29 June 2021

Patients don’t understand how we are paid

Comment KnowCents Rural

The defunding of general practice has been largely invisible to the public. Talk to them about it.


Let me tell you about a beautiful little town on the coast in southwest Victoria.

It is nestled around a port, with quiet beaches and views of the ocean that take your breath away. Whales can be seen off the shore if you’re lucky. Fishing and camping can be enjoyed every weekend. There is a plentiful choice of good kindergartens and schools. You can always get a parking space. The sunsets are spectacular. The community is friendly. It is even possible to buy good coffee.

Yet the town has a big problem: it doesn’t have enough doctors.

One by one, GPs have either retired or moved away without being replaced. This is not the fault of the doctors who have left. They are human beings with lives and families and needs of their own.

It is getting harder and harder to recruit GPs in rural areas all over Australia.

Why is this?

I have my own perspective because I am a rural GP. The town described above is my home. I moved here seven years ago, during which time I have seen the number of doctors and clinics gradually decline while the population has grown. The level of distress currently experienced by patients, doctors and staff is very high. The wait for non-urgent appointments is now several weeks. For the first time ever, clinics have had to close their books to new patients. The emergency department is under even greater demand than normal. Patients are driving over an hour away to seek care in other towns.

As a GP, this is devastating. My vocation as a doctor is to help those who are sick and in distress. It is heartbreaking to be unable to meet the needs of everyone seeking help. I worry about this constantly. The truth is that I am human and there is a limit to how many patients I can safely see in a day. General practice is a challenging job, and the risk of burnout is high. All of us at the clinic are working longer hours and fitting in more appointments, but it is never enough. There simply aren’t enough of us.

The way things are headed, eventually there are not going to be enough GPs anywhere in rural Australia.

The difficulties we are facing in our town are not the result of a couple of years of bad luck. The issue is that primary healthcare has been underfunded for many years, and we are seeing the fruits of this now. Fewer and fewer graduating doctors are choosing general practice as a specialty, let alone rural general practice.

All GPs know the financial pressure that we are under, and the stress of navigating the MBS in addition to our challenging clinical decision making. We know the constant worry about being audited if our billings fall outside the norm. I have seen many GPs on social media expressing frustration at their patients’ expectations to be bulk-billed.

What I have realised in talking to my patients was that they genuinely have no idea about how the system works. They are frustrated and frightened by the doctor shortage, but don’t understand what is causing it.

There is a common misunderstanding that the government pays GPs a salary, and that bulk-billing just means the government pays the bill instead of the patient. Many then think that doctors who charge a gap are double-dipping or just being greedy.

Deep down, I think most of our patients really do value us and what we do. They honestly don’t know what they are asking of us when they request to be bulk billed. They also don’t realise how the system penalises us for spending longer with our patients. They don’t understand that we cannot care for them the way they deserve on the rebate the government is willing to provide.

I love my patients and my colleagues, and therefore I am not going to quit. The practice I work at has extraordinarily dedicated doctors and have become like my second family. I will keep doing my best in a system that is not set up for the type of GP that I am. I will continue to participate in medical education and encouraging the next generation of GPs.

So back to the original question: Why is it so hard to get doctors to come here?

Having made my home in the country, I can understand and share the frustration of the local community. I love the peace and quiet, my veggie garden and my chickens. I often wonder why city doctors can’t see what an amazing place this is to live. I then remember how I felt seven years ago when my husband was first looking at a job here. I looked at the map and immediately thought no way, that is too far. It was hard moving away from all our family and friends whilst raising a young family. It is still hard being away from them all. Being a rural GP can be incredibly lonely at times, as the challenges of small town medicine can make it difficult to make friends. We won’t solve this problem by pretending that there are no hardships involved.

I believe, however, that the fundamental reason why we don’t have enough GPs is that we have had almost 10 years of relentless defunding of primary care. This is the reason why junior doctors are walking away from general practice. 

You may ask then, why did I stay? There was no single reason for this decision, it was one that built up slowly over time. I can say that it had nothing to do with money, and everything to do with the people I met here. I think deep down I have always had a longing to live in the country, and the little acreage we are living on now truly feels like home to me. My husband and children are settled here now and with time we have made good friends. I have had an incredibly generous and kind mentor at work who supported me through my training and taught me to be a better doctor. She was the main reason I wanted to stay on after I completed my specialist training. The clinic had been so good to me while I was training that I wanted to stay and give back to the community.

