2023-07-02
Healthcare should be free at the point of delivery with no co-payments, which are in fact taxes on illness. Part of the reason why bulk billing rates are falling is the freeze on Medicare rebates since 2013, but the income disparity between GPs and other specialists is also a reason – and this needs to change.
By Brett Montgomery, a Fremantle Greens member, and a GP and also teaches General Practice to medical students at UWA.
(The following is the transcript of an address Brett gave on June 27th at The Fremantle Network’s Politics in the Pub on the topic of making healthcare more affordable)
Let me start with my philosophy on how we should fund health care. I like the quote attributed (perhaps falsely) to Aneurin Bevan, the Welsh MP who, in the 1940s, was an architect of the UK’s National Health Service. It goes like this:
“Illness is neither an indulgence for which people should have to pay nor an offence for which they should be penalised, but a misfortune the cost of which should be shared by the community.”
I think this encapsulates well the principle of socialised health care. It’s something I believe in. And yet I’m a GP who doesn’t always bulk bill his patients. Perhaps I’m a terrible hypocrite!
I think I bulk bill around 90% of the consultations I do. But not all of them.
In this, I’m similar to many of my fellow GPs. The latest Medicare statistics tell us that between July 2022 and March 2023, the rate of bulk billing of GP attendances nationally was 80.7%. (It was 76.9% in WA.) This means that more than three in every four GP consultations is paid for entirely by the government, without a co-payment from the patient. For fans of socialised healthcare, that could be better, but it’s not as terrible a statistic as recent headlines might suggest.
But the bulk-billing rate is starting to fall. That’s a concern.
And these numbers are more complicated than they may seem. They tell us the proportion of consultations that are bulk billed, but we can also ask what proportion of people are bulk billed. That gives us a smaller proportion – nationally, only 65.8% are “always” bulk billed, though another 23.2% are “usually” bulk billed.
Many of you probably know what I mean by bulk billing. But just to clarify: it’s when GPs accept the Medicare rebate from the government instead of billing the patient directly. The alternative is to ask the patient to pay the whole bill, and then have the patient receive the Medicare rebate themselves. If you've been asked to sign something for Medicare when you are bulk-billed, what you’re doing is signing your right to that Medicare rebate over to the doctor.
Why are bulk-billing rates falling? It’s about money. General practice has in recent years been funded less and less. There was a long “freeze” on Medicare rebates, started by a Labor government in 2013 as a temporary policy measure, but perpetuated for years by Coalition governments. A freeze meant that rebates were fixed in dollar-and-cents terms. But as they were not keeping pace with inflation, in real terms this was a funding cut. The freeze slowly started to thaw for GPs in 2017 and 2018. But there was not any catch-up to bring rebates back to where they would have been had the freeze not happened. They’ve merely been indexed, roughly to inflation, I think. So, in real terms, the Medicare rebates for the work of many health professionals, including GPs, are smaller than they were 10 years ago. Today, the Medicare rebate for a standard GP consultation, of under 20 minutes in length, is $39.75. And nearly all the funding for general practices comes in this “fee-for-service” manner. Doctors keep a proportion of this fee, but some also goes to the practice to pay the wages of reception staff, practice managers, practice nurses, plus rent, equipment, and so on.
I’m not surprised that bulk-billing rates are falling. In fact, I’m surprised that they took so long to start falling. That bulk billing is still so prevalent speaks, I think, to the fact that many GPs truly do care to make health care accessible.
Many GPs will charge out of pocket fees to people who they perceive as being likely to be able to pay, to help them keep bulk billing those who can’t. I have come to accept charging a gap to, say, a well-paid fossil fuel company executive, if it helps me to provide free health care to the disability pensioners that follow him in my appointment schedule. Arguably, this is ethical. But I’d much rather this was done for me with sensible, progressive income taxation, and ample Medicare benefits for everyone, rather than me having to do it in my practice. And I have the privilege of working in a suburb where this “Robin Hood” sort of billing is possible. In some regions, there just aren’t enough rich patients to cross-subsidise the poor.
