Issue 20 / 30 May 2016

A COUPLE of weeks ago, after seeing some last-minute patients, I did the marathon 5-hour flight from Emerald to Canberra; having worked the Monday public holiday, which was Labour Day in Queensland.

I was excited to be invited to the “Budget lock-up”, where I would get to see first-hand the deliberations of the Turnbull government regarding health.

I surrendered my iPhone, dare I tweet in the room, as Martin Bowles, Secretary for the Department of Health, gave his presentation, and I received in return over 50 pieces of paper and glossy A4 sheets espousing the magnificence of this well thought-out Budget.

As I flicked through the documents, I could see that much was on offer – an announcement for the Health Care Homes trials; the confirmation that remote doctors in training, from the Australian College of Rural and Remote Medicine, could access the same Medicare rebates as everyone else without the red tape; and that the failed Rural General Practice Grants Program would be revamped to improve infrastructure for training in the bush.

The Medicare Benefits Scheme (MBS) review was seeing some $5.1 million in savings, which I am told isn’t the point, through abolishing outdated procedures and items. There were some important programs for Aboriginal and Torres Strait Islander peoples, and an announcement of an item number for general practitioners to do retinal scans in rural and remote areas.

Buried deep in the folder was one piece of paper that told a different story. This was soon confirmed by the Secretary with his opening comment: “You aren’t going to be happy about some of this”.

And we weren’t.

We soon found out that primary care would be frozen out of any indexation of items for another 4 years, “saving” the Government nearly a billion dollars.

This was the pause on indexation of the MBS that stole the night. Any important investments mentioned in the Budget have since been smothered by an outcry from health-related groups.

In the days since the Budget much has been said.

Punters blame the “doctors’ union” – the Australian Medical Association – for self-interest and it being all about doctors’ income. Various politicians and commentators say that the freeze cannot be hurting because bulk-billing rates have never been higher.

The government has stated that GPs can choose to charge their patients. Angry consumers complain on forums that the gap they pay is already too great, creating some dissonance between narratives.

What is lost in the argy-bargy is a basic economic fact – rural general practice will be frozen out of any indexation for the next 4 years, on the back of 4 years in an already frozen wasteland.

Within hours of the Budget, I was receiving messages of concern from doctors right across rural Australia. There was a common theme – rural general practice is not viable and it’s becoming worse. As the undeclared recession hits rural Australia, the capacity for patients to pay at all worsens and they can find themselves with widening gaps.

Rural practices don’t have large numbers of patients, competition and economies of scale that have seen the rise of corporate medicine and a focus on shareholder value. Rural practices don’t have a bevy of bulk-billing, after-hours junior doctors to manage their fatigue and burnout; it’s the same GP at 2 am as it is at 2 pm in many towns.

Within 300 kilometres of my practice there are marginal and non-viable small rural practices limping along, some on life support, in an effort to maintain some service to their patients. Doctors in other towns are closing their doors, or even working second jobs to stay afloat.

Practices are firing nursing staff, the backbone of rural health care, or restricting the services available to their people, creating greater challenges for rural people to access quality and affordable care. Every day, rural people pay a “rural GP tax” – a tank of fuel – to get in to a GP.

My practice is mixed billing. This allows us to look after kids, the aged, those on health care cards and those with chronic and complex illness; but we do that by charging a gap for other patients.

Many of my consultations are long. I and most of the clinicians in the practice run late, not because we’re inefficient, but because people are sicker and have often left their problems to fester for too long.

We do the best we can, but in the back of our minds is how long we can keep the doors open, pay the staff we need and offer the services we do. To criticise doctors for thinking of the bottom line, when failure means that rural people miss out, is disingenuous at best.

There is already a $2.1 billion difference in health spending between city and rural areas each year. Health outcomes across the board are poorer for rural people. Rural doctors, nurses, Aboriginal health services and other health professionals are at the mercy of government because we weigh heavily the social obligation to ensure that people can access health care when they are in need.

No one benefits from the freeze in the bush and no amount of selective programs will replace comprehensive care for country people. The health quality and equity gap will continue to widen for the 30% of Australians who live beyond the coastal fringe.

