The new bulk-billing regime doesn’t start until next week but we’ve already started seeing a potentially insidious rift in what was once a reasonably cohesive GP culture.
Of all the dark arts in business, the darkest is pricing.
People will tell you there is science and process to getting pricing right, but there isn’t. It’s too complex and emotional.
There are way too many unknown unknowns.
You have to be extremely careful when fiddling with your pricing if you dare do it at all. If you do it, you must do it in small iterative steps, lest you fall over yourself and quickly destroy years of built-up customer trust and loyalty.
Pricing has a lot in common with funding.
It’s all about predicting, incentivising and changing behaviour to achieve new goals, and there’s always lots of unknown unknowns that can trip you up big time.
Which is why it’s so hard being in government when trends in demographics and technology start creating massive structural rifts in healthcare and funding is a major behavioural lever you know you’re going to have to use at some point.
Enter our new bulk-billing incentive regime, due to start, officially on 1 November.
There’s a lot of people with a lot to say on how and why the government may not have thought long enough and hard enough about the changes.
For one thing, GPs and practice owners are saying out loud why they won’t be responding in the manner the government would like. There have been some good surveys and the noise is pretty loud. If you believe any of it, the government’s modelling path to 90% bulk billing is way off the mark.
Then there are quite a few philosophers and analysts out there mapping out various potential long-term implications of the very idea of the new incentive regime, for both GPs and patients.
A common theme is that it is incentivising a two-tiered system of practice – government doctors vs private family doctors – and through that, a two-tiered system of patient care.
There’s a third dimension, related to the above two-tiered problem, not much talked about, but increasingly apparent, that everyone should be worrying about: the culture within GP practices is splitting as well, into two tribes.
You can’t model an emerging dynamic like this, or where it will end. But it feels bad.
Here are two quick examples of the sort of things happening.
The first we’ve already written about here, and involves when a practice already has a pretty high bulk-billing rate, but the owner, or the majority of the GPs in the practice, or both (depending on how savvy they are on avoiding tax problems), decide they would like the 12.5% bonus, so they exit the hold-out mixed billers in one way or another in order to get to 100% bulk billing.
In this case, a doctor who was forced out of his centre moved down the street to a competing mixed-billing centre. Immediately after, the centre that lost the doctor started targeting the mixed-billing centre for recruitment with some attractive offers.
So, two tribes are literally metres apart from each other and doctors in each tribe are philosophically moving more and more apart about how the sector should be dealing with patients. In that suburb, we now have two tribes. And they don’t like each other.
The other story we have is a weird opposite of the above: a high-level mixed-billing practice that for some reason started bullying a GP that vehemently wanted to retain her right to bulk bill when she saw the need, a stance that made her an outcast for some reason.
She too left to a practice nearby, we think, ironically, to a practice converting to 100% bulk billing because it is a corporate with a high existing percentage of bulk billers.
The way the departure was described was, “the younger doctors weren’t happy with being lectured to about access, equity and the importance of retaining some bulk billing, and the particular GP was shown the door” (presumably by the practice owner, but that surely wouldn’t happen … as it would be a red flag for payroll tax and the ATO).
This practice advertises to all patients that all consults are mixed billing, something they technically should not be doing lest they want to bring upon themselves payroll and ATO hell and damnation.
They haven’t actually done that, or at least, they used not to do it. A few of the doctors in there would at times identify someone in need and bulk bill, or do it when something was really simple.
The GP that left had argued with a large younger cohort of doctors that bulk billing should remain as a key part of their repertoire. Notwithstanding that the practice was in a relatively high socioeconomic area there were clearly some patients who couldn’t afford the co-payment.
Now this practice seems to be actively discouraging such patients.
That can’t be good over time for a whole lot of reasons.
There exists a remnant of GPs at the mixed-billing practice that agreed with the doctor who left but didn’t want to speak up. They are now afraid to bulk bill the patients they always have for fear of being called out and treated in a similar manner.
Needless to say the culture at this mixed-billing practice isn’t exactly one of sisters and brothers in arms performing high levels of team-based care. It’s a little more East Germany pre-1989 from the sounds of things, at least at the moment.
Not exactly the sort of culture you want if you want to be nurturing the benefits of team-based medicine, a major argument for mixed billing, the other being that the system can afford for the well off to pay extra, so long as you keep looking after those who can’t with bulk billing. And this helps everyone because it’s a money stressed funding paradigm.
How then might culture be evolving in those practices that are moving to 100% bulk billing?
I have two different corporate bulk-billing practices in my area, and one urgent clinic.
The two corporates could hardly be further apart in culture. One reminds me of the movie Solomon’s Mines. The other seems to be pretty well managed from a people and culture perspective.
Squint just a little and you’d swear most of the doctors were happy and so is a reasonable proportion of the patients.
One possibly relevant observation: both of these practices are similar in profile and culture now to what they were prior to the announcement of the new regime ie, worlds apart.
The good one is a corporate which has been recognising the pattern of the Labor government backing more and more into bulk billing for some time – even if in words only – has worked out the scale game, invested, and recognised that happy doctors who don’t leave are productive doctors.
It is employing doctors that suit its model – mostly young, often part time, and more transactional – and providing them with good conditions and variety to keep them happy.
Nothing wrong with any of that. But it is going to be a different culture to that 100% mixed-billing practice for sure.
In market this group takes the high ground, like the government, arguing that bulk billing is all about more access and equity, which it would be, if the government had the budget and funded it properly, which it can’t and it doesn’t.
Some irony here on the equity angle, as this particular group is owned by private equity, not that PE can’t sometimes align a business model and profit with delivering the community something good.
But even this well-oiled corporate isn’t escaping the cultural issues being catalysed by the new incentive regime. It is the same group in the story above where the minority of GPs mixed billing were either converted to fit into the 100% model, or, in essence, purged.
So, no matter what the type of practice prior to the new incentive, post the new incentive we are going to see amplification of cultural differences, making the argument that we might be going two tiered more believable.
Getting GPs on the same page on important issues has always been somewhat of a “herding cats” exercise.
But that goes, in part at least, to their independent and creative nature.
Until now, the GP tribe has been characterised by a few key traits – patients first, passion for generalism, not overly transactional, independent, creative, stubborn – which although eclectic for sure, has been easily recognisable as “one tribe”.
The new bulk-billing regime hasn’t even started formally, and it’s already changing that quite a bit.
