End universal bulk-billing with just one shot?

20 minute read

The government has lost any upper hand it had in the health system debate and doctors have a unique window in which to effect real and significant change.

As far as cartoon characters go, Dr Karen Price makes a pretty good Daffy Duck. 

Just as in one of the Looney Tunes Rabbit Season Duck Season cartoons, she snatched the gun off Elmer Fudd (the government) last week and we’ve suddenly got what looks like a massive short-term shift in power balance, not long before a federal election.  

Being president of the RACGP had until this alarming incident felt largely like a lame duck role (duck metaphor heaven here at The Medical Republic). 

You have to be good to great to do anything within your two-year term to make even a scratch on the surface of the key issues, given the situation the RACGP puts you in: no time, training or experience to get up to speed in the hothouse of Canberra, little support if you do get up to speed if you’re not in alignment with the board (and sometimes the executive), no board power really as you’re one of 10 or so, but best of all,  a two-year-only term. 

So if you do manage to kick up a fuss that others aren’t sanctioning, you can quickly pass into posterity.

Until a week ago, Dr Price was doing an OK job. She plays very well on TV, largely practised love-ins when in Canberra, and mostly kept everyone happy. 

So essentially, obsolescence by design.

Then she had to go and say that thing about universal bulk-billing at the RACGP AGM a week ago (that is, let’s end it, it’s not working for GPs and likely never will now, given the government’s stance on GP pay).

Right at the wrong time. 

The wrong time for the government, that is. 

So she lay in wait and  snatched the gun off Elmer?

If you look at the video of the Q&A session where her comments emerged, you do wonder if it was even planned on her part. 

No matter. It might end up as genius. 

Timing wise, you couldn’t fault it. 

The federal government, and especially our PM, are starting to get pretty whiffy in terms of trust; there’s an election coming, health hasn’t really come up yet, but it will as it inevitably does.

And it was so off reservation for any current or previous RACGP president (even the late great Dr Harry Nespolon) and so seemingly in your face to the government, that although it was just an answer to a question in a Q&A session on a YouTube video of an AGM, it has already had a fair bit of resonating shock value. 

It seems to have stirred the troops quite a bit and got a lot of people thinking and talking.

It’s causing a lot of normally sedate players to question a lot of things in a time the government doesn’t want anyone questioning anything.

The more noise, the better (my excuse for this rant).

She may even end up inciting a bit of a GP rebellion (let’s wait and see, we can only hope). 

If the troops can just keep on grumbling and carrying on and the noise grows, and the whole thing eventually finds its way to the consumer press, as the PSR issue did this week in spectacular fashion via a deftly written piece by Rick Morton in the Saturday Paper, then it’s very likely to catch fire.

PSR noise also having impact now

Maybe smelling blood in the water spread by Dr Price’s comment, this week, AMA president Dr Omar Khorshid decided to weigh into the PSR debate with a comment to doctors that if they get what they wish for and end the PSR, then they may instead find themselves facing criminal prosecution by the police.

He is quoted in Australian Doctor as follows:

“But the PSR itself is in the interests of the profession. The reality is you have to look at the alternative, which could be fraud investigations by the police.”

The possible problem with what Dr Khorshid is saying is that if you had to choose between a police prosecution and the PSR, you’ll almost certainly go with police prosecution, because that avenue at least follows the law of the land and when you present actual evidence in your case it is taken for what it is. 

You stand a fighting chance of winning if the evidence is on your side; this isn’t the case with a PSR process that, according to the judge in the recent case of Karmakar vs Minister for Health had nothing to do with the “merits” of the defendant’s case. It was about whether a process was followed, and it wasn’t.

If you go into the PSR system, we know you won’t make it through. So as bad as the word “police” sounds, in this case it sounds just a little better than the initials PSR.

The PSR, plain and simple, is not a fair process, as the judge in the recent case of Karmakar vs Minister for Health pointed out to everyone. It’s not even meant to be fair. It’s a process that the government has set up and the process is what is important, not what is fair or not.

Only one person ever has won a PSR case. This person is almost certainly broke now and since that case the PSR has patched the holes this individual went through.

