Issue 22 / 23 June 2014

AS is typical at any gathering of doctors since the federal Budget, during lunch with a staff specialist friend we discussed the patient copayment.

He mentioned that is was a good thing to try to curb the Medicare cost blow-out in general practice. However, my friend became somewhat dyspeptic when I suggested that any copayment should also apply to specialist consultations.

Instead of offering him a proton-pump remedy, I thought an explanation of my reasoning might be more helpful.
Nobody appears to be contesting the premise that a GP copayment will see more patients attending emergency departments, but few have highlighted the potential shift towards specialist visits, particularly staff specialist clinics linked to public hospitals that almost invariably bulk bill.

For instance, a pregnant patient may choose to attend the hospital antenatal clinic over the GP shared-care model. The patient with diabetes may attend quarterly reviews by the endocrinologist instead of the GP.

If staff specialist clinics are exempted from the copayment it will also keep fuelling what is essentially a cost-shifting exercise by the states, as they generate income from their employees by billing Medicare for consultations, therefore shifting the costs to the federal government.

The copayment debates have also added to the debate of supposedly high out-of-pocket medical expenses. However, the GP Medicare rebate is paltry in comparison with the rebates for specialist consultations, and few other specialties have to suffer the red tape of accreditation and blended payments that GPs have to cop.

If the copayment is applied to GPs and not specialists, it will only accentuate this imbalance.

My lunchtime discussion with my specialist friend also touched on the main concerns within the health sector about the copayment — equity, practice viability for non-corporate medical practices, and a reluctance by nurses and doctors to be seen as “tax collectors”.

But labelling the copayment a tax is ludicrous. When we pay a real tax we don’t receive a specific service, nor do we get to select the provider. And the provider doesn’t have the option of charging or waiving it.

Some organisations now appear to be talking of not supporting the copayment in its current format but we are yet to see concrete suggestions to improve it.

In the $7 spirit, I think these seven modifications would improve the copayment:

1.    Spread the base to all Medicare items. Applying it to everything will make it easier to administer and may allow a drop from $7 and abolition of punitive measures for those who do not charge it.
2.    Exempt the Indigenous Access Program. I have written about this previously and we can afford to exempt our Indigenous patients for the sake of better outcomes.
3.    Overhaul the concession card system. We’ve all seen people with huge assets using concession cards — where a good accountant can be as important as being in genuine need. Only when this anomaly is overhauled could concession card holders be exempted from the copayment.
4.    Exempt residential aged care facility residents. Many of our colleagues are reluctant to visit aged care facilities for many reasons. Having to collect money in this setting will be an even greater turn-off, not to mention nearly impossible to administer.
5.    Exempt children 16 years and under — needs no explanation.
6.    Include all state government non-inpatient services. This will be the only way to prevent further gaming and cost-shifting between state and federal governments. State governments already selectively — and inconsistently — charge for various health services.
7.    Make the copayment either $5 or $10. It will be so much easier to administer with such a simple modification — just ask any bakery or coffee shop.

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

9 thoughts on “Aniello Iannuzzi: Copay for specialists

  1. David Roberts says:

    Dear MJA

    Please correct me if I am wrong. I had thought that teaching hospitals that offer outpatient services do so under the state-federal Medicare arrangement. And that the law is quite specific on public sector services; that is, no fee shall be raised against the provision of medical services. That being the case, In the provision of medical services in Outpatient Departments of teaching hospitals, an account should not be raised. Hospitals and doctors who do so are in breach of the law in two ways. First, it is Medicare fraud; and secondly, it is the operation of a cartel (in terms of Trade Practice Law), which is illegal if the hopsital has not sought an excemption with ACCC prior to commencing the service.

    It is a testament to how widespread this fraudulent practice is, that It is discussed in the above article as if it were normal practice.

    David Roberts.





