Going broke is not part of the job

5 minute read

The tripled incentive is not enough to bring back universal bulk billing. We can’t feel guilty about staying afloat.

The cost of living is affecting us all lately and it’s truly hard for everyone.  

Patients are deferring appointments for as long as they can, and when they do present, it’s often with a long list.  

A few weeks ago, I had someone email to complain they felt rushed in their consultation; on checking notes, I noted they’d booked (and paid for) a standard 15-minute consultation and spent 22 minutes in active care with me.  

Dr Pallavi Prathivadi wrote about this recently for TMR alongside the importance of not letting this stop us from doing what is needed to keep our businesses afloat.  

Most people, including many self-employed healthcare workers, don’t realise that altruism costs all of us twice – once in our personal lives, and once as small business owners. This has a flow-on impact every time we discount someone.  

I used to discount some of my longterm patients until 2023 when the cost of seeing these patients began to hurt. I had the conversation then that I could no longer afford to do so, and I understood if that meant they sought their care elsewhere.  

The point of healthy boundaries isn’t to harm people, nor to be a doormat; it’s to determine what is right for you, inform others and let them decide what they’d like to do. 

Many of my patients are GPs themselves. Over the last 18-24 months most have stopped universal bulk billing and many have stopped discounting any category of patients because it is unsustainable for the business.  

With the introduction of the triple bulk billing incentive for eligible groups in November 2023, there was some debate about whether practices that continue to universally bulk bill (UBB), will continue to survive; those who had the move to gap fees wondered if there would be pressure to return to bulk billing. One of my colleagues, who’s been ideologically opposed to gap fees, was hopeful the triple BB incentive would enable them to survive; alas, I heard from them recently asking me if I knew anyone who’d be interested in buying the practice out.  

Bulk billing is unsustainable and has been for at least a decade. So the ones who will survive the next few years will be the ones who are realistic about this, and do the hard work of learning a new way to work and to bill.  

For my GP patients, for most part, none of the fears around a return to bulk billing in any real capacity has come to fruition.  

One of my patients, who is entirely private billing, told me this week that there is no appetite for the practice to return to bulk billing anyone. When I refer one of my patients to her for mainstream general practice care, even colleagues, she is firm: “Please let them know I don’t bulk bill, including colleagues” – which I totally support and respect.  

Another of my patients worked in a UBB and was hopeful the changes in November 2023 would provide some relief to practice viability as well as her own take-home pay. I saw this week that her practice (she is not an owner) has (finally) moved to gap fees of $30 for a standard consultation and $50 for a long consultation. They also charge the gap fee for no-shows and late cancellations.  

To which I can only say: it’s about time.  

A common explainer for why we continue to bulk bill is that “my patients cannot afford it”. This may well be true AND YET, I remind them, it is not our burden as individuals to fulfil a government promise to subsidise healthcare. As the Medicare rebate freeze showed us, the longer we delay the pain, the worse it gets for us to remain in business.  

Health economists and non-GPs wax on about how we (GPs) are overpaid, how the fee-for-service structure does not work. I’d love for them to spend even a single day doing our job, without any guarantee of the take-home at the end, after a service fee of 35-40% of the total billed, to see how they feel.  

Two seemingly competing ideas can both be true.  

It is sad that we are at a point in Australia where most of us, without additional (government) funding, need to charge a gap fee for everyone in order to stay viable; yes, this will hurt the vulnerable the most.  

As always, when I’m tempted to discount or provide free care, I remind myself of my fiscal bottom line that I need to keep my business running, pay my staff living wages, overheads and more.  

If I discount even once or twice a week, can I remain solvent?  

If the answer is yes, then I consider it. More often than not, the answer is no because people don’t realise how thin the margins often are.  

People are told of our policies when they book an appointment so they are aware of the fees and cost to see me. It’s been a very long time coming, this change, but this is slowly becoming the new normal and in the absence of governmental efforts beyond bandaids, this will need to be accepted; the alternative will be ED and outpatient services with their unacceptably long wait times.  

As the saying goes, “Good, fast or cheap. Pick two.” If you want good and timely, i.e. fast, you’ll have to find the money unless the government sees fit to change this.  

Dr Imaan Joshi is a Sydney GP; she tweets @imaanjoshi. 

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