Many practices can walk away from bulk billing, but there are communities where people simply can’t afford to pay. Rebates cannot be left to rot.
You’ve probably stopped bulk billing. Many practices have.
And now, with the prominent inaccurate guesstimate of $8 billion of Medicare money being improperly claimed by doctors, that’s probably enough to make many of us avoid any involvement with Medicare altogether.
When patient rebates alone are inadequate to fund the staff resources and infrastructure to provide high-quality care, and there’s the added regulatory and compliance burden and the threat of the PSR, who can blame us for opting out?
I’m not here to persuade you otherwise. I am clear that altruism doesn’t fund healthcare, and the health system should not expect altruism of us as its sole strategy. However, if all we do is charge patients, without advocacy for those who can’t pay, then we are abandoning our colleagues working in these communities, and more importantly, abandoning our most vulnerable patients. This is a surefire way to amplify the “greedy doctors” narrative.
What got much less attention than the made-up figure of $8bn in Medicare rorts was the recent Anti-Poverty Week (16-22 October this year). So you may have missed that more than 13% of the Australian population live below the poverty line – defined as less than half of the median household income. One in six children live in poverty. Of Aboriginal and Torres Strait Islander people, 24% of those in major cities live in poverty, and an astonishing 54% in very remote communities. Poverty is not spread evenly across the country, it clusters and collects in small pockets of our cities, regional towns and rural and remote communities. You can find which are the poorest communities in the Dropping off the Edge report, and think about GPs providing care in these communities.
Most services in the Aboriginal and Torres Strait Islander health sector, in which I work, are Aboriginal Community Controlled Health Services, meaning that they are owned and run by the local Aboriginal community along co-operative lines. Just about all services are bulk billed. The reason for this is that they are there to provide medical services for a community where the vast majority of people can’t afford to pay. Median household income for Aboriginal and Torres Strait Islander adults is $553, while for non-Indigenous Australians it’s $915.
“Closing the Gap” has been a government policy imperative for over a decade, aiming to improve a range of health and social indicators. Health, of course, depends on good primary care, including general practice, to provide cradle-to-grave care. Even though Medicare is available to all Australians, on the latest figures available, Medicare spending on general practice for Aboriginal and Torres Strait Islander people was $180 per person, compared to $243 per person for non-Indigenous people. This is 0.74 times as much, despite there being twice the need.
Where people have more complex needs – for example, due to the mix of multimorbidity, mental health needs and social circumstances common in the Aboriginal and Torres Strait Islander health sector – then longer consultations are needed. The longer the consultation, the more suppressed is the funding we get through Medicare. Clearly, as we all know, Medicare rebates alone are not enough to fund the primary care required. While there is top-up funding to Aboriginal Community Controlled Health Services, to try to compensate for the longer consultations and more health professionals seen at each visit, this is capped and comes with significant reporting requirements. There is a lot of encouragement made to Aboriginal Medical Services to increase Medicare billing to fund services.
As more and more practices charge co-payments, this will result in people being unable to afford medical care, especially as the current cost of living crisis continues to bite. People won’t care too much what their GP income is or how many years of training we have if they are struggling themselves, though there may be some empathy between doctors and patients knowing that Medicare rebates and the Newstart allowance have been frozen, the latter since 1994. People will ration their own healthcare and their own medications as they worry about affording food, petrol or rent. Practices themselves will be fine, as long as there are enough patients who can pay co-payments to keep the business open.
As this happens, the funding gap between Aboriginal Medical Services and private practice opens up further. Patients who are Aboriginal or Torres Strait Islander will attend an AMS if they have one nearby, but AMSs don’t have a magic ability to increase capacity, to find extra GPs, health professionals, rooms or opening hours.
Other patients, be they non-Indigenous, or Aboriginal or Torres Strait Islander without an AMS nearby, run the risk of going without primary care altogether. They may only have access to emergency and urgent care clinics, neither of which is the place to attend for chronic disease management or preventive care.
