It’s no use protesting this choice of language if you choose bulk billing as your only income.
Over the past few weeks the issue of “GP pay” has become inflamed.
Last week, following the release of the disappointing Strengthening Medicare Taskforce report, there were plenty of heated threads on Twitter that featured this language.
Disgruntled members of the public insist that the rebate is our pay, that they have paid in full for their GP healthcare via the Medicare levy, and so we have an obligation to treat everyone without charge and “to take it up with your employer the government if you’re unhappy, or leave”. But it’s also used by politicians and academics, despite our colleagues’ corrections.
One comment in the flood struck me. To paraphrase: yes, it is the patient’s rebate, but if you accept it as your full fee then effectively it is your wage.
I’ve been mulling on that statement as fellow FRACGPs continue to fight to correct the belief that Medicare pays GPs’ wages – to educate people that it is the patient rebate, and increases are the patient’s to lobby for.
That we have relied on bulk billing for 40 years, and that we’ve not done anything to fight its erosion in a unified way, has led us to this day.
We have fallen into the trap of believing it would always be this way; when I was a trainee, I had several supervisors who chose general practice and bulk billing because “I’m not comfortable talking about money”. Others did so because they believed that doctors in general fare far better than the general public and so it is greedy/unethical/ immoral to charge. Yet others tried to talk me out of charging gaps as a final term contractor trainee, saying “you’ll lose business, it’s important to keep the customer happy”.
This fear of losing patients drives a lot of our behaviour outside billing. During my training, when I refused to prescribe antibiotics for a viral URTI, instead educating the patient and advising they return if still unwell, my supervisors would chide me “Why didn’t you just give them the antibiotics? Now they’ll just go to the clinic next door and we’ll have lost a customer.”
Across several terms (all of them bulk billing), this was a regular refrain from disgruntled supervisors annoyed with me for choosing education over unnecessary antibiotics.
Over my decade in general practice I’ve watched over and over as seniors and supervisors and peers have caved in to keep the “customer happy”.
So is it only fair that our time has come?
Is it so strange that the public sees us as public servants, and that the nuance between patient rebate and GP wage has been lost? When you have not had to get your wallet out in 40 years, is it not understandable you think your taxpayer dollars pay for our wages, like ED and public hospital staff?
It’s easy to see why everyone, including many of us, believe the patient rebate IS our pay. Are those people even wrong?
Bulk billing has allowed many of us to deliver so-so care because there haven’t been many checks (paying customers are more demanding) and arguably, allowed many corporates, often not doctor-owned, to set up centres with international doctors on moratorium, insisting they bulk bill too.
The bulk-billing Urgent Care Clinics are being propped up with millions in funding by the government, which is a tacit admission that bulk billing is not sustainable.
Yet here we are, holding on to the sinking raft. Trying to educate an increasingly irate public, academics and laypeople alike on what is needed, many of whom, perhaps rightly, tell us that “if you accept the rebate as full fee, then you are on a wage, it is your pay”.
Perhaps everyone who insists that it is the “patient rebate” while bulk billing is only adding to the confusion.
When will we look beyond the immediacy of this issue, i.e. the genuinely vulnerable are suffering and will do so (though there IS a safety net in ED), to the fact that the longer this drags on, the more actual FRACGPs in their 30s and 40s are leaving, older ones retiring, and the projected shortage of 11,000 FTE GPs by 2030 will blow out to a much bigger number? And that’s not even thinking of medical students shunning general practice as a career choice.
Our choices have long-reaching consequences.
The best time to think about that, ideally, was in 2013, with the beginning of the rebate freeze. It didn’t happen. We continued in our daze.
The next best time is today. At this stage, every single person holding on is directly impacting the viability of our speciality and its future. Those who have moved to private billing are all saying “I wish I’d done it sooner”, and “there is no amount of rebate the government could offer that would tempt me to return to bulk billing (everyone)”.
Once you leave abuse, you never return unless there is no other choice. Those who’ve left have seen that there is a path, the grass can be greener where you water it, including within general practice.
As for all the fragmentation of care promised by UCCs and nurses and pharmacists taking over some of our roles – let them. They’re short-staffed themselves, and I doubt they have the ability or the time. If UCCs are staffed similarly to the respiratory clinics during covid and paid per patient seen rather than with a guaranteed wage, then I doubt many will take off.
This is a golden opportunity: if we mean it that the rebate belongs to the patient, then we need to act accordingly. It is possible to want to help patients advocate for themselves and their rebate AND to want to be healthy, rested and earning enough to love the work.
We have, like the Giving Tree, tried to give until it’s worn us out, to no avail. If we love our speciality and want change, we have to put the responsibility back where it belongs: between the patient and the government that’s failing them.
Dr Imaan Joshi is a Sydney GP; she tweets @imaanjoshi.
