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The GP co-payment could sink my practice

- Featured Image

By Dr Declan Green, a Melbourne GP

This article first appeared in The Guardian on 11 December 2015, and can be viewed at: http://www.theguardian.com/commentisfree/2014/dec/11/price-signals-are-a…

My general practice is like the TV show Cheers: a place where everybody knows your name.

My reception and nursing staff know the quirks of the majority our patients. We know Mrs Jones will need a taxi to take her to her appointment. It’s easier for our staff to book Mr Verona’s high resolution thoracic CT scan for him, because of his thick accent and poor hearing.

I am grateful for having such good staff, pay them above the award and try to provide them with a yearly pay rise. Now I’m unsure if I can afford to keep them.

Each year it has become progressively harder to maintain a level of service at a time when the ageing population presents with complex, chronic conditions. To prevent an expensive hospitalisation, patients require more time and resources than ever. General practice sometimes seems like a death by a thousand cuts.

The woefully inadequate indexation of the yearly Medicare rebate, crawling along at half the rate of inflation, has made it more expensive to give these patients the care they need. Now, with the Abbott government’s “optional” co-payment, the thousandth cut to general practice may have finally arrived.

There are three components to Abbott’s policy. The first, the “optional” co-payment itself, cuts the Medicare rebate by $5 (about 13.5 per cent for those without concession cards). In principle, most GPs believe that those with the means should pay for their health care, but the reality is we bulk bill many who don’t meet the criteria due to personal circumstance and competitive pressures. 

The second component of the Abbott plan is to freeze the Medicare Benefits Schedule indexation for the next four years. This is the killer.

Already, most GPs lament how the rate of indexation has eroded over a generation. To compensate, general practices have had to generate efficiencies, largely through economies of scale.

For instance, my own middle-sized practice was formed by the amalgamation of three smaller, struggling practices, eager to share the increasing costs and regulatory complexity associated with treating patients in a primary care setting. Many GPs have had to change the way they practice medicine to survive in the regulatory mire that has become modern general practice.

Combined with the cut to the Medicare rebate and with costs rising at 5 per cent per annum, the net effect is a cut to income of around 25 per cent. It is up to GPs to decide whether they will accept this and become de facto Medicare levy subsidisers for the general population.

The third component in the Abbott Government’s reforms is the increase in length of a standard consultation, from six to 10 minutes. Most patients don’t realise that the Government pays the same rate whether the GP sees you for six minutes or 19 minutes (I can’t wait for the legal profession to adopt the same condition). Nor do they realise that the rebates for longer consultations are less per minute than shorter consultations.

The Government says this is a quality control measure aimed at reducing “six minute medicine”. How foolish! The reason we have six minute medicine is because the woeful rebates from successive governments have forced GPs to churn patients to cover costs.

The business model of many corporate (and increasingly private) clinics requires short appointments, quick patient turnover at a low price point (bulk billing), with overheads defrayed by having 20 doctors on site. This results in Mrs Jones’s shopping list of medical problems being dealt with one problem at a time over many sessions rather than one longer consultation.

And don’t think about personalised service. Mrs Jones can take a number like the rest of them and see the next available doctor, whose primary motive is to take the order, complete the transaction and get her out of the consulting room as soon as possible. It’s fast food medicine, without the preventative “fries with that”.

A few months ago, I treated a new patient to my practice, a young woman with chest pain. She had been to her usual “fast food” clinic, where on two separate occasions she was told by different doctors to take over-the-counter painkillers for muscle aches. This young woman, a mother of six children, was never examined.

Within a few minutes of her presentation, I realised she was having a heart attack, and spent the next hour treating her, writing letters and arranging a hospital transfer. Her symptoms were classical, and a medical student would have been able to make the diagnosis.

I wonder if successive doctors thought about the financial penalty to them of assuming that this patient was having a heart attack and spending an hour treating her versus seeing three sore throats in 20 minutes for the same remuneration. I certainly hope they didn’t chase the easy money.

The patient survived and has many years ahead of her. More importantly, her six children and husband still have their most precious resource. The cost of prevention goes far beyond dollars.

Like most GPs, I believe in a universal health system. I also believe price signalling is a necessary evil – not because it saves the government a single penny, but because it allows us to have a discussion about the rising cost of health care in an ageing society.

But I cannot see how the “optional” co-payment will improve the nation’s health. For a generation, governments have turned their backs on primary care and used it as a scapegoat for policy change. If only they would measure the vital signs of our general practices!

If things continue as they have, I’ll be joining my staff in looking for an alternative career – perhaps one where there have been three pay rises in about two years. Federal politics might be a good option.