Governments have millions of dollars to throw at health programs – let’s see how many GPs you could get for what they’ve spent.
There has been a lot of talk about what a GP is worth, and what we, as a community, can afford.
The community is clearly telling us that paying a gap to see a GP is problematic. The argument has always been that we are in a tight fiscal environment, and it’s difficult to afford to increase the Medicare rebate.
I would accept this argument were it not obvious that other investments are possible. So I thought it might be helpful to break down the comparative statistics.
Let’s take a “standard” GP in a regional community and work out what they cost per year. We’ll assume this GP does 15-minute consultations for 38 hours a week for 48 weeks a year. It’s an approximation, but a reasonable one. Then we’ll add a regional level of incentive for every patient – not because they all get one, but to paint the rosiest picture possible.
That’s $41.40 for an item 23 + $36.90 bulk billing incentive for MM2, which is $313.20 per hour, multiplied by 1824 hours, which comes to $571,277.
A standard GP year then costs the community ~$571,000 per year, and includes all the infrastructure a GP needs, including their building and staff.
Then let’s take a “mental health” GP, who sees mental health patients for 40 minutes each, which is a common scenario for many complex patients. Mental health items cost the community much less, at $78.95 a go (item 2713) whether you spend 20 minutes or an hour – 40 minutes is about average. These items are excluded from the new incentives, but you can use the old 10991, which is worth $12.25. Let’s also assume they bill one long mental health treatment plan item (2717) a fortnight, adding a little to their income because those items are more lucrative at $147.65.
That’s $78.95 + $12.25 = $91.20 per 40 minutes, or $136.8 per hour. That comes to $246,240 + $3543.60 for the MHTPs, for a total $249,783.60.
A standard mental health GP year then costs the community around $250,000 per year.
Some of you may ask why I am not using a long consultation item number, like a level D or level E. The reason is that most GPs are keen to avoid potential audit. I am following the Ask MBS Advisories, a series of statements produced to guide those using MBS item numbers. Let’s look at their response to the question as to whether a consultation item number can be charged instead of a 2713.
It is a fundamental principle of Medicare that the item that best describes the service is the item that should be claimed for that service. This means, for example, that it would not be appropriate to claim a general attendance item for mental health treatment service if it were possible to claim a dedicated mental health treatment item. The time requirement for … item 2713, “at least 20 minutes”.
So assuming this mental health GP is doing mental health work, the maximum rebate s/he can charge is a 2713, no matter how long the consultation runs. The inequity is staggering.
Comparing investments in healthcare
Every year, there are programs that are supported by federal and state governments “to relieve pressure on the health system”. Most of these are good programs, with the potential to make a significant difference to patients. However …
‘Top of scope’ investments
There is currently substantial investments to enable health professionals to work at the “top of their scope”. I am yet to see an initiative targeting GPs, but the review “Unleashing the Potential of the Health Workforce” is based on the idea that other health professionals working at the “top of their scope” can somehow free up GPs to do more difficult work.
Mark Butler’s position is this: “For too long, too many of our health workforce haven’t been able to work to their full potential. Whether it is nurses, pharmacists or allied health professionals, in a global health workforce shortage we need everyone working as close as possible to the top of their scope.”
The arguments are usually around cost, recruiting a larger pool of health professionals to do the work, and trying to attract more people into the health professionals by enabling more interesting, challenging and presumably lucrative work. The programs are expensive and the table below shows how many standard GPs each program would fund.
| Program | Cost to the taxpayer (’000,000) | Cost in GP years |
| Pharmacy vaccination program | $114 | 200 standard GP years |
| Pharmacy opioid dependence program for 50,000 people requiring support | $373 | 653 standard GP years 1492 mental health GP years |
| My Health Record, estimated cost to date | $2000 | 3503 standard GP years |
| Australian Digital Health Agency, 2023-2024 | $951.2 | 1666 standard GP years |
| Commencing rollout of 50 Medicare Urgent Care Clinics | $235 | 412 standard GP years |
| Initial investment to reduce fraud | $29.8 | 52 standard GP years |
| Total investment to date in three ACT nurse-led walk in clinics | $14.36 | 25 standard GP years |
Women’s budget statements
| Program | Cost to the taxpayer (’000,000) | Cost in GP years |
| Piloting a new model of care, delivered through Primary Health Networks, for improved coordination and access to trauma-informed recovery services for people who have experienced family, domestic or sexual violence | $67.2 | 269 mental health GP years |
Mental health investments
| Program | Cost to the taxpayer (’000,000) | Cost in GP years |
| Orygen building, housing the National Centre of Excellence in Youth Mental Health | $68 | 272 mental health GP years |
| Initial Assessment and Referral Decision Support Tool (IART) for assessment and triage of patients needing PHN mental health services | $34.2 | 137 mental health GP years |
| Wellbeing locals Victoria | $353 | 1412 mental health GP years |
All of these initiatives are worthy, and will undoubtedly add value. That, in my view, is no longer enough. What we need is to demonstrate that any innovation adds MORE value than the existing model of care. We also need to show that the benefits outweigh the harms.
I do not want to take over any of these functions. Goodness knows I’m busy enough. But don’t tell me they represent value for money.
Let’s take an exemplar. My patient has survived a terrible childhood and multiple foster homes. He has an intellectual disability, and a multitude of mental and physical health issues. He is dangerously thin because he doesn’t care for himself well. He is also addicted to the opiates he was prescribed after surgery some years back. And before you tell me he’s an outlier, there are many similar patients on all of our books. Let’s look at what adds value to his care.
He is excluded from the pharmacy opioid program by his multiple addictions. The Urgent Care Clinic in my state missed his septicaemia from a UTI (and he would not have been eligible for the pharmacy UTI trial). I suspect it is because he is not a great communicator, and gets emotionally dysregulated, making him hard to assess. Although his mother is frankly dangerous, he is not ready to acknowledge the family violence, so no help there.
The nurse-led clinics managed an acute presentation of his, but don’t offer ongoing care. The IART told me he was highly unwell, but I know that anyway, and he is not suitable for PHN programs. He does not respond to the type of care they offer. I suspect the same would be said of the “wellbeing” centres. There is no way he would get appropriate care at Headspace.
Public psychiatry has rejected him because his problem is substance abuse. Drug and alcohol services have rejected him because his problem is psychiatric.
So he sees me. Just me. For $80. I have spent countless fruitless hours trying to get him into any other service. Do not tell me a multidisciplinary team would provide better care. They are not the experts in the patients they refuse to see.