This week we reported that the PSR was busy amending legislation, the effect of which was really just to plug a few more holes that emerged in recent cases, so there is really no way through.

PSR and ending bulk-billing are related

Believe it or not, Dr Price’s call to end universal bulk-billing and the PSR problem are closely related. 

They both relate directly to doctors’ pay and patient safety.

Some would argue that the PSR is a simple construction of fear designed ultimately to keep Medicare billing in check: if you end up in its web, you’re a goner, so steer as far clear as you can to stay safe. Which, of course, means: don’t practise what you think is the safest medicine, practise medicine so you don’t end up in the PSR web. Or, practise less medicine (especially if it’s expensive) and save everyone money.

If you think about Daffy Du…Dr Price and her “arms in the air, I give up, just start mixed billing as much as you can, guys” remonstration last week, it’s ultimately about patients and safety as well.

You can’t keep underpaying doctors without at some point over-balancing what is a very finely tuned setting on patient safety. 

Underpaid, overworked doctors do not equal better patient outcomes, no matter what spin the government attempts.

In some of the hoo-ha this week, some GPs have weighed into the “end universal bulk-billing debate” with a shock-horror “the poor people won’t be able to afford it, you nasty rich people” argument. 

Some are even saying the RACGP should be ashamed … but I don’t think too many are on this bandwagon, thank heavens.

The thing is, GPs won’t be here much longer if they don’t find some way of upping their income a little, so going to mixed billing in a bigger way feels a bit inevitable here. 

For those who think that GPs should continue to provide what is a very high-quality healthcare service without ever getting a pay rise, or even do it at a loss, because it’s the right social thing to do, well, it’s not really the responsibility of the GP profession to do this; it’s the responsibility of the government. 

The government is making the choice here, not GPs, and you can bet that as ending bulk-billing starts catching on, nearly every GP in the country is going to make sure that their disadvantaged patients are taken care of anyway. 

They are essentially going to do a “ take from the rich and give to the poor” sort of thing. That’s what my GP already does and I applaud her for it (even though I’m the rich person in this anecdote).

There’s an interesting irony pointed out by one GP this week – Dr Joe Kosterich – which is worth mentioning. And which is surely some comfort to some GPs, that starting to kill off bulk-billing can be done if we really put our minds to it.

Dr Kosterich wrote in a comment piece to Australian Doctor that was then reproduced in an article (so I think we can use it): 

 “Memo, RACGP: Who was it, in concert with the AMA, who virulently opposed the 2014 plan under Tony Abbott to introduce a co-payment?

“It was only $7, but once the principle is established, increasing it is much easier. A modicum of vision and backbone in 2014 would have seen general practice in a far better state in 2021.”

In other words (I think), it actually nearly happened once back when – in retrospect we probably shouldn’t have stopped it back then, silly us, but having nearly happened once it may not end up being that big a deal a second time around, everyone.

Good point, I think. Thank you, Dr Kosterich.

When you think about it, it’s really only the politicians who care about universal bulk-billing.

And it’s not because they love patients. It’s, of course, because they are scared witless that they’ll lose an election hands down if they’re seen to tinker with Medicare. 

Thanks, Labor Party. Way to go. 

OK, death taxes were a low shot too, Liberal Party; can you both please stop all this crap.

By making bulk-billing a no go for no good reason, you’ve sort of stuffed it up for everyone. 

Ask any patient what is going on in terms of free healthcare or not, and/or Medicare, and they mostly do not have a clue.

Not many people stop to explain to patients what is going on, and to find out whether they have any real understanding.

Ask almost any five patients and your answers will be pretty random.

It’s not the patient’s fault.

Take my entitled 28-year-old son, brought up privileged on the Northern Beaches of Sydney, who thought visits to GPs were always free, like some sort of American constitutional right. 

No one ever explained a thing to him (I should have probably, given what I do). He just lived the experience until one day his lovely and quite talented GP asked him to pay an extra $40 on his credit card.

