24 January 2021

Patients should be free to choose even if the vaccine is not free

COVID-19 General practice KnowCents Medicare

Forcing GPs to bulk bill for a COVID vaccination denies patient's and GP's choice, makes the system less effective overall and may not be constitutional

Continuing his analysis on the government’s GP COVID vaccination MBS items and rules, principal of GP accounting accounting and advisory firm Health and Life, David Dahm, argues that forcing bulk billing on GPs is bad for patients and doctors alike, and might even be unconstitutional

As a patient and provider advocate, my bottom line is patients should always be free to choose their care. This does not mean it always has to be free care.  If other safe alternatives are possible patients should be free to choose. 

Let the free market prevail and patients be free to choose

The free market is the bedrock and the fabric that Australia has successfully innovated and been built on since Federation.

To discourage this by forcing bulk billing (which may be unconstitutional) may reduce convenient access to the vaccine. Many practices may conclude it is not worth participating and this will then fall back on a fewer number of clinics. This may do more harm than good. 

To maintain capacity we need to keep our current Medicare hybrid system. Ultimately people who can pay for convenience should be encouraged to. Everyone wins. Just do not discourage it.

The politically popular free ideology when the Government has finite resources is not sustainable. This is about giving patients an informed choice.

Yesterday, my article “New GP vaccination items don’t add up” (January 23, 2021) was designed provide some cautious guidance to practices applying to set up a COVID19 GP clinic in their community. 

Practices are not “profiteering”

A well-intended person on social media said to me that not all practices were about “profiteering”. I am happy to stand corrected, but the opposite is true. It is next to impossible to profiteer if you tick all the EOI boxes and comply with your medical indemnity insurer and patient expectations.

The EOI and the numbers pinpoint to the real complexity and risk of delivering a sustainable and socially responsible service.  It is easy to play the greed card and be dismissive of financial critics. Some healthcare professional critics feel they carry a higher moral and social authority than others. They sometimes unfairly label patient safety critics who use funding in their arguments as encouraging rorting. 

This is certainly something I do not condone. In the name of patient safety, all I ask is people take a deeper dive and consider all the issues before stereotyping the message and the messengers. We do not have time for short term identity politics. We cannot afford to effectively deligitimise and dismiss constructive debate away from serious systemic patient and practice safety and community concerns. 

The real cost will be people’s lives and livelihoods. 

Like it or not it costs money to deliver safe and sustainable care. Somebody has to pay for the Taj Mahal shopping list of things to do and buy to fight this deadly bug! I do empathise with the government. It is a hard sell when you use the free idealogy and resources are finite. Setting the right community expectation is key.

We need practical solutions. We need private practice clinics that are free to charge, just like our current medicare co-pay system. With appropriate consent, let patients be free to choose. COVID19 does not care what we think, for most of us we want to get out of harms way as soon as possible. 

All I ask is for our Government officials and politicians to stop publicly naming and shaming clinics who are trying to do the right thing. The free market and competition using open and transparent pricing will make sure people are not taken advantage of. The Australian Consumer Competition Commission will make sure of this. So I am not sure where all the concern is. We are overengineering a serious problem. 

COVID19 and its variant strains will take many years to go away so each community has to build permanent capacity. This new social business model needs to be right from the outset.

Unless you have received a large inheritance, people including doctors, nurses and practice staff do not and cannot for an indefinite period afford to work for free.

The last thing we need is another self-made systemic public health risk to patients, providers and practices.

What do patients want?

My family is a case in point. Our family in the UK have been affected by COVID19. In Adelaide late last year we had a lockdown. We had a friend with her 10-year-old child that spent 8 hours in a long COVID19 Federal Government testing line. Much to her frustration, just as it was her turn,  she was told to go away and come back the next morning only to wait again an additional 6 hours.

On the same day, my young daughter made an appointment for a test thanks to Dr Vikas Jasoria’s general practice called the Arkaba Medical Practice (no conflict of interest). There was no wait. She was greeted with friendly staff and excellent service.  Thankfully she quickly tested negative. We could safely get back to looking after her elderly grandparents. Incidentally, it was a free service and we would have paid for the convenience and expected to.

There is no business case to put in an Expression of Interest

The Government is to be applauded in recognising the important role general practice has. Unfortunately for their guidelines they have underestimated the significant back-office resourcing which goes beyond a traditional vaccination practice. 

Unfortunately, an average consult of $75 per vaccination is not enough if practices are forced to bulk bill. (Detail on all MBS GP Vaccination Items can be found HERE)

We used our national Doctors Pay Calculator to crunch the numbers. We could not make any configuration work unless a doctor risked a Medicare inappropriate practice investigation and the practice cut a lot of corners. 

Practices need back office block funding as a minimum to build permanent standby capacity.

The devil is in the detail

There are a lot of expensive little things you have and do. It can trip practices up and new ongoing costs are involved and or are not rebatable. This includes patient consents, screening before administering the vaccine (i.e. need telehealth) compulsory training for doctors, nurses and administration, defibrillators, a new $3,000 fridge, a dedicated vaccine area, preparing multi-dose vials which require more nursing staff, soundproof rooms, first aid person in addition to the vaccinator, cleaning between patients and technology integration with a national database. 

