The government may not be prepared to help general practice any further during COVID-19 because it now thinks the health part of the crisis is controlled enough, and it wants to see how general practice changes under severe duress
The government may not be prepared to help general practice any further during COVID-19 because it now thinks the health part of the crisis is controlled enough, and it wants to see how general practice changes under severe duress.
By this edition of “A week in COVID-19”, there are certain awful realities for GPs who feel they may have reached the “good as it gets” point of inflection. I hope not.
Our survey on practice revenue patterns continues to grow statistically sound (now well over the 400 mark in answers), and the early results, unfortunately, are remaining worryingly stable. More than 50% of practices continue to report their revenues have dropped 30% year on year. I’m not the expert on practice economics, but 30% is not margin of revenue loss I think many small businesses can maintain for any length of time.
Typically, a lot of independent practice owners can be observed on social media, and in commentary, arguing that they can’t, and possibly others shouldn’t, complain. After all, a good proportion of their patients have lost their jobs, or are suffering in some other way, far more. And at least the government saw the need to change things for them rapidly, such as introducing broad-ranging telehealth.
Typically, a lot of GPs are deciding to wear it on the chin, adapt as best they can and get on with helping their patients. It’s like they’re getting used to it.
This awkward societal context for GPs, I suspect, is one that the government has tended to play upon for a long time. The trend for the last decade has been that GPs will find a way to look after themselves, and their patients, therefore the increasingly difficult lot in life can be put down the priority list of things to fix.
It doesn’t help that general practice is essentially a collage of, at times, quite disparate, small businesses, difficult to organise, and represented by a college, the existence of which is dependent on the imprimatur granted it for running education and governance by what is ultimately a group that is government controlled, ie. the Medical Board of Australia.
A week or so ago, I thought that the federal government was doing its best for GPs under extraordinary circumstances. After more than a decade of resisting the idea of widely rebated telehealth, despite the concept being proven to be hugely efficient overseas if implemented the right way, within weeks telehealth was unleashed so GPs could manage their situations more practically. It was throttled wide to most MBS items, and when the bulk-billing limit was identified as an issue, it was lifted for a good proportion of these items.
The problem was that telehealth in one week, without preparation, quickly became the next nightmare to manage. Without patient education or awareness, preparation, equipment, rules and training, telehealth introduced a whole new set of issues for GPs, not the least of which was that with patients being isolated and not being even aware they could use telehealth, revenue started to plummet regardless of the initiative. For some specialist groups, such as rheumatologists, whose bread and butter is chronically ill patients, the new telehealth regime actually locked in losses of revenue of up to 70% per practice per consult (chronic care patients can still only be bulk billed).
GPs were faced with having to restructure, re-skill, buy new gear, and get themselves educated on what they could and could not do.
Less than two weeks into the new telehealth paradigm for GPs, and adding the odd other significant issue facing many practices, such as some of the large (some billion-dollar) pathology groups sending legal letters demanding rent drops, I’m not convinced the federal government isn’t back to its old stance on general practice of, ‘They’’ll be right…what can they do?”
What felt stunning about this at first was how much the government had been pushing that their major strategy in this crisis was that we had to “fix the health crisis first”. To fix a health crisis, you need health care professionals of all sorts to be on their game. GPs started as, and continue to be, the major frontline of triage and testing for the country. There has been a lot of focus given, as ever, to hospitals because when things go bad this is where the mess ends up, and overseas it’s been very messy and graphic.
What seemed obvious was that the government would quickly realise that general practice had never faced a survival crisis like this one in its entire history.
What seemed obvious was that while the government had acted pragmatically and rapidly to help with telehealth and to increase short term incentives, such as ePIP, and that GPs, as small businesses, also had access to all those new government small business initiatives as well, is that general practice isn’t your average small business in this crisis. It is the business that is holding your frontline and playing a pivotal role in preventing a lot of the mess we are seeing overseas.
What seemed obvious was that the government would, like it has been doing of late, quickly wake up to a very obvious issue – you can’t have your frontline in your health strategy break down before your eyes if you are going to sort out this health crisis – and fix it quickly, like they have other things like childcare, and small business continuity.
But apparently it isn’t obvious yet.
I’ve spoken to a few people who are mixing it with the likes of the AHPPC, the deputy medical officer fraternity, and even the federal health minister, and they are so far saying that there are so many things happening that it’s been difficult to get the message through. But the message will get through.