He was so upset he deserted his long-time, caring and talented GP to give the local super medical centre his custom, although at this point I told him he was making a really dumb decision because the difference in care between the two was incomparable and he was even possibly putting his life at risk.

I tried.

But was our GP able to get that message through to him? Did she really even try?

No. Not really her skillset, and she’s pretty busy staying above the waterline these days, Northern Beaches location or not (she’s a two-GP practice and we’ve got lots of GPs to choose from here, some with very shiny waiting rooms). 

Still, that she wasn’t prepared or had the requisite planning and skillset to let her erstwhile millennial go without much of a fight is an important problem for all of general practice.

As much as we love to demonise the government for not indexing Medicare and the PSR it’s not actually their fault there is not money left. They are trying to make ends meet (albeit pretty awkwardly)

In Dr Price’s brave new world, GPs, who are mostly pretty smart, are going to have to take a step back for just for a bit and go over some of the basics of marketing and economics.

Marketing is not rocket science. GPs can be good marketers if they want to be.

But there’s a bit of a perspective issue in play GPs might need to comprehend as well.

Here’s a couple of quick ideas and pointers:

  • If you’re essentially free, then how does anyone understand your real value? They don’t. In the world of nasty commerce you’re termed a price taker. There is no pricing signal to say anything other than, well, “you’re free” so start by assuming low or no value. The opposite of a price taker is a price maker. A price maker sets a price and can keep resetting a price and get it, because they are proving to their customers that they are worth that price.
  • Do you think that you aren’t providing a really good and valuable service to your patients? Right, but if you’re only free, they are never going to understand that value, are they? My son, for instance.
  • Do you back yourself to ask your patients to pay some more for your valuable service, or even, to pay out of their own pocket initially and get reimbursed that whole amount by the government later (that is, stop bulk-billing?) This is a really important question because if you don’t, you might be in a bit of trouble, moving forward, given post-covid economics.
  •  If you can’t convince your well-off patients to realise your value and pay some more, why do you think the government would ever pay you more? They’d be silly if they did in any commercial sense, when you think about it.
  • Finally, a favourite Bob Hawkeism: “If you don’t believe in yourself, why should anyone else?”

If this all sounds a bit harsh, don’t panic. 

GPs have been imbedded almost forever in what is an artificial and surreal world where they provide a stunningly high-value service but it’s been made free for nearly everyone in Australian society. This isn’t normal, given the amount of value being provided.

Getting out of this surreal bubble is much more natural, normal and possibly even easy than most GPs might suspect.

For one thing, it never has to be big bang. You aren’t going to shock everyone overnight. Or at least you shouldn’t try too. You’ll need to plan, segment your patients, and do some “segmented marketing”. Believe me, medicine is a lot harder than marketing, no matter what stupid terms we marketers come up with.

Eeewh, more work and cost? Marketing? Education?

Sorry, yes. 

If you’re thinking it’s more time and cost, it is, but just put your mixed bill rate up to cover that too. It’s called a budget and a plan.

If not for the toxic politics, this should be a wholly manageable problem for the GP profession. 

And honestly, the pollies are going to thank you for it later, as the last thing they want is to have to face up to this problem at every election. They’d love to not have to directly pay you as much and have the population start accepting a two-tiered payment system over time.

Mediscare? – no thanks.

This whole issue is in fact mostly a marketing problem for GPs and with a little professional advice and planning I’m pretty sure most are clever enough to plan some sort of transition over time. 

In the end, all you’d be doing as a GP is educating a certain cohort of your patients about how much value they really are getting.

You’ll of course lose the odd millennial, such as my son, along the way. 

And if you’re in an urban hotspot with a high concentration of GP practices, then it’s going to be harder again, because some smart operator will always work out a way to be the 100% bulk-billing option of your region.

I wonder if you could get your local council to ban such an outfit, like some do if McDonalds wants to set up in the region. Given what is at stake you could make a good argument it just isn’t that good for the community to have these low rent ‘walk in’ operators. Leave it to the good GP practices to make the decisions on those who really need to be bulk billed.

