All aboard the cattle class medicine train

7 minute read

Making the healthcare system more overtly two-tiered won’t solve anything for embattled GPs and their patients.

In episode 364 in a seemingly never-ending series called Non-GPs Telling GPs How to Fix GP-Land, the latest plot twist would appear to be ignoring the villain while making things even more difficult for our heroes.

Last week in The Conversation, Professor Stephen Duckett, late of the Grattan Institute and now with the Department of General Practice at the University of Melbourne, and Associate Professor Fiona McDonald from the Australian Centre for Health Law Research at QUT, proposed a Plan.

What if, they suggested, we restricted access to Medicare to just those GPs who agree to bulk bill all their patients.

“Rather than an ‘all comers’ approach, a new basis for Medicare could be one where practices sign up to Medicare and agree to meet Medicare’s contractual conditions such as agreement to bulk bill all patients, participation in training future health professionals and in quality improvement programs, and that practices are multidisciplinary,” said Duckett and McDonald.

Twitter had views, not unexpectedly.

One world-weary, battle-scarred veteran GP who barely had the remaining strength to roll her eyes at the Duckett/McDonald suggestion, came up with an alternative.

“What would happen if, say, two-thirds of GPs decided not to bill Medicare at all?” she said.

“What if we just set up these beautiful private clinics, and we said to people out there: ‘listen, either you can get your $39 back from Medicare, and the government has your data and can dip into your notes anytime they feel like it, or you can pay me privately and I can keep your data private’?

“What would happen if the government only had access to a third of the data? That’s the bargaining chip we’ve got.

“If we do what [Duckett and McDonald] suggest – either bulk bill all of our patients or none of them – some GPs will work two practices with two provider numbers. We’ll volunteer a day a week at the bulk-billing clinic and do the other four days in our private practice, charging enough to cover the time we spend in the bulk-billing clinic.”

It’s an interesting proposition and after all, that’s what doctors have been doing since the 12th century, isn’t it? Charging the rich to donate to the poor?

“We would need to say to our middle-class and up private patients, ‘if you come and see me in my private clinic, it’s going to cost you a little bit extra, but the government doesn’t get your data’.

“And what’s more, the government can’t nudge me into supplying it. They can’t influence me about what tests I order. They can’t tell me I’m a high needs person when it comes to doing women’s health tests, so therefore I’m a bad doctor.

“They can’t influence my prescribing if I don’t use the PBS. What if I say to my patients, ‘how about I just write you private scripts, and you can have a year’s medications at once’?

“Not only can you have a year at once, the government won’t know what you’re taking.

“I would still be under the auspices of AHPRA, so you could still take me to AHPRA if I’m terrible. But you cannot take me to the PSR.

“It’s a great idea, but we would need about two-thirds of us to do that to make it work, and we would need to leverage the data.”

Doesn’t that sound lovely? Those who can afford it will get the care they want, and those who can’t afford it will get the care they need.

The problem with Duckett and McDonald’s approach is it doesn’t change anything other than widening the gap between the haves and the have-nots.

We already have a two-tiered health system, albeit one we don’t like to talk about. Those who can afford it rely on the private system to provide the elective surgeries, the tests and the ready access they want. We know that the socioeconomically disadvantaged people in our society are delaying care, waiting weeks for GP appointments, overloading emergency departments and living shorter lives as a result.

How, exactly, does the Duckett-McDonald Plan improve that situation? If bringing it out into the open as an explicit decision about how we want our health system to be is a good thing, then I guess it achieves that.

To be fair to Duckett and McDonald they did give a few nods to the villain of the piece in their article.

“Fair remuneration needs to underpin all this,” they wrote.

Well, yes. Exactly. Talk about burying the lede.

Our world-weary, battle-scarred veteran GP gets the last say.

“Let’s just stop kidding ourselves,” she said. “We’re not providing best practice care for everyone.

“We’ve got three choices.

“We can say to the entitled, you can’t have this, sorry, because we only provide this much care. You can’t have five orthopaedic opinions before you get your hip done. You get whoever is on, on the day.

“But we don’t say that to our private patients because that annoys the voters.

“Our next choice is to be overt, and say we’re going to give more care to those who can afford it, but we don’t want to be overt because that would show how racist and sexist and classist we are.

“So, what we do is we create administrative barriers that just happen to mean that poor people don’t get in.”

In other words, the Duckett-McDonald Plan will simply make what’s happening now more overt.

“This is cattle-class medicine – and over there is first-class medicine. And we will own up to what we’re already doing.”

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