I’m not so sure now.
And the reason I’m not so sure isn’t entirely comforting.
In Australia, at least for now, we have our “curve issues” under relative control. For now, it looks as if the health part of the crisis, though not solved, is being managed, and could be managed back to point where we can start attacking the economic issues. This is all going to take a while still – six to 12 months at least.
In such a situation I wonder if the government doesn’t now feel immediate and comprehensive assistance to general practice to ensure that the sector doesn’t substantially have to restructure itself may not be so important. In other words, with things under relative control, is the government now sitting back and rolling the dice to see what the massive financial pressures on general practice might do to the sector?
That sounds a little risky, even a bit crazy in some respects. But if the government now doesn’t feel the pressure to make certain its front line defence against COVID-19 is entirely intact, then might it be thinking any of the following:
• All small business is going through crisis and needs to adapt, we’ve done a lot to help GPs, more you could argue than for any other small business sector, we can’t do any more
• We are actually spending less on the MBS as the moment. I wonder where this actually leads us in healthcare spending? Let’s keep going for a bit and see.
• We know some aspects of the specialist and GP sector payment system has been warped over time – particularly specialist rebates. Maybe the pressure and the subsequent need to restructure how they operate through this crisis could be a good thing for healthcare efficiency and spending over time.
Maybe I’m being paranoid. But what else explains the government not acting to shore up the now obvious the crisis in general practice?
If you saw David Dahm’s survival 101 six steps guide story this week, and read through the whole 170-page guide, you will note that in some instances Dahm is pointing many practices to the inevitability of restructure or closure, and if closure, he is recommending that GPs get on top of the concept as quickly as possible to optimise exit.
If this is as good as it gets in this crisis, if there isn’t going to be much more help for general practice, and if we have another six to 12 months of this weird existence, then there really isn’t any option but to do the research and get on with restructuring your business in some way that will see you through.
It is entirely unlikely that such restructuring on mass by practices and their owners, and even the big corporates (they must be under even greater relative pressure given that pathology is the biggest part of their revenues and the only testing going on is COVID-19), will not endure now far into the future, and change the nature of general practice for ever. Part of that will be a not insignificant proportion of small or single owner practices who simply decide to exit.
I think that without the government stepping in to help soon, COVID-19 is going to significantly change the nature and structure of general practice delivery, and likely specialist services, forever.
If this is going to happen there isn’t much question that we are up to “the bad and the ugly”.
But most smart practice owners aren’t going to waste a crisis under these circumstances.
If practices have to restructure, they will have to be significantly more efficient in how they provide services. Presumably, telehealth will play some role in that moving forward, and it seems unlikely that if practices eventually learn to embrace telehealth in the right way, then more efficiency for both GPs and their patients will occur.
And probably telehealth is just going to be the start of how innovative practice owners and their GPs are going to have be.
When we look back at COVID-19 from a healthcare point of view one of the clear silver linings will be the great leap forward that digital health will have taken.
COVID-19 has provided the opportunity to bash down bureaucracy, government risk aversion, privacy issues and the like, to open the sector up to seriously more effective ways of getting things done. The obvious early examples are telehealth, electronic script ecosystems, and cloud based patient management, not just for doctors but for all manner of health care professionals organisations.
The trick in all this for general practice owners, and their doctors, will be not allowing the government to take the efficiencies they create in restructuring and adopting these new technologies, back into the middle by using the MBS payments as some means of clawing these efficiencies into government coffers.
COVID-19 is awful – for GPs, for everyone.
It feels very much like the government is going to allow general practice to fend for itself despite its initial position on strategy to manage the crisis and the role of health care professionals.
David Dahm in his survival guide for COVID-19 seems to be saying to a lot of GPs:
“Wake up, we’re not in Kansas anymore…”
Dahm’s message is that significant change now is probably inevitable and rather than keep fretting about it, start working on getting in front of it.
Not that most GPs aren’t in some way doing this.
In the prime minister’s language, there is a bridge here somewhere over the COVID-19 crisis river. There is another side of this crisis.
Those that embrace where we are now, restructure, change and survive, might just find themselves in a better world than before when, eventually, they get to that other side.
Following are some of the most interesting stories from this week which relate to this piece.
See you next week.