Even if they can’t contribute money, government can and should help

Now if the government could just come to the party a bit and after the election find some ways to take the heat off you in the process – like they were preparing to do in 2014 – then wouldn’t that be a good thing? 

As things stand, in Australia we are pretty good at keeping patients safe compared with most health systems around the world. 

But if you consider that it is estimated that up to 38% of patient interactions with junior doctors involve some error in servicing, and that death by medical misadventure is the third-highest cause of death in developed countries (of which we are one) you can’t say we’re superstars either. 

No one really wants to be making this figure start to climb if this shocking 38% estimate is actually true.

But here’s the rub for everyone.

Covid hasn’t been a cheap exercise for governments. And while we’re all going to get spending promises until the next election (with Dr Price’s exquisite timing I wouldn’t be surprised if the government caves in  before the next election and does throw GPs a bone with a minor increase to the Medicare rebate), within a year or so, covid damage to government coffers is going to bite and money is going to get very scarce.

What happens then to GP pay? 

This is what Dr Price was probably thinking when she made the comment that the government is never going to come to the party on pay. She loves the government.

We all like to demonise the government when we can. I love doing it myself because they present such an easy target from time to time. 

But if we go back to Duck Season for a minute and look at Elmer’s face when Daffy gets the gun, it’s probably simulating closely just how confused the government has become in trying to solve this problem.

There’s no money left for more healthcare expenditure of the sort needed to fix the issue, no matter how much gun pointing we do.

Keeping people safe by keeping doctors paid well enough, when paying doctors is about the number one expense in your federal budget and you don’t actually have any money left, is the mother of all healthcare funding problems. 

One we are now all up against, unfortunately.

So kudos to Dr Price for breaking the mould and grabbing the gun and pointing it at the government at the right time, and maybe even starting a bit of a riot.

But if the government doesn’t actually have any money in the end, then it’s back at GPs mainly to fix the problem by taking from the rich and giving to the poor as they see fit.

They can do this by marketing to and educating their patients on just how valuable a service they provide and slowly reducing their the bulk-billing rate over time by making the right sort of patient (myself and my son) pay some more directly to them. 

And if  the government hasn’t got the money then the least they could do after the election is think of some process of taking the heat off GPs as they accidentally nearly did with their $7 co-payment idea in 2014.

Common clinical and ethical standards will help

There’s one other very interesting idea to throw into the mix of this “wicked” problem and this idea has the value-added incentive of largely dispensing with the fear-based construction that is the PSR.

The idea is the one we raised in an article a few months ago, about the profession in concert with the government developing a comprehensive set of clear clinical and ethical standards or guidelines for doctors and patients to work off in Australia.

How will this help?

With such a set of standards both doctors and patients will become a lot more empowered:

  • Much of the PSR process wouldn’t be required because there would be a published, professionally reviewed and moderated set of agreed standards by which doctors could easily understand what to bill and not. In the terminology of recent PSR debates, where victims have likened the process to getting speeding fines when no one publishes the speed limits or road rules, such a set of standards would be akin to having a comprehensive set of road rules in place.
  • Insurance premiums for doctors would probably plummet, because there would be so much more clarity about what is right and wrong to do, and we’re going to guess that a lot fewer mistakes (wrong) would happen.
  • Standardisation almost always leads to efficiency. Doctors will do things the same way, according to standards rather than going with their experience and gut. This probably will end up saving lives, and if it does the opposite, the problem will be obvious and will fix itself reasonably quickly. It should end up as a sort of virtuous circle of quality improvement.
  • It would be easier to explain a lot more things to patients and if patients weren’t happy, they could be guided to the standards rather than having a fight with their doctor. In essence, they’d need to fight the profession, but if they did, the road rules would be clear.
  • The standards would be maintained by the profession (the key colleges) in some sort of rational partnership with key government departments. Doctors would have more say and power in the system, but governments, for practical (yes, often financial) reasons would not be locked out.

We’ve plugged this idea before and we’ll keep plugging it until someone debunks the logic of the above.

If you’re interested in the idea in the context of the issues facing the profession and government during and hopefully after covid, then you can get a bit more information at the International Health Standards and Ethics Board home page here.

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