Issue 22 / 23 June 2014

THERE is probably no better example of how differing opinions can hold up legislation than the proposed $7 copayment for GP and diagnostic services.

Announced in the federal Budget 6 weeks ago, we seem no closer to resolution of the, at times, heated debate over the rights and wrongs of a copayment. The new AMA president Associate Professor Brian Owler made the AMA’s position quite clear last week, writing in the Sydney Morning Herald that the AMA “is supportive of some co-payments, but not the one proposed by the government”.

MJA InSight columnist Dr Aniello Iannuzzi thinks our legislators should consider the equity of the current copayment proposal. Why, he asks in his comment article this week, is there no copayment for specialist services, particularly when “the GP Medicare rebate is paltry in comparison with the rebates for specialist consultations”?

In the next fortnight a new Senate will sit in Canberra and will hold the outcome of this debate in its hands.

Another debate that legislators may have to grapple with is whether e-cigarettes should be made legally available in Australia. The evidence for e-cigarettes is shrouded in as much fog as the smoking area outside a city office building.

In our first news story this week, InSight reports on how leading public health advocates in Australia and around the world are split on whether legislators should regulate the sale and use of this new product.

Debate also swirls around the use of some drugs by mothers while pregnant and when breastfeeding. For women with epilepsy or depression, concerns about the impact of anticonvulsants and antidepressants on their children can put their own treatment at risk.

Our second story this week provides some reassurance about continued use of these treatments during pregnancy and breastfeeding, although, again, the experts are not all reading off the same sheet. Weighing up risks and benefits for both mother and baby is likely to remain a conversation that must be had with each patient.

Risks and benefits are also front of mind when an obese patient seeks advice about bariatric surgery, particularly laparoscopic adjustable gastric banding. Our third news story highlights the need to add revisional surgery to the list of risks for those undergoing a lap band procedure.

And let’s hope that those carrying out the procedure are using a safety checklist to reduce any chance of complications. Yet, not all doctors embrace what is often described as “tick-box” medicine.

In a comment article this week Dr Simon Hendel argues why they should, even in hospitals with low rates of postoperative complications, as there is always room for improvement.

Medicine and its practice are ever evolving as new research brings new wisdom. But in the heat of any debate about medicine, it may be worth remembering the wise words of Michael Palin in his book Diaries 1969-1979: The Python Years: “I am very cautious of people who are absolutely right, especially when they are vehemently so.”


Dr Christine Gee is a deputy medical editor of the MJA and acting medical editor of MJA InSight. Dr Ruth Armstrong is on leave.

10 thoughts on “Christine Gee: Open for debate

  1. Geoffrey L. Brooke-Cowden says:

    Aniello Ianuzzi queries why no copayment for specialist services when GP Medicare rebate is paltry in comparison to rebates for specialist consultations. I would suspect this is because GP consults vastly outnumber those of specialsts, presenting low hanging fruit for Government and Bureaucracies and avoiding opening a second front with Specialists.In other words, the gain/pain ratio isn’t worth it.  

  2. judith omalley-ford says:

    Why, I ask, should GPs be considered ‘low hanging fruit’  by political parties?

    It is a disgrace to think that the co-payment is to come off the top  of already  substandard remuneration rates for GPs. in other words GPs are effectively funding this scheme. There is no talk of this aspect of the co-payment in the media, or minimal talk of it.

  3. Greg Hockings says:

    The obvious answer is that most specialist consultations already have a co-payment and the intention of the budget change is to reduce overservicing (perceived or actual) by making it financially non-viable for the medical profession to bulk-bill, thus allowing the government to blame the doctors rather than lose too many votes over the issue. It is not just GPs who will be forced to charge a co-payment, but also certain specialists such as radiologists and pathologists. The logical next step would be to reduce the MBS fee for proceedures to  ensure that they are also not bulk-billed.

    I don’t know any consultative specialists who run their own practices (as opposed to just renting a session here and there) and can afford to bulk-bill after covering the  costs of their rooms, staff, indemnity, etc.  Bulk-billing was meant to be an additional safety net (in addition to our “free” public hospitals) for the small percentage of the population who genuinely can’t afford to pay a small gap for medical care. I’m not talking about all the concession card holders who do their annual overseas trips and cruises and then whinge when their specialist declines to bulk-bill them.

    Now bulk-billing has become part of the ALP’s socialist wealth redistribution platform to ensure that everyone is equal, regardless of the contribution they have or haven’t made to society, the hard work and sacrifice it takes to be self-supporting and self-reliant in today’s society, and the many non-compliant people who make no effort to look after their own health and then expect to have unlimited free medical care. The co-payment should proceed and I hope that it passes in the Senate.

  4. judith o'malley-ford says:

    the government encourages bulk billing, in fact they gauge the success of the health system by the fact that GPs are increasingly bulk billing paitents for services rendered.

    On the other hand there is currently a surplus of doctors who are competing  in the GP market for patients, and patients gravitate to practices where BBing occurs. There is a vast increase in the numbers of medical gaduates and this is only going to increase, and if these doctors are starting to set up in general practice, they are going to bulk bill, as a means of attracting patients.

    Patients have been conditioned to receiving “free” health care,… from GPs, pathology, radiology. services..  at least they perceive it to be free, and expect it to be covered by Medicare.  These days you are only good as your last consultation. Paients will find BBing practices where they receive 5 minute medicine. Do we have to wait until this systerm fails dramatically before some meaningful change comes about?  

    Patients do not realise that the co-payment will come directly out of the GP’s pocket, nor do they really care.

