We’re the only ones expected to subsist on rebates amid abuse from the public and scrutiny from government.
A few weeks ago I blocked off three hours to spend with the ABC for a planned piece on doctors’ mental health, specifically, GP mental health in the face of recent changes including the decision by more and more of us to abandon bulk billing and the pushback we have gotten since, prompting some of us to (temporarily) leave general practice. I was told it would air sometime the next week.
But that was the last I heard of it. What happened instead was two weeks of coverage by the ABC and Nine newspapers about how $8 billion of Medicare money was being wasted every year, including through deceitful claims, featuring TMR contributor Dr Margaret Faux. Many people have now pointed out the lack of foundation for the $8 billion figure in her thesis or elsewhere, and the fact that her thesis says Medicare complexity rather than fraud is the source of most non-compliant billing.
Yet fraud was the angle the media companies pushed, and many on social media were only too happy to run with it.
One Twitter user, Dr Kathy Eager, asked why GPs were taking it so personally, even though we were not the only health professionals singled out.
It’s a fair question, but I think even non-GP doctors – let alone non-doctors – often fail to understand how much of a toll the past 2.5 years have taken on the morale of general practice especially. So here are a few reasons:
- We are the largest users and billers of the MBS since we are largely private small businesses – even, and especially, if we accept the inadequate patient rebate as full fee for service.
- There is hardly any time spent teaching us how to use the MBS.
- In general practice, unlike other specialities, there is a bewildering array of item numbers with complex codes and conditions, resulting in most of us regularly underbilling as well as doing unpaid work.
- Even though radiology and pathology also bulk bill, I am unaware of them getting the nudge letters and audits that we all fear in general practice, which have us toeing an invisible line.
In response to these unsubstantiated claims, there has been a form of quiet quitting on social media fora with multiple threads of FRACGPs asking what other options they should consider with their qualifications that do not involve Medicare billings in their name. Others asked about non-GP work on a salary. Yet others who were considering leaving to retrain felt this was the final straw that had pushed them to make a decision. Even some, who’d previously been proudly entirely private billing, were shaken, and considering leaving for greener pastures.
Journalist Samantha Maiden contributed by telling doctors to get “off their high horse”, tweeting that GPs “want you in and out in 5 minutes [and] constantly whinge about how much they are getting paid”, and that she had refused to pay at the front desk when called back for a second appointment, because that amounted to “Medicare fraud”.
By the way I refused to pay the bill the Second time. I explained she didn’t provide any service and explained to the front desk “that’s Medicare fraud.”
— Samantha Maiden (@samanthamaiden) October 17, 2022
Is it any wonder more and more of us are leaving, whether for a while or for good? There are those among us who stay, because they serve the most disadvantaged and say they are stubborn, but increasingly for the rest of us, this is about our own sanity, our own survival.
Increasingly our relationship with the government, with Medicare and even with the media and public, feels like an abusive relationship where we work ever harder for less and less by way of recognition and remuneration.
My allied health and psychologist friends made the transition long ago to gap fees, simply saying “bulk billing is unsustainable”. The more they and non-GP specialities do this, the more it has fallen on us, as GPs, to be the default healthcare worker for the most vulnerable and anyone who doesn’t wish to pay a gap fee. Even those that help the most disadvantaged, such as Aboriginal services and refugee services, usually secure some extra funding through grants and other means because bulk billing only has been unsustainable for years now. It is mind-boggling to me that universal bulk billing elsewhere has persisted for as long as it has.
What is it about us in general practice? How much more do we need to put up with from people who have never stood in our shoes?
What has to happen for us to say “enough” and walk away? When will we stop justifying our billings to people committed to misunderstanding us and arguing with us? When will we realise it is not our problem to fix?
As someone who has gone through two speciality training programs full time as an accredited trainee and nearly completed both, I feel sad and bereft. I’ve been a doctor for 21 years and in the end, the speciality I did end up completing doesn’t seem to be worth very much at all at the moment. All my years were for naught, it seems. Is my FRACGP simply a piece of paper, when every second person on social media says things like “why pay for a GP when you can just Google your symptoms and save money?”
Last week a soon-to-be doctor asked me for advice about doing general practice. I found myself telling her it is among the best specialities I’ve done, but if she chooses it, to be firm with her boundaries, and to not bulk bill everyone because that way madness lies. Later that week I gave an intern the same advice: bulk billing is a death knell. The patient rebate is not only inadequate, it is grossly offensive, and in no way reflects the skills, education and time a good GP spends on you.
Another colleague has finally decided she will stop bulk billing everyone, after a taxable income of $60k last year.
Paradoxically, many who are trying to make do end up cutting corners and reinforcing the very idea they are trying to avoid: rushed, two-minute medicine, contempt from the public and a sense that “a GP is not worth paying a gap fee for”.
I’ve been doing ED locums, and seeing patients referred by GPs who can no longer stock consumables needed to run a proper general practice if they bulk bill everyone; or GPs who refer because they are double and triple booked and have no time to squeeze anyone else in, even for “GP stuff”.
When push comes to shove, it’s well and fine to glorify the seemingly endless hours we do unpaid for our patients, but in reality, it’s not healthy for anyone, and it simply props up a broken system that is in long overdue need of repair and reform.
It needs to begin with respecting and rescuing ourselves. No one else is coming to save us.
Dr Imaan Joshi is – at heart – a Sydney GP; she tweets @imaanjoshi.
