co-payments have been a fact of life almost since day one of every socialised medical scheme.  Doctors are far too ready to devalue themselves when they succumbed to the incessant government pressure to bulk bill.   Here is a radical thought.  See the strugglers and down-and-outs gratis.  “Love of Godders” were a fact of life in my grandfather’s day before the medical profession started sucking on the government teat.   

  18. Shoba Krishnan says:

    Of all of you who have supported the co-payment not one of you have explained while it is ok for GP’s to take a pay cut? When are the specialists going to take a pay cut? Would that be ok? When we are the most efficient end of the health care system why are we slugged with the problem of saving money? Shouldn’t that be occuring outside of primary care?

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