This feels like the final nail in the general practice coffin.
Labor’s new attack on the chronic disease MBS items in Medicare comes just weeks after their historic election victory where they campaigned on a platform of “strengthening Medicare”.
Only if we use the most perverse Orwellian double-think could we see the slashing of Medicare rebates for chronic disease items, including the annual 721 and 723, by almost 50% or $150, could anyone see this as anything but an attack on the foundations of universal healthcare and, specifically, the care of our most vulnerable patients, living with chronic diseases and disorders.
The stated goals of the “changes” to the chronic disease item numbers was to:
- simplify, streamline, and modernise the arrangements for health care professionals and patients;
- promote continuity of care;
- encourage the regular review of chronic condition management plans;
- support communications between a patient’s multidisciplinary care team; and,
- ensure existing patients can continue to access the care they need.
These changes will achieve none of those goals and it’s clear now that the goal was simply to save a lot of money at the expense of GPs and our most vulnerable patients.
It doesn’t matter how inefficient or costly, it appears that the government will put money anywhere but to general practice.
This is how those changes would affect a GP bulk billing a concession cardholder with a chronic disease:
Current arrangement:
GP management plan (GPMP), item 721, has a rebate of $164.35 or $176.55 with the bulk-billing (BB) incentive of $12.20 (MMM region 5, where I work).
Team care arrangement (TCA), item 723, has a rebate of $130.25 or $142.45 with the BB incentive.
Review TCA or GPMP, item 732 has a rebate of $82.10 each or $94.30 each with the BB incentive, or $188.60.
For a concession cardholder this means we could charge: once per year a GPMP and TCA: $319; three reviews of the GPMP and TCA throughout the year at $188.60 each or $565.80.
Total for concession cardholder per year: $884.80.
New fees and items:
GP chronic condition management plan (GPCCMP), item 965, has a rebate $156.55 or $168.75 with the BB incentive.
To review the GPCCMP has the same rebate, is item 967, and can be billed three times per year.
For concession cardholders this means a total annual amount to create and review chronic disease MBS items: $675.
Which leaves practices $209.80 worse off and equates to a 23% reduction in the fees to manage chronic conditions – at a time when GPs were begging the government to increase the MBS rebates, particularly for the complex, lengthy consults needed to manage those with chronic medical and mental health conditions.
Investing in quality primary care of these individuals is the area of the health budget where the government would see the biggest savings and health benefits, as these are the patients who end up in hospital, develop complications and cost the health system the most.
Chronic disease items and mental health items already missed out on the tripled bulk-billing incentives.
For myself, most of my patients have chronic conditions and are on concessions cards. In the past 12 months, I billed just over 300 GPMPs and TCAs, almost all bulk billed. I billed 623 reviews, almost all bulk billed.
Related
Chronic disease items made up over 41% of my billings for the just under 5000 MBS items I bill per year.
Under the changes, there will be no more TCAs, so I would lose over $40,000 for this item.
The reduced fee for the GPMP would lose me between $2379 and $6100, depending on the bulk billing; the reviews would lose me between $6143 and $9937, depending on the bulk billing.
Making me $49,470 to $56,985 worse off.
It is conceivable that I could increase my billing of the GPCCMP to include patients who have not required others be involved in their care, but these would have to number in the hundreds (364 if I see them once per year, 182 if I see them twice, etc) and for each GPCCMP, I would not be claiming the usual timed consult fee, which for me is usually a long consult item 36 or 44, would really only be a small net gain.
If we look at consult item C, I would normally get around $82.90 and would instead get $156.55, an extra $73.65, so I would actually need to have an extra 671 consults for people with chronic conditions to break even.
Further, the reviews can only be done every three months, or technically three months and one day; for the annual reviews, this again must be 12 months and one day.
Prescriptions last 28 or 30 days, so when these are due is almost always going to be just before a chronic disease item can be billed. If the government allowed us to do three reviews at a minimum of a two-month interval, this would allow us to actually use these items fully.
If the government had instead set the GPCCMP at $221.20, an extra $52.45, it would have been the same amount with no loss of income for GP practices that bulk bill concession cardholders.
This would also have reduced the annual item and increased the review items, thus incentivising practices to review plans, not just do a once per year plan and encourage patients to stick with the one GP or practice.
Chronic conditions management activities make up a substantial proportion of general practice activity with 2022 -23 data from the Australian Institute of Health and Welfare identifying that:
- almost one in six (16%; 4.1 million) Australians claimed a Chronic Disease Management service, and
- 60% of people (10.2 million) who visited a GP in the last 12 months had a long-term health condition.
With the government quoting that around 16% or 4 million Australians access chronic disease MBS items per year, this gives them a saving of up to $208 million dollars taken directly from the pockets of GPs or having to be passed on to our most vulnerable patients.
Those of us trying desperately to keep providing bulk-billed services to our concession cardholders and most vulnerable already use these higher billing items to subsidise bulk billing the normal timed consults and these changes fundamentally alter how we will have to manage our patients and billings.
The $209.80 gap equates to four visits with a $50 gap and most patients don’t see their GP more often than that, meaning that if we disperse this shortfall throughout the year on other consults, we effectively must abandon bulk billing concession cardholders entirely.
The bulk-billing incentive planned to be applied to non-concession cardholders in November is now meaningless. We would already have been taking a $20 to $50 pay cut on each consult by switching to bulk billing them.
With the gutting of the chronic disease items, I doubt anyone will be changing their private billing policies. The money the government allocated to this incentive more than ever appears purely symbolic as it is unlikely to even be accessed.
It reminds me of the early days of the NDIS when the government boasted that it was more than adequately funded as some participants were not accessing their full packages, when the real reason was that there weren’t any specialist OT, allied health or other services in the area for the participant to access.
This doesn’t sound like “strengthening Medicare”, it sounds like the final nail in the coffin.
Dr Kelly Hamill is a GP in Bellingen. She also has a BA in Philosophy and previously worked for Greenpeace, Amnesty International, the Bodleian Library at Oxford University, and pro bono for the Medevac program for refugees on Manus Island.