  2. Marsh Godsall says:

    David Roberts is out of touch.This bulkbilling of patients has been happening in Queensland Health facilities for years with federal Governments of both parties turning a blind eye-and it is not merely Specialist OPD but also small rural hospitals bulkbilling for after hours services in competition with established GP practices-Queensland Health and its Ministers used to boast about Queensland’s  ‘Great Free Hospital System’ but in recent times the first two words can no longer be used-‘Free’ yes it is free to patients at point of service but not free to taxpayers of all other states who subsidise QH via Canberra -‘Great’ judge for yourself.

  3. John Furler says:

    I disagree with a number of points in Dr Iannuzzi’s piece. He asks for simplification of the copayment tto make it easier to administer but immediately excludes Indigenous people, residents of aged care facilities and children. If  we allow exemptions then there are many more we should consider. The low-income employed, pensioners,  people with a disability, and unemployed. These people with  be paying  a much higher proportion of their income to see a GP despite a higher burden of illness. As the list of exemptions goes on, based on real issues of equity, the simplicity disappears.

    The “co-payment”  as proposed in GP is actually a combined package of  rebate reduction and financially incentivised “low gap” payments. As most specialists charge private fees well above the rebate amounts, any implementation of such a package would surely simply be ignored by those practitioners?

    Iannuzzi  suggets that “real” taxes dont follow specific services or allow provider selection. Surely the GST is just such a tax?

    I think the overwehelming evidence is that this is bad, inequitable policy and that we should defend and support a unversally accessible primary care system and look elsewhere  in the costly secondary and tertiary care sectors for health savings

  4. Berardo Ioannoni says:

    In WA a large amount of public hospital departments are double dipping into Medicare leading to over servicing. A deplorable and corrupt practice in my opinion and one that should be stopped as the burden on Medicare funds is huge

  5. Annabelle Shannon says:

    Specilaists on average in Australia are reported to already earn 6 times higher than GPs. As finances are limited  why do they need more of the health budget ?

  6. Michael Gliksman says:

    It’s a good point Aniello but to expect equity from so fundamentally iniquitous a proposal as charging a non-means tested copayment seems futile.

  7. terry ahern says:

    I agree with Aniello on some changes to improve equality of care and access.

    Gps should be discouraged from 6 minute consultations and funding for better Chronic disease management rewarded. So I dsagree wth charging all medicare  items, and exempting kids . Aged care patients should be means tested , as they are on entry to ACHs, and poorer patients exempt.

    I agree wth exemption of indigenious ( as higher morbidity ) and concession card entitlement reviewed.

    Specialist should be assessed by availability , past experience , their fees and timeliness to reply to GPs. A webste could be organisd and up – dated, as well as ED avaiabiliy or by -pass , out patient access etc. Similar to DHS elective surgeryweb site, but daily up dates. Healhpathways site assists GPs here.

    Why is NZ smarter than Aus??





  8. Peter O'Brien says:

    As a specialist who does most of his work via TELEHEALTH from GP practices collecting a co payment would be a nightmare which could only by solved by the GP practice collecting it for me. I would not wish to put this impost on any GP so if copayment becomes part of specialist practice I would have to retire.great for the medical workforce but!

  9. Genevieve Freer says:

    Michael Gliksman’s description of the co-payment  as “iniquitous”  is to be applauded.

    To pretend that GPs  are the cause of a  budget blowout in health services is a farce, and even more farcical is the notion that a GP co-payment wil fix the health budget. .

    The maldistribution of GPs has been caused by our  previous governments.

    Any co-payment will worsen this maldistribution, forcing solo rural GPs out of business, as we cannot afford to employ another staff member nor  pay onerous accounting costs to be a tax collector for the government, collecting taxes from poor rural patients who cannot afford to pay,  to fund a ridiculous scheme dreamed up  by some public servants earning more than GPs do, sitting  in  heated offices  in some capital city.

    Tony Abbott needs to get out of his office, face the cold winds blowing in rural Australia, and get in touch with poor including  rural Australians , many of whom are now shivering in their freezing  homes,  and sack his  advisors before the country sacks him.


Leave a Reply

Your email address will not be published.