As we try to normalise taking payment for our services, we should be prepared to pay for quality care ourselves.
“You cannot appeal to your ideal client if you are not one.”
I came across this idea recently and it made me think.
With the cost-of-living crisis that is 2024 and plummeting rates of bulk billing across the board, including, finally, by GPs, it is important to sit with the discomfort of charging to stay viable.
It’s been a long time since we’ve routinely had anyone ask if I bulk bill (I don’t) but we still get the occasional incensed person yell at staff on the phone “it’s not about the price but why does she charge so much?” and “is that even legal?”
For so long, we’ve all been worn down by the expectation that we should rely entirely on bulk billing to pay our own bills. It’s seen as an Australian right, despite making us unviable.
At the same time, there’s a culture in medicine that says we should bulk bill each other (and our families by extension) irrespective of the rebate as a professional courtesy.
I’ve seen colleagues complain, in groups and to me, about seeing a doctor (especially if a specialist GP) and say “they didn’t bulk bill me; they charged me and the service wasn’t even that good! I mean, I don’t mind paying but …”
Reminder: that “but” negates everything that came before it.
“I don’t mind paying but …” = my colleague DID mind paying.
“It’s not about the money, but how can she charge so much?” It WAS about the money.
While many of us routinely want patients to pay, we baulk at the idea of paying when we are the patients.
Just as we want our patients to appreciate what they get for their fees, we should do the same.
I have an SEO guy who also works for other healthcare professionals, including dentists and orthodontists.
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“People who are used to working at a high skill level and are used to talking about money with ease, without shame, tend to expect the same of the people they choose for their own care,” he says.
Similarly, a patient in an entirely private billing practice said to me: “You doctors get all twisted up about how much you charge, but for those people who can afford to work with you, it really doesn’t matter that much if we feel we get value.”
Most GPs will likely groan at this point and say: “This may apply to non-GP specialists but not to us.” Or “yes, but you don’t understand my patient load”.
I was working in one of the lowest SES areas in Sydney in 2013 when I stopped bulk billing. Most of the people who left, saying they couldn’t afford to see me, eventually came back. Some followed me to other practices I moved to with higher fees.
People can and do pay for value, so to my mind, the idea that we have to drop fees, or be competing on price, is always flawed and predicated on factors other than true need. If someone really needed my help and was unable to pay, I’d rather do it bulk billed or literally free (e.g. refugee health) than do it for discounted rates or specials.
Over the years I have been invited to join new practices where the goal is to start with bulk billing and then implement fees; or start with “opening specials” and then put prices up after a few months.
To me these tactics feel dishonest. Start as you mean to go on, because psychology tells us that once we get something for cheap or free, we baulk at paying more for it. Second, we tend to value what we get for free or cheap less than what we have paid for.
It can be argued that this shouldn’t apply to healthcare, and that may be right, except every unpaid or underpaid consultation affects the business’ viability. Utopian dreams are great, but don’t pay the bills.
So, who did I attract as my core demographic as a private-billing GP?
People who valued their time more than the fee they paid. And because I’m someone for whom punctuality matters and who is happy to pay for punctuality myself, we worked well together. They were also people with boundaries – lawyers, accountants, doctors, dentists, orthodontists – people who were used to talking about money without shame, who valued the skills and expertise of a fellow professional.
This well-paying job allowed me to work in an entirely bulk-billing practice one or two days a week for years for low-SES people.
“You cannot appeal to your ideal patient if you aren’t one.”
This means seeking out value, not just a lower price.
Cheap, fast or good; at best you can have two of the three. And I choose to work, in my private practice, with people who choose for value above mere price also.
It’s taken me a very long time to be okay talking about money and fees for my services; to hold boundaries and enforce policies and protocols.
We are all waking up from the free-at-point-of-care dream. And it is okay to mourn that, without blaming the people charging to stay viable and hopefully, make a profit. Healthcare businesses are not charities. Additional training takes a lot of money.
In groups, we often talk about how expensive tradesmen are and how little we make by comparison, given the risk we carry.
Funnily enough, I’ve never had a tradie patient haggle over my fees, nor try to barter with me for cheap treatment. Similarly, I’ve never had a dentist or orthodontist ask me to explain or to justify my fees. They either decide they can afford to pay me, so they will; or they don’t proceed with the appointment.
If we are to transition smoothly from bulk billing all/most of our patients to private billing most of them, we have to examine our own money blocks and mindsets that are holding us back from also valuing the care our colleagues provide us, and their need and right to also earn well.
After all, you cannot appeal to the ideal patient if you’re not one.
Dr Imaan Joshi is a Sydney GP; she tweets @imaanjoshi.
