Telling the public to shop for a bulk-billing practice is a huge blunder that reminds us of a long history of abuse of general practice by government.
You might think of Medicare and bulk billing as like a marriage between government and GPs – a contract of sorts – with the government as the dominant and financially powerful partner in the marriage and the patients as the children.
Mark Butler’s comments this week to the media about patients needing to shop around for a bulk-billing practice in one fell swoop took us backwards to a relationship dynamic we all hoped we had moved on from.
That relationship has had some of the key elements of what happens in domestic abuse.
Consider these parts of what has gone on between GPs and the government over the last 10-15 years, and what Butler’s comments this week reveal, in retrospect, about that journey.
Medicare and bulk billing was never anyone’s idea of an ideal contract between general practice and government. But 15 years ago one partner was at least making a deal with the other that they’d bring in enough income to meet the bills and keep the children safe to an agreed standard of care.
Over that period the dominant partner in the relationship, the one with all the financial power (and other overtly coercive powers – the PSR, for instance) started breaking that deal and began gaslighting the other partner when they started asking questions.
We don’t have enough money to pay the bills like we used to, it’s not my fault, you’ll just have to suck it up until times get better. Think about the kids.
GPs swallowed that line for a while, but eventually started asking more pertinent and difficult questions about what was actually going on.
When they did, they were then positioned from time to time as being greedy, selfish and even unethical. They were compared, largely out of context, to other workers who didn’t have their income and lifestyle and told to stop behaving so badly.
Questioning GPs as to whether it was ethical to stop bulk billing was very plainly a form of emotional abuse.
GPs are small business operators. They live or die on income largely from volume of consults and if bulk billing does not deliver that income they have no contract, ethical or otherwise, that dictates that it’s OK for them to go broke.
GPs, who study and train for up to 12 years, have the most patient-facing and personal job in medicine, so the line about whether bulk billing was ethical or not was specifically targeted to confuse and hurt.
The politicians dictating budgets and the public servants executing policy all had handsome pay rises over the years that GPs were denied one.
Yet for some reason in that time, resentment started to emerge within certain government groups within certain departments about why GPs were making such a fuss.
Does this relationship pattern ring any bells?
One reason GPs persisted with bulk billing for that 10 years was “the children”.
A large proportion of GPs felt that if they started mixed billing their patients would end up suffering so they didn’t feel like they could.
The dominant partner in the relationship, the government, understood this dynamic all too well and played on it. Stop bulk billing and you will be hurting the kids.
Does that sound familiar?
A lot of GPs genuinely felt trapped in this the unfolding and clearly dysfunctional dynamic.
A lot hadn’t experienced life outside the dynamic so were understandably fearful, anxious, stressed, and even depressed by what was occurring. So they did everything in their power to keep trying to make an increasingly stressful and abusive relationship work.
The way the dominant partner played the situation was to keep blaming GPs for being selfish and greedy, often leaking or briefing to the media and suggesting that essentially they were in fact some of the best paid workers in the country, far better paid than the average struggling worker, so they should be ashamed.
Some GPs were.
Some GPs fell for the ethical line, which is a very nasty card to have played against a profession so bound by trust and ethics.
No matter that in the time they weren’t getting any pay rises at all, their cousins in other specialist medical fields were experiencing extraordinary increases in income thanks to a Medicare model based on paying more and more for specialised procedures rather than outcomes.
But that model was starting to wobble.
In November 2021 then RACGP president, Adjunct Professor Karen Price, took the unprecedented step of calling on all her members to start privately billing as many of their patients as they felt they could, citing impending financial crises for many practices if they didn’t.
Professor Price’s call eventually got reported in the media as a call to “abandon bulk billing altogether”.
But that isn’t what she said. She said “start privately billing as many as you can”.
In other words, look after who you can and charge the ones you are pretty sure will be able to pay.
But of course, the government initially framed GPs as villains abandoning patients en masse.
That framing returned in a manner this week with Butler’s comments.
Professor Price wasn’t naïve. She knew that at some point in this new paradigm some patients would be upset and that would have political ramifications as well as emotional ones for some GPs. But GPs were now well and truly between a rock and a hard place.
Professor Price played two cards: one to resuscitate financially struggling practices as quickly as possible and a second to put the government in a position where their long-term financial abuse could more easily be outed with patients.
It was a gamble.
A lot of patients complained because although there was never a contract for primary care to be free to the public, this is how the government had always sold Medicare to the public and that line was never challenged by GPs.
Until 2021 at least.
Two years on from putting that stake in the ground – perhaps akin to an abused partner deciding to pull up sticks and leaving the house and the relationship – a lot of GPs have learnt a lot about their patients through moving to more and more mixed billing.
The government should have too, but this week’s comments suggest they may not have.
One thing GPs learned is a lot more patients are capable of paying than they thought might be, and are OK with paying. Many that don’t like paying are still doing it and are getting more and more used to it.
There are still a lot of issues created around patient access because this fundamental change in the paradigm of GP income was never planned, or indeed supported by policies that might make the transition much easier for patients and GPs.
But like a partner who has broken free, moved to a new city with the kids, and secured a good new job and a few new friends, there is no way that partner is going back.
This has massive implications for Medicare and the whole system, which you sense – in part from Butler’s comments this week – the government still hasn’t got their head around.
One of the biggest headaches this new paradigm is creating and will continue to create is that a lot of patients who can’t find a bulk billing GP now are defaulting to hospital EDs, as they must.
To be clear, this is not a problem GPs have created, it’s a problem entirely created by 15 years of bad – abusive – government policy, and any narrative from government or the media that seeks to lay the blame at the feet of GPs for the mess is pretty classic emotionally abusive behaviour.