Medicare is a broken system. It fails the fairness test, it fails the equity test, it fails on delivering universal access to care, and it certainly fails to provide safe and sustainable services for rural Australians.

Unfreezing the MBS will be a hollow victory. We need and should be having a very different conversation.

That conversation was started by this current government with the Primary Health Care Advisory Group, the MBS review, the Private Health Insurance inquiry and a number of other reviews.

It’s a conversation that must continue regardless of who wins this election. The future of our health system depends on it, rural communities expect it, and the sick, the disadvantaged and the dying demand it.

Dr Ewen McPhee is a GP practising in Emerald in central Queensland. He is president of the Rural Doctors Association of Australia.


Poll

Do you believe the ALP will lift the rebate freeze if elected?
  • Maybe, but I'm not holding my breath (41%, 107 Votes)
  • No, it's an empty election promise (38%, 100 Votes)
  • Yes (22%, 57 Votes)

Total Voters: 264

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10 thoughts on “Medicare is broken in the bush

  1. Jennifer Fischer says:

    In addition to the general discussion around rebates for General Practitioners, there seems to have been a resounding silence on the freezing of rebates for Allied Health items under the Chronic Disease management Program. In many rural areas, the public health sector has been steadiily running down its Allied Health services by pulling back service criteria to include only people who have been immediate inpatients or (sometimes) those who may be at risk of hospitalisation. This has left the majority of people reliant on private practitioners for service access. As private businesses in economically challenged areas, it has been very difficult to increase our gap charges (in line with increases in input costs) and explain to patients not only that the scheme is not “free” (as is often outlined by our local GPs) but that the amounts being rebated have not increased for some years. In addition, because of the lack of alternative providers, patients are frequently referred through the CDM program for acute injuries and/or to supplement their private health fund coverage (“you can use these 5 free ones from the government). This tendency must surely be increasing the costs of the program (and provides a really good example of State/Commonwealth cost-shifting in my view)

  2. Mark Woodrow says:

    As one of many but a small number of the total, as a non-VR practitioner with over 25 years of experience, my MBS rebates, still time based, have not increased since the inception of Medicare in 1984.  Beat that!

  3. Ewen McPhee says:

    The issue of access to allied health professionals is a critical one and I agree that the expectation that somehow the chronic disease items provide for “free” services underpins a failure of understanding of the process (that is overly bureaucratic and unneccesailty weighted to the initial consultation, and the GP, rather than agreed outcomes of the plan). Further there are groups that continue to offer “free” services as “outreach” sucking up whatever public funds are available, in direct competition with local providers. Healthcare reform is too important to trust to simplistic sloganism, and it isnt just about GPs but the whole helath team.

  4. Jonathan Davies says:

    When Medicare was introduced I had been in private/public practice for 4 years.  At that time the AMA advised against bulk billing.  I have have not bulk billed in my 30 years of practice.  Deserving cases were charged benefit only but did recieve an account.   Despite the increasing level of bulk billing in the profession I did not feel my practice suffered financially.   The current deterioration in rural servces and else where, can be sheeted home as much to our profession as the Government.  We as a group fell for the temptations of Medicare and failled to heed the warnings from many of our professional bodies when it was introduced.

  5. Dr David De Leacy says:

    Indeed you are right in part Mr Retired surgeon. Dr Peter Arnold (GPs Society) in the fierce debates with Bill Haydon in the 1970s leading up to the double dissolution election that heralded direct state funding for healthcare in Australia stated clearly and with prescience that Medibank simply was the first step on the road to nationalisation. Now three generations of doctors honestly believe they work for the government and hence have allowed Canberra bureuacrats to metaphorically sit in their consultation room, to undermine the Colleges and allowed them to define how they should practice so as to achieve efficiency dividends (cuts). Unfortunely the AMA and the RCGP have often provided them with Kapos. Careful reading of the appropriate Act should disabuse all doctors of that belief. It states it is the patients who are remunerated for the service, not the doctor. Doctors were bought off by Whitlam when he literally ‘stuffed their mouths with gold’ however, from Medibanks’ inception both parties have constantly frozen or actively reduced payments for service to practicising doctors. Also unfortunately, the massive inequity in the system from day one that ensured ‘proceduralists’ such as Mr Retired Surgeon were very generously remunerated was not reflected in General Practice or other non-procedural specialties making his comments and perhaps solutions somewhat invalid. The only hope for Medicare as it now stands is for the burgeoning numbers of non-urgent medical/life-style procedures to be removed from the schedule asap and for doctors enmass to directly charge all patients and allow the bureaucrats in Canberra to resurrect their pateint rebating system. Stop Bulk Billing!

