Why you still bulk-bill everyone and why you should stop

8 minute read

There’s a lot of angst around private billing, but there is also significant distress when your patients take you for granted.

Since RACGP president Dr Karen Price urged all GPs to move as many patients as possible on to private billing, there has been much discussion in the social media groups for peers.

I have seen a lot of anxiety (“we cannot unless we all do it”), a lot of handwringing (“no one will pay to see us”) , and yes, some bleeding hearts (“it is not right, there are people who cannot afford to pay” and “how can you impose an invalid contract on someone with a mental illness? It would be void”). 

There has been a lot of “we cannot, there are bulk-billing centres all around us who will take our patients away”. 

Underneath the angst, which I have been hearing more and more of over the eight years since I moved away from universal bulk billing (UBB) as a final-term registrar awaiting Fellowship, is genuine fear. 

There is also burnout, frustration and disillusionment with general practice. We are the specialty few want to take up, because of the long hours, the poor remuneration – in no small part our own doing – and the general sense by our non-GP peers and the general public alike that we are #justaGP –  that is, not worth paying to see. There is also the sense that their Medicare levy pays us enough, or that if we charge a gap, we are “greedy doctors”. 

Most of us have had enough. I have written before about this, and defeated doctors who are young enough retrain to look at other options. 

For those who are still here and wondering, who talk about a strike, I try to ask: “Why do you want to move from bulk-billing?” And the flip side of that: “Why do you feel you CANNOT stop bulk-billing?”

To me, as someone who has been doing mental health and therapy since 2011, these are the pertinent questions: the WHY and following that, based on the answers, the HOW to do the thing we say is important.

After all, what someone else does or does not do is psych 101: placing the key to our happiness in someone else’s pocket is a recipe for disaster nine times out of 10. So any sentence that begins with “I cannot charge because they will not pay” is already flawed because you have based a conclusion on something you cannot possibly know. 

What I try to explore instead is: why should you move away from bulk-billing everyone; and, in part II, how do you do it, if you determine it is right for you? 

Some examples of the why, based on my own and others’ experiences over the years: 

  • Being so busy and frantically booked out that it begins to feel unsafe 
  • Feeling resentful of no-shows and late cancellations, especially for long appointments, without any penalty to the patient (warning, late fee etc.) 
  • Feeling resentful listening to them talk about renovations/holidays/private school fees while expecting to not pay anything at the point of service 
  • Practices feeling unable to say no to the walk-in at 5pm when the practice is meant to close so as to have “one extra sale” before COB and asking the doctor, especially trainees, to stay back
  • Little respect or regard to individual doctors’ wishes on billing – my practice principals tried to talk me out of changing to mixed billing as a final-term registrar in 2013; I was told it would not work, I’d lose my patients and would sit around all day with no one to see. I was a contractor so they had no right to try to stop me. 
  • Waking up feeling low, demoralised and frustrated at the thought of yet another day of feeling taken for granted/frustrated/burnt out
  • Patients abusing us for charging a private fee for doing paperwork not related to Medicare and not Medicare rebateable 
  • Patients taking up more time via phone calls (back when they were not rebateable), losing paperwork (scripts, referrals) and getting angry if asked to pay for a replacement 

These are all real-life examples of the day-to-day stresses in a GP practice that disrupt our days, add to our workloads and stresses, and leave us feeling tired, angry and frustrated. 

Added to that, we are not employees and therefore we are not obliged to follow any of the directions of the places we contract for, but to negotiate terms that are acceptable for us. So why do most of us simply accept it and keep showing up day to day? 

Having a healthy sense of self, decent self-esteem and a sense of being valued all add immensely to our sense of ourselves, studies show over and over. And when we spend the bulk of our waking days at work, feeling unappreciated, demoralised and devalued, it adds up. 

For me, it got to a stage where I was regularly resentful of patients, including many pensioners, regularly talking about their overseas holidays, renovations and more, knowing that they would not be paying a cent for the excellent care they were getting with me. 

It distracted me enough that I began wondering if I was providing competent care because my own feelings and frustration were interfering with the care I was (not) providing. I also got so busy it felt frantic and unsafe on some days, and I began to feel as if I’d make a mistake if it continued that way. 

Equally, while I had very few no-shows, and was mostly fully booked most days, I was not booked out for weeks. At my last practice, which was 100% private billing, I’d book out only 80% on the day for the years I was there, but that was enough for me to earn the equivalent of what I’d be making run off my feet in a UBB clinic. The difference was that now I had time to be with my patients, to catch up with them, and to do things at my own pace. I got value out of the consultations as much as my patients did. 

My final why, when I moved back to a mixed-billing clinic earlier this year, was this: the vast majority can afford to pay a fee at the point of service. We might twist ourselves into knots at the thought of talking money and gaps, but most people, when I actually tell them “I don’t bulk-bill”, go ahead and book anyway, and the gap is not a deterrent to them. 

When most of them who can afford to pay do pay, it allows me to practise the kind of medicine I enjoy, with patient satisfaction and safety at the forefront, alongside my own. 

It also allows me to genuinely choose to bulk-bill (for a period of time or permanently) a tiny percentage who genuinely cannot afford to pay a gap or to charge a reduced gap for them, because I am not worrying about my own finances as a self-employed person. 

Many people who have moved to mixed or private billing successfully set up the expectation of “charge what you’re worth”. But this implies that those who cannot are losers who do not understand this. And many, if not most, of us who choose medicine did not do so with money foremost in mind. 

At the same time, political and financial pressures have meant that most GPs are now struggling and we, as a group, are vulnerable to exploitation as well as extinction. Fewer and fewer junior doctors are interested in general practice as a viable career choice and speciality that still has  so much to offer –  if we can learn effective boundaries, and how to discuss money and shift our scarcity and fearful mindset. 

Next time, I’ll talk about how to move to mixed billing if you’re unsure. For now, remember that the government will NOT advocate for us, and nor will the colleges or unions – not the RACGP to date, nor the AMA. As with most movements, this fight, if we are to win it, must be fought and won by each and every one of us who has the courage to be terrified and to do it anyway. 

Dr Imaan Joshi is a Sydney GP; follow her @imaanjoshi

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