How to stop bulk-billing everyone

A run-sheet for making the transition, from conversations at your practice to sitting with the guilt you may feel.

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With bulk-billing rates up around 90% of services and a massive debt due to covid, the government probably sees NO reason to raise the patient rebate – currently estimated to be around 50% of actual cost of said service. 

So if the government isn’t going to change, we have to. 

Last time, I wrote about how RACGP President Dr Karen Price had urged everyone to move as many patients to private billing as possible. 

We covered WHY someone might want to stop bulk billing everyone and reserve it for the true minority that genuinely cannot afford a gap – whether temporarily eg job loss, or permanently as with someone on the poverty line. 

As a group of 40,000 professionals in this speciality, we will never reach true consensus and there will never be enough of us willing to go on strike as teachers are doing. There will always be those among us who believe that we owe it to patients to accept what we get. 

But if you do want to move to mixed billing, how do you do it? I don’t think it is quite as simple as getting Tyro and charging patients. 

I have been inundated with messages from FRACGPs wanting advice on how to transition to mixed billing, so here are some processes that have worked for those of us who have managed it:

• If you are a contractor, speak to the principles and practice manager about your intention to begin charging gap fees for your patients and what that might look like. You don’t need their permission as a contractor but it is an important courtesy to get them on board if not actually to join you. 
• Speak to the practice manager about talking to the front desk staff about your intentions. Prepare a spiel for them to offer patients booking with you. For eg “Dr Joshi is a private-billing doctor. That means she does not bulk bill. Your fee for a 15-minute consult will be $X and you will get $39.10 from Medicare.” 
• Engage the practice manager’s help in placing signs at the front desk advising patients of your intention to move to mixed billing from a set date and categories of people who will be excluded from gap fees, e.g. children < 16. The less complicated the message, the better. 
• If patients ask you about it in consultation, try not to fall into the temptation to JADE – Justify/Apologise/Defend/Explain – more than you want to (or at all). Most people will have already decided if they will pay the gap or go elsewhere when booking. 
• It is easier to switch to mixed billing when you are regularly booked; it need not be for weeks ahead – even on the day or a day or two ahead is enough if your practice has walk-ins or children as a significant %. When I began mixed billing I charged a gap for everyone except children under 16. Easily 50% of my demographic was children, so it was easier to transition. Their parents initially said they’d loved seeing me but would be going elsewhere. I’d smile and say, “No problem, I understand, I’ll be delighted to continue caring for your child”. Most of them returned to me and paid the gaps within weeks of going elsewhere. A handful followed me to my next (private billing practice) too. 
• It may help to keep bulk-billing the regulars and to implement new gap fees for all new patients who qualify if you do not have a significant demographic that you’re happy to bulk-bill, as I did. Over time, this will increase and you will begin with patients who know you don’t bulk-bill and who choose to pay to see you anyway. 
• Other doctors when transitioning kept only last-minute appointments at quiet times of the day, such as lunch hour, for bulk-billing appointments – if you can come then, you get bulk-billed. 
• The reverse also holds, some practices charge gap fees beginning with more desirable appointment slots for those who have to get to work. One practice I worked at charged an extra gap fee for the 0730-0800 time slot on weekdays and charged only gap fees for ALL patients on Saturdays/after 6pm to offset having to pay staff extra and to incentivise getting contractors in on a weekend. 

Once you have decided how it will work for you with your demographic and your locality, begin. 

Our brains do not like change; they especially do not like difficult conversations and for many of us, talk of money feels shameful even though we accept it in every other area of life. So when the chatter starts, what can you do? 

• Prepare ahead: “when I am asked about my fees I will feel shame/embarrassment/guilt and I will do xyz.” 
• Be mindful that some people will be upset and say they won’t be able to see you – sit with your own guilt; they are adults and most do not need rescuing; sit on your hands and your guilt, feel it, and smile and say “I understand. It has been a pleasure.” 
• When I began, some people suggested I explain to patients my decision to charge a gap – I decided against it; it felt manipulative to me; it is a service and as with anything else, we decide if we can buy based on the price and go elsewhere if we decide we don’t want to. 
• Don’t take it personally. Their decision not to see you is not a reflection of your (lack of) worth. I regularly tell myself (still) “if the only reason they want to see me is cos I’m cheap/free, are they even really choosing me?” 
• Be prepared to be anxious and to do it anyway. It will take time – it took me six weeks before it began to get busy again, and many of the people who had left came back, and paid my gap. A handful even followed me to my next private-billing practice 30 minutes away. 

So when a peer says to me “People won’t pay to see a GP”, I have to laugh because I, alongside many others, know this is simply not true. I began mixed billing as a final year registrar in Blacktown; I currently work out of mixed and private billing practices in Penrith and Liverpool. 

One of my patients once gave me the advice that I have carried ever since: “You doctors tie yourselves up in knots worrying about money and whether patients can afford to pay, but for most of us (not the genuinely destitute) if we value the service, we will happily pay. Focus on providing the value, and you can worry less about the dollar value.” 

Almost weekly since I have been a fellow of the RACGP, I hear of fellow GPs including trainees who dread the thought of going to work, who feel exhausted just thinking of it, who are clutching at other options to avoid going back to the clinic as a GP. 

To those who hold firm to the idea that we should simply have higher rebates so we won’t have to discuss money, it won’t happen. The government is happy with us accepting a paltry, inadequate patient rebate as full payment for services, and it is leading more and more of us to leave, to retrain and to look for avenues to work that is decently paid – not Medicare, where the only way to earn more is by seeing more patients, sometimes to a point where it feels dangerous, for the patients and for you. 

The choices as I see it, are fairly simple: 

• Accept that if we are lucky, there won’t be a further patient rebate freeze to justify debt minimisation since “bulk-billing rates are at an all-time high” – i.e. GPs and patients are happy! If we are unlucky, there may indeed be a further rebate freeze given the massive ongoing covid debt. 
• Accept that nothing will change unless we change what is within our power to change: our own outlook. Not the rebate, not the government’s outlook on what we are worth and not the patients’, who, as long as they don’t have to get their wallets out, will be none the wiser as to the true cost. 

Even if you, as an individual, are happy with accepting universal bulk billing, many if not most in your community of fellow GPs are not. 

We are losing the best trainees to other specialities because there is little in general practice to appeal to them and we are racing to the bottom. 

So as an election looms, what will we choose? More of the same, or the courage to change ourselves and thereby our circumstances? It’s a tremendous opportunity for growth. Will we take it? 

Dr Imaan Joshi is a GP in Sydney; follower her @imaanjoshi