How much is a lack of boundaries costing you?

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By

Dr Imaan Joshi

Let's put a dollar figure on what the no-shows and charity bulk-billings are sucking from your income – and the quality of your care.

Since my last piece, I’ve had more reason to rethink the way I do things in the practices I work at.  

I currently work across three jobs. One is a locum, with an hourly wage, so no brainwork there.  

The other two are mixed/private billing practices.  

I recently took a course by a service provider (a hairdresser, of all things) who was talking about how much late cancellations, no-shows and emotional discounts cost her business. She had nearly pulled the plug on her business due to chronic dissatisfaction, burnout and fear of losing clients to competitors if she dared to implement policies for those situations. 

So I sat down to do the maths myself to see how much money we lose each week and annually through our own lack of boundaries.  

Let’s assume we work 46 weeks/year and take six weeks of leave.  

Let’s assume an average of five late cancellations/no-shows a week.  

In a bulk-billing practice, if every consultation is a standard consult:  

  • 5 x $39.10 x 46 = $8993 in lost revenue per year 

In a mixed-billing practice, where a standard consultation is $70 (ie gap of $30.90): 

  • 5 x $70 x 46 = $16,100 in lost revenue per year

Let’s also assume 10 emotional discounts in this mixed-billing clinic where we cave in and bulk-bill someone because they ask us to:  

  • 10 x $30.9 x 46 = $14,214 in lost revenue per year 

In each of the scenarios, this is practice revenue loss, of which a percentage is our take-home pre-tax income.  

Add to those sums the time wasted in paperwork, in telephone calls that are not paid for, in rewriting lost scripts, reprinting lost certificates and more. How much revenue and time are we actually wasting in each of these activities that people by and large accept as being part and parcel of the work of general practice, but which truly is not?  

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What it is, is a gradual wearing-down of GPs such that we feel like our sole job and purpose is to write the scripts and the certificates and referrals for a fraction of what we are worth – and not even that, because some of the time, people don’t even bother showing up because it costs them nothing not to.  

Some of you are saying: “But I don’t mind. My patient demographic is really hard done by; they have chaotic disorganised lives and need my help.”  

Maybe. It is entirely possible that some of our peers do work with the genuinely chaotic and needy – those with drug and alcohol issues; those on the poverty line; those escaping domestic violence etc, and for those, I absolutely agree, we should make concessions and do our best to help.  

That is not, in my estimation, the bulk of what most of us work with in GP.  

Most of the time I dare say it is a lack of effective boundaries on our own part, a fear of having the difficult conversations and saying “when you don’t show up for your appointment, it is a waste of my time and I feel upset, frustrated and disrespected.” (I actually said this to a patient just last week.) Or, “when you are regularly late for your appointment, it throws my schedule out of array and I hate running late for my patients.” (I recently said something like this to a patient who regularly runs into traffic/parking issues.) 

I think while we all ought to recognise when our patients are genuinely struggling and do what we can to help, many of us fail to recognise our own saviour complex that may cause us to see everyone as being worthy of our (often unsolicited) rescue efforts when they are able to manage life in every other area save their GP’s office.  

What has come out for me from attending that talk and doing the calculations is a recognition of how much money I’m actually losing each year by choosing to stay silent or to accept the status quo.  

As a result, I don’t bulk-bill anyone unless it is my choice. I don’t offer mates’ rates or discounts routinely especially if people can afford to pay. Generally speaking, the harder the work (mental health) or the higher the insurance risk (procedures – IUDs, surgery) the firmer I am, unless there is genuine need.  

Each time I’m tempted (I’m still regularly tempted) I remember:  

  • My overheads 
  • My own bills 
  • The charities I can support by billing appropriately those who can afford to pay 
  • The blurring of boundaries in a therapeutic relationship due to expectations/ entitlement  
  • My own resentment and exhaustion after not saying no when I want to.  

If I choose not to charge, it will be because it has genuine, actual meaning to the patient and to me. 