I estimate nearly 80% of this work will need to be undertaken by the practice and not the doctor.

The largest overhead is the staff. They do expect to be paid a premium for stressful and additional work expected of them. Our live monthly national benchmarks have seen an average 5% to 8% increase since July 2021.

These all erode a once sustainable bottom line. 

Feeling exploited 

So if you do nothing you feel pretty guilty and feel you are no longer part of the solution and you have broken your social contract with your local community. 

Understandably, in COVID times many practices may feel a heightened sense of  moral and ethical obligation to their local community. Your local general practice are a central go to point, a safety net.

Many continue to deeply worry about their future lives and livelihoods and the people they care for. To be able to alleviate this concern, to humbly serve your community in a time of need, is indeed a badge of honour.

Fuelling this sentiment is the recent Government national media’s expression of confidence in general practice. This places more pressure on practices to participate which is a good thing except for the plethora of  unprecedented financial and or medico-legal risks. With appropriate and timely funding much of these concerns can be mitigated. The talk about money can be polarising within a practice. It is usually something we do not like to talk about. It feels dirty and unethical especially with a virulent virus at our doorstep. 

The sad truth is that this can be the deal breaker unless you have deep pockets and courage to match the responsibility that comes with it. The temptation to cut corners is great with such a low rebate.

To opt out is not an option for some. Ultimately this may mark a practice’s demise and may be the subject of a public naming and shaming.

Is the risk of negative media worth it if you get it wrong? Is all of it really worth the risk?

Private billing is a solution not naming and shaming practices who charge a fair fee

We have to be practical and less ideological. We need to build capacity. We need more options like a mixture of block funding. 

We need to encourage private billing and not discourage it. This will help the taxpayer, patients and practices out with convenient, safe and cost effective access.

The do nothing option is not really a practical option. The government needs to admit it does have finite resources and it is ok for those who can pay for better access. This will free up resources to those who cannot afford it.

Surely more timely access to safer and cost effective care is a better outcome for the greater good. 

We can do more with less with the Government’s blessing.


Can the Federal Government force a practice to bulk bill?

The government can name and shame you or persuade you but the evidence is they cannot force you or they would have by now.

It appears Practices should and are free to charge as they see fit free from Government interference. They are price takers and not makers, practices voluntarily accept the fee offered by the government. If they set the price this would be illegal. In1973 there was a national referendum. The people of Australia sensibly voted that the Government could not price fix any good or service.

From my legal channels, the way doctors are implicated is when a doctor signs a bulk billing form assigning the patients’ debt to the Government. Then Medicare’s rules start to have some real legislative teeth.

The primary intent of Medicare was to be an insurer under the Health Insurance Act. To provide universal but not total access to healthcare. It simply could not afford to foot our nations entire health bill.

After a client’s female doctor in the 1990’s was investigated for doing “too many pap smears”due to patient demand, I had appeared and stated the 2011 Professional Service Review Federal Senate hearing into Medicare inappropriate practice. I question34e the Medicare rules and a patient’s right to chooose.

I cited the High Court judge Justice Gibbs comment that it was not the role of the Government to interfere with the doctor patient relationship of a private medical practice. I was citing a 1980 RACGP V Commonwealth High Court case which found the government could not explicitly engage in Civil Conscription or interfere with a private medical practice under the Constitution – see the Devaluation of a Constitutional Guarantee: The History of Section 51(XXIIIA) of the Commonwealth Constitution

“Gibbs J delivered the leading judgment. His Honour reiterated the principle that there is no explicit head of power under which the Federal Parliament can regulate private medical practice, in the sense of the physician–patient relationship.[98] The Commonwealth’s powers are limited to regulation of those financial and administrative incidents of practice that pertain to provision by the Commonwealth of medical and pharmaceutical benefits. 

Gibbs J was critical of the wide interpretation of the civil conscription prohibition clause provided by Latham CJ, Webb and Williams JJ in BMA. Specifically, he disagreed with the notion that without strong restraints, Parliament would be able to legislate so as to bring about a complete control of medical and dental practices”. 

For those seeking to bring on a new angle to this often confused and perplexing system, not being a lawyer I look forward to our legal fraternity picking up on this salient point in the near future.

About me:

After a serious worked related car accident in 1989, and nine operations later I continue to be a patient and provider advocate. I enter my third decade as a Chartered Accountant. I am a former 10-year Australian General Practice Accreditation surveyor, I come from a medico family. I have served on the AAPM national Board and was the inaugural national Chair of the Certified Practice Manager CPM post nominal.  I continue to provide accounting and practice management advice to many practices all over Australia. 

You know who you are and I thank you. It continues to be a real honour and privilege to serve you and your community through you. Note I am not a lawyer please seek appropriate legal and accounting advice. This information is for general information and discussion only.