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Strengthening general practice

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The Government’s Budget proposal for a general practice co-payment has been universally condemned since it was announced, and deservedly so. It is bad health policy.

At the request of the Prime Minister, the AMA developed an alternative co-payment model. Late last month, we released that proposal. It aims to protect vulnerable groups in our community while suggesting that, where people can afford to contribute, they should do so.

The AMA proposes a co-payment of $6.15 for concession card holders and those under 16 years of age, which would be paid for by the Government, and not from their own pocket. Only non-concession patients over 16 years of age would be asked to make a co-payment of at least $6.15. This amount was chosen on the basis that it is the current GP bulk billing incentive. The amount would be indexed.

The Government has argued that the co-payment should be a price signal to reduce unnecessary visits to the doctor. However, as the Government itself has modeled, this is likely to lead to just a 1 per cent reduction in GP visits in its first year, an outcome that underlines the confused thinking behind the co-payment proposal.

A $7 co-payment on all patients seems like a very significant impost on society for a very, very modest return. It simply does not make sense.

What has become clear is that the Government’s $7 co-payment proposal is nothing more than an attempt to make the Budget bottom line ‘look better’.

The pre-election commitment to not cut health was always going to be a problem for the Government.

So, taking $20 billion dollars out of health by 2020 and putting it into the Medical Research Future Fund (MRFF) allows the Government to say that the money has been kept in health. It also, as the Finance Minister has finally articulated, means that the Government can make debt look better because the MRFF will offset debt. Ingenious!

That is also the reason that the Government can’t accept the AMA’s proposal.

As the AMA has repeatedly said, we cannot accept a cut to the Medicare rebate. Consequently, our alternative co-payment proposal does not save the Government the $3.5 billion it has budgeted to come from the cut to Medicare rebates. Instead, it provides for only a very modest saving.

For the Opposition, this is an opportunity to capitalise on the Government’s intentions for Medicare – real or perceived. The Opposition has stated that it will never support any GP co-payment. It has attacked the Government for trying to get rid of our universal health system. However, they ignore the fact that almost 20 per cent of GP services are not bulk billed and instead attract a significant co-payment.

For many people, the concept of universality means that everyone has access to health care using Medicare bulk billing. However, universal access to care is not the same as access that is free of charge.

The AMA agrees that there is a role for free medical care for some patients in our society, particularly those for whom any sort of financial barrier to care would deny or deter them from accessing health care. We know that almost 6 per cent of adults already state that this is the case.

So, why has the AMA suggested a co-payment for patients who can afford to contribute?

It is because if we continue to encourage a bulk billing culture in general practice for all patients, the quality of general practice will suffer. Today, bulk billing relies on a Medicare rebate whose value has, in real terms, continually dwindled.

Competitive pressures mean that GP consultation times are becoming shorter and doctors can only treat a single health issue at a time.

The long-term sustainability of our health care system hinges on the ability of general practice to focus on prevention and manage chronic disease.

Managing the burden of chronic disease is the greatest challenge for Australia’s health care system. A modest co-payment for those who can afford to contribute will encourage the sort of quality general practice that we need to see, and which is so important in keeping patients well and out of more expensive hospital care.

It’s an easy shot to paint the AMA and its members as only being interested in a ‘cash grab’, as the Health Minister has done. In fact, the AMA has led the debate in relation to concerns about vulnerable patients in our community. The AMA has been consistent in its support for some co-payments, but also in its strong opposition to the Government’s co-payment proposal.

For many GPs, particularly those in suburban small practices or in regional areas, their practices grapple with how to provide quality and comprehensive care for their patients in a competitive environment. If they don’t bulk bill, their patients go up the road to the bulk billing clinic or they only attend when they have a serious problem that needs a longer consultation. This is why the AMA wants significant new investment in general practice.

While the AMA’s proposal does result in an increase of funding for general practice of $580 million over three years (compared with the Government’s Budget ‘windfall’ of $480 million), it also protects vulnerable patients and children – and also excludes out of clinic services such as visits to residential aged care facilities.

This investment is not a pay rise for GPs. It is an investment in more staff and better facilities in general practice to further improve the quality of care and meet growing demand for GP services.

If practices are to gear up for the introduction of a co-payment next July, they will need information and plenty of notice. The Government needs to put its model to Parliament for scrutiny and debate sooner rather than later.

If the Government’s co-payment is to be ditched completely, we will need an alternative plan to strengthen general practice.

The AMA’s proposal does not make the Government’s debt level ‘look better’. Rather, the AMA’s proposal is about sustaining the health care system through investing in general practice, while maintaining access to affordable health care for everyone.

This is a plan for a universal health care system that will serve the for community much longer than the stressed current model.

This article was originally published in Fairfax newspapers – The Age, The Sydney Morning Herald, and The Canberra Times – on 28 August 2014