When grappling with patients who tend to routinely run late, I allocate an appropriate amount of time, and start with that “we have 20/30 mins for this appt. How can I help?” So I am less likely to run late for the next patient, because valuing others’ time is just as important to me as having my own time valued.  

Psychologists and psychotherapists rarely run late, rarely discount and almost never bulk-bill because they are taught effective boundaries that are enforced as part of their own health and wellbeing.  

We doctors are not. If we are to enjoy our work, it must begin with us. We cannot pour from an empty, depleted cup; we cannot be good to anyone else, ourselves our families, least of all our patients, if we cannot begin to care for ourselves in addition to our patients.

Martyrs are lauded only in retrospect.

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Irfan
Irfan
2 years ago

It’s not uncommon to have around 16 no shows during week end shift

1
Peter Bradley
Peter Bradley
2 years ago

You know Dr Yoshi. Your article seems to me to be yet another example of a major reason as to why GPs should at least have the option to be salaried. That would then alleviate most of those issues.
However, I’m not proposing it be free at point of service. Not on your nelly. The punters should still pay an up-front user payment, otherwise it would be a bad thing, as it would be over-used and abused just like the UK NHS, which is not a salaried service, but capitation at its worst. But the fee would not be towards your income, but to general running costs, and set by the employing authority, which would normally be the state govt., and I bet they would not be anywhere near as ready to waive it as GPs are and do.

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Paul Triggs
Paul Triggs
2 years ago

Good points. The financial losses are sobering but the issues of boundaries are probably more important. There is also a lack of respect from patients in bulk billing practices that is not present in private building; on the flip side, I have worked in practices charging $90 per standard consult. This certainly puts an onus on us to provide thoroughness in the consultation and keep our knowledge current.

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Chris Lawson
Chris Lawson
2 years ago

Well, yes, but there are several reasons why psychologists rarely run late. It’s not just boundary training.

1. Minute-per-minute, the MBS Mental Health Care Plan rebates for clinical psychologists are only a little less than for GPs, despite the costs of running a general practice being much greater, including unavoidables like AHPRA fees and indemnity insurance premiums. This makes it easer to manage the business side of things.

2. Psychologists have access to generous group therapy rebates, which means if they have a 1-hour, 10-patient session, they can bill Medicare at $225.50 per hour…and then add a gap fee on top. (There are group therapy items that GPs can access — but these are only helpful for GPs with a special interest in family therapy and are paid significantly less generously.)

3. Fees by psychologists can be claimed back from health insurers, while insurers are forbidden by law from reimbursing out of pocket fees for any Medicare item (except where the service is provided in hospital — which of course excludes GPs). For clarification: health insurers can’t rebate a psychologist’s gap payment on a MHCP visit because the service was billed to Medicare.

4. If a psychologist’s fees are too expensive for low-income patients, the responsibility for care will fall back to general practice.

5. Emergencies are exceptionally rare in private psychology practice. Emergency walk-ins from unknown patients? Even rarer. Patients being dropped off by ambulance/family at the clinic door rather than the hospital ED? Never.

6. Psychologists are not the at the front gate of the health care system, so they are not facing the pressures such as the need to write ever more detailed referrals to get past public hospital censor teams looking for spurious reasons to reject referrals to make their waiting times look better. This is currently one of the most frustrating drivers of my underpaid work. When a public hospital finds some petty reason to reject a referral — in one particularly egregious example, because I had not included a test result *that was in the hospital records but had not been copied to me, as pointed out in the referral itself* — it generates further time and energy costs. I have strategies to address this, but that is still time and energy that I would rather be putting into useful medicine.

None of this is a criticism of clinical psychologists. But their professional obligations are very different to GPs and Medicare is set up to support the long consultation times needed for effective psychological care while pushing GPs onto a low-rebate, high-turnover model, which would work wonderfully well in a universe where GP consults were always simple and predictable.

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