Structural problems won’t be fixed by doubling rebates. Voluntary patient enrolment can improve access, if funding varies with SES.
Our health services are struggling.
For patients, even the wealthy, it can be difficult to access timely care. For patients there is no “system”. They see a collection of poorly connected, differently funded services which they are expected to negotiate.
Then they see co-payments, sometimes hundreds of dollars. That’s affordable for the wealthy but try finding $40 each repeated visit if one is on a pension or the dole and paying rent. Even on a median income with rental or mortgage stress that’s not possible. These people either delay or don’t get care or join public hospital outpatient waiting lists or attend ED, either at the time or when they become very sick.
About 65% of patients are bulk billed by GPs, 40% by specialists and 34% by psychologists using the Better Access scheme. These professionals recognise their patients’ financial hardship. Others also do but feel they must charge to make their practices viable. Some simply have no understanding of financial hardship or believe it is an individual responsibility. Some are just greedy.
According to the Grattan Institute report A new Medicare: strengthening general practice, GP and GP trainee numbers are increasing and Australia has more GPs than most other OECD countries. The problems are in their distribution and their utilisation to make maximum use of their skills. Patients in less wealthy areas tend to be sicker, more difficult to treat and less able to afford co-payments. That is not attractive to most GPs or other health professionals. It needs to change.
Our health services model was designed and fit for purpose in the 1980s. Forty years later health service capacity and health needs are completely different. But we still run on the archaic 1980s model. There is an acute crisis for which some Band-Aids are appropriate. But the system needs reconstructive surgery, not Band-Aids.
The biggest suggested Band-Aid is to double the GP rebates. This completely ignores the structural issues. It might help a bit at enormous cost.
Special GP clinics are planned by the federal government and some states. They may help in the short term if GPs can be found.
The Grattan Institute report is about major reconstruction. But only 1000 of the 6000 medical practices in Australia would be involved by 2026. There are things that can be done now which are about reconstruction and can improve care across Australia more quickly. These changes would set up practices to be a part of a Grattan-like reconstruction.
The concept of voluntary patient enrolment with a medical practice is supported now by the conservative Australian Medical Association. It could be introduced almost immediately. For it to work one needs a benefit for both patient and practice.
The patient benefit could be a bulk-billed service with priority access to appointments. A financial benefit to the practice could be given that would, at a minimum, need to compensate for loss of co-payments. This practice benefit should be adjusted for socio-economic status (SES).
Similar small payments to general practices are already adjusted for age and gender. Data on SES is available at the level of 60 house units. This would mean practices in areas of disadvantage would receive an immediate increase in funding and those in wealthy areas would lose nothing.
The size of this payment could be increased over time to incorporate payment for other co-located services such as physiotherapists, nurses, psychologists and even dentists, and for time spent by all health professionals including GPs, to build a team approach to care, which is so challenging with the current funding model. Over time the itemised rebate for a specific appointment could be phased out for these enrolled patients, promoting even more interaction between health professionals.
Thus the system would be a fusion of fee for service for some patients and situations and block funding for others, and even the potential to move to salaried health professionals, which is the norm in public hospitals and Aboriginal Community Controlled Health Organisations. The bonus would be that rorting would be minimised as that requires rebates.
While addressing the mess of GP and primary health care it would be timely to consider dedicated federal funding for an increase in salaried specialists both in public hospitals and in the community. This would be in direct competition with private specialists but would address the appalling wait times and financial stress for patients who are not wealthy.
It is time for reconstructive surgery for our archaic health system. Band-Aids are neither efficient nor sufficient.
Dr Tim Woodruff is president of the Doctors Reform Society, an organisation of doctors and medical students formed in 1974 to support the introduction of universal health insurance, initially Medibank. He is a rheumatologist in private practice.