  6. Sandra Skinner says:

    The quality of a lot of bulk billed GP services are so low that aren’t worth throwing more public funds into, sadly. 

  7. Ulf Steinvorth says:

    Private billing on top of medicare has never been proven to produce better health outcomes for patients than bulk-billing and Australian doctors are still amongst the best paid in the world, regularly making up most of the top ten income earners.

    Saying that there is no doubt about the inequality between bush and city medicine, both in severity, working conditions and pay which explains why so few Australian doctors want to do it and why international doctors who according to our Colleges are ‘less qualified’ are forced to serve our most vulnerable and sickest population with the least support.

    Surgeons and other procedural specialists who proudly proclaim that they have never bulk-billed have very little of mine or my patient’s sympathies as it is a real burden for rural Australians to get to see them and it hurts me personally to see them having to fork out over 100$ out of pocket to be treated by the very doctor whose studies and training they financed with their taxes, just so the doctor makes more than 300K/year.

    The current system is broken and needs fixing but increasing medicare payments alone will not help close the Gap, neither will increased private billing magically lead to better health outcomes, more likely to worse,  as seen in the US where 17% instead of 9% of GDP is spent on health and infant mortality is nearly twice ours.

  8. Jonathan Davies says:

    I thank Dr de Leacy for his comments.  To further place some ilightenment on my comments.  I was a FRACGP before before FRACS and spent 4 years in Western Queensland.  In fact when the MBS schedule was composed many procedures in General Surgery were also done by GPs this weighited the schedule fee for general surgeons proportionately less than for the rising sub specialiteis.  General Sugeons were exposed to the risk that bulk billing would have a significant deteriorative effect on the viability of private practice in the long term.  Perhaps Surgeons were more prescient than the GPs who succumbed to the initial temptation of bulk billing.  The comment that surgical procedures were more highly rebated than GP services only emphasises the folly of GPs accepting a schedule fee that was determined by Government and subject to detrimental adjustment by the  Government.

  9. fiona wallace says:

    As a doctor with special interests in palliative care and adult cognitive disability, I was hoping to build up a practice as a domiciliary GP. Having trained in a rural area in the UK I am used to home visits, enjoy them, and am horrified that so many gps in my region provide only an office based service. However, with 30 minutes or more driving time between patients, it is essentially impossible to offer this kind of service. Palliative care patients are regularly ambulanced to the emergency department, overinvestigated and inappropriately treated by junior staff at a cost of thousands of dollars, and this is somehow the best, most cost effective service.

    Families caring for relatives with severe cognitive and physical disabilities are the least able to travel to a GP or to afford the gap fee that would make visiting at home financially viable.

    The UK manages to offer GP cover including home visits, to the whole country 24/7. This is not possible in the remote areas here, but to make it financially non viable in a region some 100km across that supports around 20+ multi-doctor practices is ridiculous.

    To be honest, as a Brit I cannot see how anyone can view medicare as fit for purpose. It is a totally unnecessary and hugely expensive layer of bureacracy that many countries operate without. Expecting it to fit to the needs of such vastly different populations, and to treat GPs as clockworkers who will only work if they are paid a fee for each move they make is demeaning and ridiculous. A well-balanced capitation payment by practice allows freedom to work to the needs of your patients without one eye on the clock and the other on practice finances.

     

     

  10. Dr Lindsay Stewart says:

    I agree about proceduralists being rebated too much compared with non-proceduralists.

     

    I think it arose because in the Whitlam days many proceduralists took their own equipment to the private hospitals eher they operated (or paid for it)  Nowadays almost all gear is prided by the hospital, whether public or private. 

     

    Much safer for all concerned, but the relativity in rebates has never been addressed. 

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