When altruism catches up with you

We owe it to our patients to stay viable, not to undersell ourselves to insolvency.

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Some weeks ago, an acquaintance and colleague who works in allied health posted that after more than a decade of service to the community, the clinics she oversaw, most of them bulk billed and funded by government grants and similar, would close their doors in three days.  

She said changes to government regulations over the years, coupled with perhaps a lack of financial savvy, had left the business struggling and owing money, including to staff. She had sought financial and legal advice and decided to close. Her own home, which had been remortgaged, would be put up for sale to make up some of the arrears.  

The announcement was met with well wishes and thanks from many in the community who’d benefited from her services over the years.  

To me, it brought home the message I’ve been pushing to any colleague who will listen about the lack of sustainability of bulk billing for at least a decade now.  

I remember years ago having the discussion with her in passing about charging gap fees, and being met with reluctance. “The people I serve can’t pay,” she said.   

Over the years, I’ve met this same explanation from other GP colleagues who work in low-SES areas and feel their patients cannot pay.  

It’s a noble sentiment except that, as happened with this colleague, at some point the altruism catches up with you.

It’s ceased to surprise me how little self-employed colleagues actually understand about how much investment a business requires, especially if they are not themselves business owners.  

As healthcare professionals, we have zero formal training in financial literacy. The fees, even when bulk billing with the frozen Medicare rebates, seem like a lot of money to some. No wonder we regularly receive snide comments about “greedy doctors”.  

It was only in recent years that I sought business coaching to understand why the seemingly large sums of money I was billing didn’t translate to a whole lot of actual profit after all expenses, taxes and more. And I’ve not routinely bulk billed since 2013!  

No surprise, then, that people are shocked and surprised when they find themselves facing insolvency and even bankruptcy while trying to help everyone else.  

It’s been a grim wakeup call for this colleague. When push came to shove she found herself on her own, losing her home for retirement and possibly more.  

This is why I push so hard for all healthcare professionals to put on their own oxygen mask first.  

During covid, when GPs were deemed less important than other healthcare professionals, I remember an emergency physician friend telling me how effectively they used PPE and how, if they weren’t adequately suited up, they would not approach anyone with covid-like symptoms to treat them. “Put on your own oxygen mask first,” she told me.  

Yet GPs, who were supposed to see all comers yet were so unsupported we had to buy our own PPE, were demonised for seeing patients remotely and in car parks to make that PPE last longer.  

We are the only doctor group with such poor boundaries. We seem to have internalised the criticism that any attempt to look after ourselves is greedy and selfish.   

Ultimately we can choose to blame everyone else. Or we can choose to recognise our own contribution to our attrition.  

We can start by educating ourselves on basic financial literacy and stop discounting our services because we feel bad.  

We can start by understanding how much of our billings translate into service fees, taxes and then go to pay for CPD, indemnity, superannuation, leave etc. and what is left to pay for the day-to-day expenses. If we have nothing left and are reliant on a spouse to pay for those, we may wish to reassess the way we practise and bill.  

Yes, it is wonderful when patients say “God bless my GP, they still bulk bill me and give me all the time I need.” To them, this GP is wonderful. To me, it is more suggestive of a GP who lacks effective boundaries and possibly has no idea how much money they might be losing and costing their practice in service fees.  

Years ago, I interviewed at a private billing practice and one of the things the owner asked me was my comfort with charging gap fees. As we are contractors, owners cannot force us to charge gap fees; but he wanted to be sure I understood that in choosing to discount or bulk bill every person, I was effectively not only undercutting my own income (a personal choice) but also the practice’s revenue to pay overheads, staff and more.  

As I say all the time, when it is cheap to you, someone else always pays the true price for that service. 

So unless you intend to run your practice (and yourself) into the ground, it may be time to revisit your billing and other practices for the good of all concerned, including the patients who can continue to see you because you remain viable and in business.  

Dr Imaan Joshi is a Sydney GP; she tweets @imaanjoshi.