And there are signs of hope – we have a GP registrar joining us next year who first came here as a medical student. She fell in love with the clinic and has now committed to moving here and being a long-term member of the community. I absolutely refuse to give up hope in general practice.

So what can we do?

I felt so passionately about our situation that I recently wrote and posted a blog article about this. My aim was to explain the way general practice is funded, why bulk billing is no longer sustainable, and why this was leading to the GP shortage. It was circulated widely through our local community, and the difference has been palpable. The overwhelming response from patients has been I had no idea it was this hard for GPs. Many have written to our local member in response.

If you are finding your patients are frustrated by the wait for appointments or the out-of-pocket cost, I encourage you to speak openly with your patients about the reality so they can better understand. Anyone can make their voice heard by contacting their local member. If enough patients speak up, we just might be able to enact some real change.

This piece was adapted from a blog post at drdeborahcarrington.com.

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8 Comments on "Patients don’t understand how we are paid"

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Tony E
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Tony E
11 months 29 days ago
Well worded and concisely expressed. I agree with the sentiments and follow up comments. Which is why i left GP at the end of the training scheme. The conflict of time constraints, unfunded work ( letters, results, phone calls- which are a significant part of every day) and the pressure to bulk bill even in mixed and private practices, was not worth it. All compounded by trying to be clinically perfect when the main strategy from the govt seems to be to prevent understanding the appallingly complex billing system, which presumably results in lower costs. I am earning more in… Read more »
Annabel
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Annabel
11 months 29 days ago

Great article Deborah. I hope your new doctor enjoys all the great things you have in your town. I think pointing out the 0.9% MBS indexation this time around – that has to be a low point. Also, the other thing that has slipped in is that while giving practices extra PIP for 2 quarters last year, they were also quietly taking all the telehealth items out of SWPE so your are losing money out the other door!. I ‘m wondering now if all these COVID vaccination items are going to be included in SWPE.

Carolyn Bennett
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Carolyn Bennett
1 year 1 day ago

General Practice has been consistently defunded since medicare began, not just the last 10 years.

JOHN QUAYLE
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JOHN QUAYLE
1 year 2 days ago
COULD NOT AGREE MORE – FOUNDATION MEMEBER OF RDAA AND RDAV. No one supports us in the medico-legal and medico-political space Co- payment was stopped by a bunch of cross benchers in the senate who did not even want to know about no increase – not even CPI to the bulk bill medicare rebates since 1998Even John Deeble admitted the non linking of rebates to at least CPI was a mistake. We need to charge EVERYONE at an independently assessed rate taking into account CPI and other wage increases since 1998.dONT EVEN GET ME STARTED ON THE CURRENT HEAD OF… Read more »
shyamala hiriyanna
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shyamala hiriyanna
1 year 2 days ago
Yes patients do not understand what is bulk billing means. I explain it to them and inform them that the doctor is agreeing to take 15% less that the amount patient needs to pay. it means us doctors are taking 15% less to provide the service. i also explain that it is the generosity of GP if they bulk bill. The only thing keeps us going is the passion we have to help our patients. That is the reason why we tried and studied so hard to become doctors. Unfortunately money matters, It costs a lot to run a practice.… Read more »
John Davis
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John Davis
1 year 2 days ago

Closer to 50%, not 15%.

A.Mazzaferro
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A.Mazzaferro
1 year 2 days ago

Ditto to all that has been written but getting a doctor in the urban areas is also very hard.
We could do with 2 more full timers but haven’t had any luck over the past 2 years. The new graduates steer away from General Practice (can’t say I blame them) they prefer to either try and specialise or work as CMO’s , less stress, financially just as good or better off. Charge an amount of gap that you feel you are worth to non pensioners and children over 16 and battle on with a happier frame of mind.

pran lal
Guest
pran lal
11 months 1 day ago
Our reps are AMA. Where are they is this plight if ours? THE ANU gets great results in pay negotiations. see Nurse Oeactitioners rates, the pharmacists are doing extremely well. AMA- lots of talks and meetings but zero gains for Doctors financially. Our defunding continues slowly and durely. AMA needs to become more assertive . just like it did when the Co-Payment saga few yrs ago. U fortunately their actions s are like those of beggars. Ask but accept only what is offered. The Govt thinks that we are a soft touch. they agree to listen to AMA then does… Read more »
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