Which brings us back to the significance of Butler’s comments this week.
You’d love it to have been a brain fart that he and his minders immediately regretted.
But you get the sense that they don’t think this at all. So far it looks like they think that leaning back into their old partner in this manner – a manipulative and abusive manner – is an OK thing to do.
What’s both surprising and very disappointing with this is that Butler and his government had until now brought energy, enthusiasm, creativity, respect and apparent good intent to the plight of general practice.
There’s some good people inside the Department of Health and Ageing as well that had started leaning into this new energy and optimism, despite being handed a huge mess from the previous government and despite there being pockets of resentment still in the department from the past.
Butler’s comments this week – “I’m not going to name and shame but … just saying”, takes the whole relationship plummeting backwards into the most ugly past times of policy, financial and emotional abuse practised on the GP community.
To resort to this shame game, to the narrative that they’re spending a new fortune on GPs and if GPs aren’t bulk billing, it’s because they’re greedy – well, it has an awful whiff of Groundhog Day to it.
To be clear here, government investment in general practice is not marching forward as we are being sold in the whole Strengthening Medicare PR parade. GPs in relative terms are still significantly behind where they would be if governments had only kept MBS reimbursements in line with CPI for the last 10 years, as they should have done.
The triple bulk billing incentive is a start only. GP income is still way behind where it would need to be for many of them to be financially secure, so grandstanding like this is without any actual merit so far on the part of the government.
Another reason the government shouldn’t be grandstanding yet: on Thursday the Productivity Commission released a treasure trove of data on the performance of our healthcare system and in this data the most standout figure was that in the last two years investment in the hospital system has risen by 8% and in the last three, investment in the primary care sector has actually decreased overall by nearly 8%.
Remember, investment in the hospital system is about $90 billion per year compared to a primary care investment of just $11 billion.
This is not a government that is in a position to start blaming the primary care sector for system and patient issues and certainly not one that can yet stand on any promise that it is genuinely committed to reinvesting properly in the sector.
It’s just one press conference, and a couple of comments, but it has wiped out almost all the good will and trust that the government has built since it came to power a couple of years ago, with what looked like genuine intent to fix past wrongs, and the system.
I have not seen one comment on social media or talked to one GP since the statement who isn’t angry, disappointed or who doesn’t feel some sense of deja vu.
Even if, as some government people apparently still think, GPs are just too precious, why would you want to upset the entire sector in this manner?
Until now we’ve been led to believe that the new government genuinely recognised how vital the primary care sector is.
It seemed to recognise that it needed to do a lot of work re-establishing trust in order to bring Australia’s struggling healthcare system to a new and better future, one with an effective primary care sector at its foundation.
Why blow that up the way Butler did this week?
When I first read about it I thought I must have missed something important, so I emailed a few of our journos to ask what they think happened.
The only publishable explanation I got back was “I reckon he must have been on the turps the night before.”
Not actually funny because if you’re following the logic of the abusive relationship narrative I’ve been building here, it feels like beneath the waterline maybe not much has changed with that dominant partner’s outlook on the original marriage.
Maybe, consciously, or subconsciously, the dominant partner remains of the view that their partner is the one in the wrong and is being selfish so they need a bit of an emotional kick up the backside to straighten them out – like in the good old days.
It’s a catastrophic error of management to say what Butler said this week if you really want to improve our healthcare system, because even if you did still fundamentally dislike your old partner, you need them to be a lot more co-operative for things to start improving.
Isn’t that the nature of being a clever politician?
One other important factor here: attempting to shame GPs in some way into adopting a lot more triple incentive bulk billing in their practices was never actually going to work because the mixed billing dynamic has simply progressed too far.
In 2021 a lot of GPs started doing a lot more private billing because they would have gone broke if they didn’t.
That dynamic hasn’t gone away. It’s just got worse, because the reality is that even with the triple bulk billing incentive, GPs are woefully underpaid.
It’s about economics and business, not ethics or morals, or some fanciful desire for the government to return to the good old days of Medicare and bulk billing.
Those days are gone. We are in a new paradigm and the government needs to work with that.
GPs and practices know their patients. Most know that no matter what the government says, their patient list isn’t going to change that much.
They are in more control than the government recognises now.
A lot of GPs have full patient lists already and if they lose a few who go shopping for bulk billing, many might be happy with the opportunity to increase their yield per patient with ones that can pay.
A big problem with telling the public to go looking for another GP that bulk bills, especially in the city, is that patients in this sort of financial distress will have to spend a lot of time and money to find one, travel there, and to get back come, if they even find one. And if they do find one, they have to start a new relationship with someone they don’t know, and who has no history or emotional bond to them. It’s very high risk for a patient and money is not the only problem they are going to have.
There is no easy way to identify who does and doesn’t offer the triple bulk billing incentives, despite several costly government based online directory initiatives.
This is all part of the broader mess.
Outside the major capital cities the difference between the added private fee many GPs have been charging and the triple bulk billing incentive is negligible. So they are quietly switching back to the bulk billing option for these patients.
This, by the way, is almost certainly why there has been a slight rebound in the bulk billing rate that Butler has boasted about this week.
It may happen off and on for the next few months while GPs outside the major cities make the adjustment with their patient cohorts.
But when this one-off adjustment has finished, the bulk billing increase will very likely stop and the slow decline across the rest of the system will almost certainly start to kick back in over time.
Because that old marriage is over.
Butler’s statement this week is a massive miscalculation on the government’s part.
The government still thinks it can act as the dominant partner because it thinks that through bulk billing it holds the financial whip hand.
But does it really any more?