And it’s getting harder, isn’t it, to find a bulk-billing doctor? Especially, I think, if you aren’t in one of the groups that the government encourages GPs to bulk bill. We are encouraged to bulk bill children under 16 and people with Centrelink concession cards – pensioners and so on. This encouragement takes the form of an extra payment of $6.60 if (and only if) we bulk bill people from these groups. This extra payment doesn’t exist for people outside these groups. And, anecdotally, I think it is these people who find it hardest to be bulk billed. University students who aren’t quite poor enough to have a health care card. People in midlife who are working, but struggling to keep up with their mortgage. Often it is people like this whose stories of expensive health care we hear in the media.
Should GPs just accept a smaller pay packet? ATO statistics tell us that the average GP income is Australia is around $150,000. (Mine’s less, by the way, – but that’s what I get for working at a university!) Compare that to the average ear, nose and throat surgeon, who earns over half a million dollars a year. Many other surgeons and procedural doctors (cardiologists, anaesthetists, etc.) are earning over $400,000 annually on average. Some of this income difference may reflect a more part-time GP workforce. But other data tells us that GPs indeed earn a lot less than other specialists on an hourly basis – roughly $70 per hour less.
Now, even the average GP’s income of $150,000 is well north of the Australian average. If your income is lower than this, then you might find it hard to care about this income inequality between the medical professions. But there are reasons to care.
First, this income difference is bad for the morale of the GP workforce.
Second, this income difference is putting medical students and junior doctors off the idea of becoming GPs. Money isn’t everything, but it is a factor in career decisions. And there is a GP workforce shortage which is significant and growing – especially in rural and remote areas.
We should care about a dwindling GP workforce for several reasons.
One comes right back to our topic – affordable health care. Workforce shortages are not going to help affordable health care. I’m no economist, but I understand that when something of value is in short supply, its price tends to go up. Doing that with health care is a recipe for out-of-pocket “co-payments”, which lead to poor health outcomes due to poorer people missing out on vital health care.
Second, a workforce shortage is stressful for those GPs remaining in the system, who may feel obliged to try to help more patients than they safely can. This is a recipe for burnout.
A third reason to care about the diminishing GP workforce is that general practice is a vital and unique part of health care systems. When researchers compare health system with strong general practice (“primary care” as they call it) to regions that emphasise other specialties, they find that good general practice is associated with better survival, better child health, greater health equity, and a more cost-effective health care system.
If income inequity between medical specialities drives new doctors away from general practice, we will lose these advantages that primary care gives us.
Whether we should solve medical income inequality by paying GPs more, or surgeons less, is a question I will leave to the audience tonight. But I hope you’ll agree that the inequality is a concern.
There were some glimmers of hope for affordable general practice care in the recent federal budget. One is a promised tripling of the bulk bill incentive payment. This doesn’t mean all GP Medicare rebates are tripling. It means that $6.60 bonus payment will triple – so to about $20. This is promised from November this year. I think that will make it easier for GPs to bulk bill eligible people. But remember: that only applies to children under 16 and to people holding Centrelink concession cards. There’s no promise of a real raise in Medicare rebates for other people. Which I think almost sends a subliminal message that the government thinks other people deserve to pay. They don’t say this out loud, but it is how I see some GPs interpreting things. And in some states, new rules on payroll taxation are likely to gobble up much or all of this apparent raise.
Perhaps we need to rethink things, and focus on broader reforms rather than tinkering with Medicare rebates. These rebates, after all, are “fee-for-service” payments. They are one way of funding health care, but they have their problems. One is that doctors get paid as much for a 6-minute consultation as a 19-minute one. And a system like that actually disincentivises thorough, slower care.
The current government convened a taskforce – the “Strengthening Medicare Taskforce” – which recently delivered a report which hints, vaguely, at possible bolder reforms. It suggests blended payment models that may better serve the needs of people living with complex chronic disease, and which cater better for underserved populations, such as Aboriginal people and people living in rural and remote regions. It foreshadows better team-based care, wiser use of health technologies, and the positioning of health consumers more centrally in health systems. These are fine words, and I hope we see progressive reforms. But it’s not yet clear if and how the government will move from good intentions to effective policy.
So, I’m looking forward to our discussions tonight about what you think we should be doing to make more affordable health care a reality.
Header photo: A health clinic in Darwin. Credit: www.carepointmedical.au.com
[Opinions expressed are those of the author and not official policy of Greens WA]