Find a practice owner who’s worth their service fees and doesn’t expect you to work for peanuts.
A colleague and GP acquantaince recently (finally!) made the switch from a universally bulk-billing practice, which she’d loved working in, to a private-billing one.
For years we’d communicated intermittently on forums and privately about her desire to charge gap fees, to earn better for her own family, only to be thwarted.
Our common tie was that I was only too familiar with this type of situation – you’re a contractor so technically they cannot tell you what to do or how to work or to bill and yet … it’s made very clear that there is a preferred way to bill (or not), which in practice, is the only way to bill … so if you’re a decent person and GP, it’s often many months, if not years, till you decide to leave.
For any number of reasons. Burnout. Stress. Resentment. Trauma from feeling repeatedly invalidated or indeed, being sent the message that it is somehow your job to subsidise a failing government policy on patient rebates.
I’ve seen colleagues leave. For greener, private billing pastures. Or for salaried roles including with pharmaceutical companies. Rarely, they switch to other speciality programs where they are encouraged to bill privately, or leave medicine altogether.
Why do we do this?
Each time, we lose a valuable team member, usually female, who is a great doctor, a hard worker, beloved by her patients.
In what ways do we do this?
In my case, 11 years ago, one of the owners told me outright that no one would pay to see me and I’d cost myself and the clinic (by way of service fees) revenue. It was madness!
Then, when I decided to go ahead anyway (I negotiated a trial of three months) I had to design the spiel for front desk staff, and set up my own fees and write it out for staff to relay over the phone: “Yes I can make an appointment with Dr Joshi. I need to advise you, she is a private-billing doctor.” Only 25% of my patient base was eligible for gap fees at that stage.
Then, patients would show up, have their consultation and dispute the fee at the front desk, saying “I wasn’t told.”
So I had to work with staff to make a note next to the patient appointment – “fee OK” or similar – to notate their consent, despite which some still disputed the fees at the front desk.
Finally, some staff were so uncomfortable with discussing money, they’d apologise for it verbally – “I’m sorry, the fee today is …” – or do so with their body language. Occasionally patients were “accidentally” bulk billed and I let it slide because it felt just too hard.
I lasted at that practice a year after I stopped bulk billing everyone. After a lull of about two to three months, most people did return and did pay my fees, but it was simply too hard to push uphill.
I moved to a mixed-billing practice, then a private-billing one where I saw firsthand how belief in the service they provided and in paying staff fairly and investing in their own families motivated the owners to have the difficult conversations and to train staff appropriately. In response, patients were filtered out early if they didn’t wish to pay or couldn’t pay.
“Yes, I can help you with an appointment. We are not a bulk-billing practice. Do you understand what that means or would you like me to explain?”
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This was all between 2013 and 2016. Since then, I’ve become much better at having difficult conversations around money and charging appropriately and letting people, adults, decide if they’ll spend some of their earnings towards their health.
This has included pensioners (no discount rates for them). People who see me now know the fee structure and pay for it without quarrel.
In an ideal world, it would be wonderful if general practice was as well remunerated as staff specialists in hospitals are, for example, and we didn’t have to talk about money.
What happens instead is that GPs, especially women, who arguably spend the longest time with patients dealing with complex issues including mental health and women’s health issues, end up burning out. They feel unsupported by their workplaces to whom they pay significant service fees but fail to get their money’s worth. Eventually they leave, to the detriment of the practice and patients alike.
General practice is in flux but I am hopeful for the first time in a while because I’m seeing that many of these peers are choosing to prioritise themselves and their families over simply continuing to beg for scraps, whether from owners who don’t prioritise them, or from government.
Most of them, like me, want to be paid adequately for the excellent work they do and are OK leaving if that’s not being respected.
In the years to come, as the numbers of GPs continues to decline, those of us who provide excellent service will be in high demand and be able to charge appropriately for our services. This will enable us to charge those who can afford to pay and to choose, if we wish, to discount or even see gratis a small handful that we wish to.
For the owners who continue to see contractors as simply Medicare billers who are obliged to do as they insist, they may be in for a rude shock if they don’t listen contractors who want change.
It’s time to rethink the strategies we use not only to attract excellent GPs but to retain them. None of us should be expected to work for free, or as a charity.
Dr Imaan Joshi is a Sydney GP; she tweets @imaanjoshi.