What to do? The solution is not just to tell you to keep bulk billing. Just to be clear, I’ll repeat that. I am not telling GPs they should be bulk billing! There is moral hazard here, though – stopping bulk billing passes the risk in the health system from ourselves to our most vulnerable patients. For many of us, the knowledge that we are forced to face the choice of charging people to fund the services we offer, resulting in not giving care to the people who most need our care, is a source of moral distress and its lingering after-effect, so-called moral residue.
There’s a recognised set of circumstances and skills in working as a GP with people in poverty, described by the GPs at the Deep End, and primary health care is essential in enhancing health equity. The Aboriginal Community Controlled Health Sector is the sector where this model of care runs most comprehensively in Australia, but good general practice also demonstrates it can do this well.
What’s the solution? The first thing to note is that funding is really inadequate. Any solution that proposes restructuring the health system without extra funding is doomed to fail. If the Health Care Homes trial taught us anything, it should have taught us that. The second thing to note is that if we don’t think about health equity from the start, then we don’t get health equity, and it is almost impossible to retrofit health equity.
So what would care look like for people who have no money? Obviously it needs to be affordable to the user, which means funded by someone else, often the federal government, but we may see state government, local councils, philanthropic, co-operative or academic organisations step in. We do need to fund multidisciplinary team care, though most of the descriptions of what this is have been at best naïve misunderstandings and at worst self-serving misdirection.
Multidisciplinary team care is not task substitution, it’s not asking other people to be less-good GPs. Remember, these patients tend to have the most complex mix of chronic diseases, mental health problems and social circumstances. Blindly following guidelines in these circumstances is likely to be harmful, and any GP would understand the Paradox of Primary Care – that non-GP specialists more frequently follow the set guidelines than GPs, but GPs get better outcomes. In fact, most team members who tried to diagnose and prescribe for these complex patients would very quickly refer back to the GP, because this is not the cherry picking they were intending.
Similarly, multidisciplinary team care doesn’t free up lots more consultation time for the GP, because the team members aren’t doing GP things. The allied health professionals are doing care that the patient wasn’t receiving – physiotherapy, podiatry, dietician advice, even medications management. Patients will be spending more time with different health professionals, rather than the same amount overall, and less with the GP. The GP may be able to spend more time with patients, but will also be spending more time managing, communicating and supervising the team. Care will be better, but it won’t create a magic new working day in the week.
Consultations with the GP need to be longer to manage the complex mix of physical, psychological and social circumstances, as well as preventive health, and to allow time for discussion and explanations with patients who often have less control over their own lives.
A large part of the work in this context is spent in navigating and co-ordinating the health system, advocating for patients who may not be listened to by the rest of the health system and advocacy in the form of necessary and time consuming NDIS, Centrelink, Housing or insurance paperwork. It’s often the GP who needs to complete these forms (and where a non-GP specialist is required, getting timely and affordable access is an entire other challenge in itself). Interestingly, there doesn’t seem to be a clamour from other craft groups to take on these tasks.
In a sense, I don’t mind too much about the funding model for this. It must be sufficient, and it should support multidisciplinary team care, not rely on task substitution. It must support longer consultations that can manage complexity and empower patients who don’t often have control over their lives. And it must acknowledge the mess of a health system where every door is closed or hidden, and help patients to navigate this.
Perhaps I am a naïve optimist. Perhaps this is a pipe dream. Governments always want cheaper and cheaper health care. Not funding primary care properly is the most expensive health you can get, though – just ask the Americans. The Aboriginal Community Controlled Health Sector shows how this might be done, even while it’s underfunded, and the gap on current policy is likely to widen. This is also the sector, however, where GPs were most satisfied with their jobs in the most recent Health of the Nation report.
Nothing worth doing is easy, and while this work is hard, it can be the most interesting, most rewarding general practice work there is – to work in communities where our patients really benefit from our skills, supported by a skilled team.
When we drop bulk billing and don’t advocate for our most vulnerable patients, then we abandon the patients who most need GPs, and we abandon our colleagues committed to working in communities who can’t afford to pay for care, many in rural and remote practice. We lose the trust of the public, and narratives about greedy doctors take hold and are hard to shake off. Continue to advocate, and we end up building a system that is better for our patients and more satisfying for us.