    GPs should be able to count on the RACGP and the AMA to look after the interests of the GP’s working conditions. This doesn’t seem to be the way this situation is panning out.

  5. Geoff Greig says:

    Easy for you to say Greg the physician. Your rebates are untouched and not cut by some 15%. You don’t go to nursing homes or even deal direct with the disadvantaged the great majority of whom are dealt with by outpatients and casualty. If we apply the safety net as you suggest to these people we actually lose 25% of our total current  fee. With colleagues like you who needs enemies.

  6. Bill McCubbery says:

    Vehemence in argument often seems inversely proportional to the logic used and the plausibility of the assumptions made. We are medical advisers not medical dictators. We give advice but the patient is responsible for taking it. If we accept a government monopoly on the provision of private health insurance then rebates will be determined by it. That some needy people find payment for medical advice and medications unaffordable does not justify forcing everybody into a trap where the government dictates fees on the pretext of paying rebates. Most insurance systems entail a “front-end loading” if they are to remain viable. Some may dispute the right of the monopoly insurer to reduce rebates; but it certainly has the power. As it has been in the past so it continues to be that the GP will reduce the fee for service provided where there appears good reason to do so. That does imply charging an appropriate fee to those who can afford to pay it. Whether we admit it or not, bulk billing GPs have subsidised our National Health Scheme out of their own net income. The AMA warned the profession in 1974 about the inherent dangers of bulk billing and advised on how to avoid it. It became so “easy” that the advice was ignored. shows how the original donation has compounded over time. Despite all the wise advice we reap the consequences of own imprudence. If general practitioners are to survive as a professional group we must convince our patients that the advice we provide has a value for which they are prepared to pay a viable fee. Otherwise the “top-down” planners will extend role-substitution to the point where the backbone of the profession consists in no more than dried out bones picked clean by vultures.

  7. Greg Hockings says:

    To Greg the GP:  Mate, I’m on your side. I do not advocate or support bulk-billing for GPs any more than for specialists.  The rebate should be increased for the genuinely disadvantaged, and if it is not, they will just have to attend public hospitals for GP services.

    GPs are not appreciated or valued by the general public because of the many GPs who bulk-bill everyone, so that the services provided are perceived to be ‘free”.  You will have an excellent reason to stop bulk-billing if the co-payment comes in, as it will not be financially viable for GPs to bulk-bill (this is the government’s intention).

    Of course, the AMA and RACGP should be fighting to substantially increase the rebates for longer GP consultations to remove the financial incentive for 5-minute medicine and reward those GPs who are thorough and take the time to do a proper history and examination, rather than ordering lots of expensive investigations..  Do you remember the findings of the Relative Value Study years ago as to how undervalued consultations by GPs and non-proceedural specialists are? Nothing was ever implemented from this study as far as I am aware.

    Our medico-political organizations should also be running a PR campaign to make it clear to the public that the demise of bulk-billing is the inevitable result of current government policy, not the fault of the doctors. 

  8. dr cherry evans says:

    i have been a gp for over 40 years and have “bulk billed”  or its equivalent all of that time. I do not think one’s medical relationship with a patient should be coloured with  a money transaction. I won’t take copayments. I would rather lose a  portion of my bulk bill fee. Let’s face it  $5.00 will go to the government and only $2.00 to the GP.I am a DOCTOR not a TAX COLLECTOR.i think ALL BULK BILL DOCTORS should go on holiday for 1 WEEK –  ALL AT THE SAME TIME!!!!!This would show the government what a difference their care makes and how the system will be stuffed up when people wait till they are sick enough to go to hospital for their care.

  9. Paul Jenkinson says:

    Ageing GP,I have been a GP for 38 years and ,unlike you,have never worked in a bulk billing practice!That is not to say I have not bulk billed my needy patients but ,in my experience ,there is a very small minority of patients that value my services for less than $15  out of pocket.Most pay $40 out of pocket after the govt rebate for an item 23.

    I’m sure I am not a better doctor than you but my patients have put up with “co-payments” for years .

    I don’t feel like a tax collector-I know that my patients must see value for money.

  10. Dr Tarun Chauhan says:

    As I see many genuinely disadvantaged patients, I would be happier to apply my discretion as to who should and who shouldn’t have to pay without financial penalty to myself. The government of course wishes the blame to lie with me for charging. I almost universally bulk bill but when the rebate, previously $160 for a mental health treatment plan dropped to 90 odd dollars I took a stand. If I spend 30 minutes to assess a patients mental health and provide a quality service and a couple of patients walk out due to extended waiting then I have been happy to accept that and charge a fair fee for my time and expertise. My numbers for these dropped as you can imagine when I started charging. 

    My patients already pay a copayment most days. They can’t make appointments and they queue up for tokens and hour before I open. They wait between 1 and 3 hours to see me. That’s their copayment.  There are 7 other practices within 1 km of my surgery which predominantly bulk bill. I don’t look at my watch or practice “5 mins medicine”. I try to practice quality medicine and apart from the example above, bulk bill patients. So my patients, especially the disadvantaged ones, won’t need further disincentive to see me. 

     So although it may discourage 5 minute medicine patients from the supposedly “frivolous” encounters, what about many of my colleagues who don’t, like myself, practice such medicine? Its already pretty unattractive to want to be a GP and who would blame the graduates from seeking greener pastures? Strong primary care saves the economy money as it has been said to be the most economical part of the health industry though due to our numbers the total cost is high and we’re an easy target.

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