Co-payments, and why they’re not always appropriate

Co-payments, and why they're not always appropriate

A one-size-fits-all approach doesn’t work in my job. There are always plenty of valid reasons why a particular approach or treatment works for one person but not for another.

One-size-fits-all healthcare is bad medicine. Bulk billing everyone doesn’t make sense. It’s not necessary and doesn’t cover the costs. In the same way, charging a co-payment across the board doesn’t make sense either.

There are people out there doing it tough, such as Melbourne mother Kaye Stirland who wrote treasurer Joe Hockey a letter that went viral on social media. Kaye represents a group of people who cannot afford to pay $7 to see their GP.

The co-payment also puts healthcare providers in a difficult position. RACGP president Liz Marles said in Medical observer: “There will be times with patients we all see – mentally ill patients, young people, homeless people, people just doing it really tough – where GPs will have to waive that money. That will mean that GPs will not only lose that $5 but if they are a concession card holder you’re also losing the $6 bulk-billing incentive.”

I believe there’s nothing wrong with co-payments in general. In the end bulk billing is not sustainable if Medicare rebates don’t keep up with inflation and business costs (see this video).

AMA president Steve Hambleton was quoted by MO saying this: “If the minister says he thinks people should pay a co-payment if they can afford to do so, the AMA has no problem with that. (…) But we believe there are people who can’t afford to… We need to know what we’re going to do about low-income earners.”

Some vulnerable groups should be excluded from paying co-payments when they visit their healthcare providers. Co-payments are not always appropriate.


8 thoughts on “Co-payments, and why they’re not always appropriate

  • If ‘one size’ truly fit everyone, we could all hang up our stethoscopes, go home, and let Dr Google see the patients! If a co-payment is inevitable (and I’m yet to be convinced it is), I think the onus is on us, as medical professionals, to make the system work for our patients. I envisage regular patients – concessional, aged, people with chronic diseases – spending time with their GP under the chronic disease item numbers (no co-payment), and with the practice nurse (no co-payment), getting better, co-ordinated care. I think the radiology and pathology companies will absorb the co-payment and just not charge it – for basic testing. This will hopefully decrease the ordering of unjustified tests – the ‘everything’ blood test and CT lumbar spine come to mind. I’ve spoken to a few doctors, and the ‘threat’ of a co-payment to our patients has really incentivised us to think ‘outside the box’ as to how we can continue to care for them – some really good ideas have come up. I’d really like to work on these ideas!


    • Nick unfortunately the one size fit issue is also applicable to the GP model.
      My wife and I have a waiting list of at least 4 weeks for patients to see us. When one of us falls ill – like I am today – that easily blows out by another day or more. We bulkbill around 40-60% of our work, spend about 15-17min on each consult and do not employ a Nurse. We rarely see simple cases like ear infections of BP checks – they go to the 6min joints – when they want their unexpected weightloss or their depression dealt with they come and see us.

      Neither of us are convinced that EPC items are anything more than a moneymaking gimmick and there are many reasons why those complex frequent flyers cannot be managed with gap-free EPC items – it it was that easy the Guvmint would have closed the loophole.

      Given the fact that we hardly ever do an EPC item there is also no justififying the cost of a Practice Nurse so we don’t have one

      I also think that you are being optimistic regarding the investigations – our local private path lab has been champing at the bit to start charging everyone. They were not happy that I routinely mark the bulkbill option whenever I request something.

      As things stand I work 12h days yet my business is in the red – if the Rebate is not indexed next month we will have to up our fees and cut down on bulkbilling – regardless of a co-payment or not


      • Sorry to hear that Thinus, and get well soon! I understand the economics of primary care in Canberra are slightly different to what I might be used to. Please feel free to privately message me in regard to your issues with the EPC item numbers – I really think these things (and practice nurses) can be made to serve patients rather than acting as a cash cow for corporate practice. The pathology providers here in SA are quite pragmatic and know that a co-payment is going to lead to a large drop in attendances – again, probably quite different to Canberra.

        Again, get well soon, feel free to message me privately, and thanks for opening my eyes to a different point of view!


  • Facing a 35-30% rebate cut if I bulkbill all my hardship cases

    If I charge a copayment they will all go to the local ED – where, guess what, I am the oncall doctor and now even more worse off. May have to sack practice staff. Or move to one of the cities. This is the death of rural general practice

    Students already voting with their feet .


  • I just signed the CoPayNoWay petition. I hope other GPs will too. We need to stand together on this. I am so angry. We’ve had rebates frozen. And rebates cut (I lost a noticeable amount in my pay packet each month with the change in 2715/GP mental health care plan changes in particular). Now we’re facing 25% drop in income if we decide we can’t in good conscience charge someone a $7 co-payment (eg. Medicare rebate drops by $5 to $31.30, and you lose the $6 bulk billing incentive too, so a $11 loss, or higher if you work in a 10991 area. Tim, I presuming that’s why your loss is 30-35%?). There’s lots of pensioners I do 2 or 3x weekly ulcer dressing changes on, or kids with weekly cryotherapy for a wart, baby vaccinations, the fortnightly depot antipsychotic-receiving patient, the elderly on pensions…. I just don’t think I can charge them $7, but I can’t drop from $42.30 to $31.30 for a level B consult for too many folks. I’m not a charity, I’m a small business. My receptionist wants a pay rise this year – should I freeze her wage too?

    I work in the Eastern suburbs and charge a $35 gap to about half my patients. Here are the options I’m considering:
    (1) Charge the $7 co-payment to most of the concession card holders I currently bulk bill, but cop the 25% drop on the ones I just can’t countenance charging. Then increase the gap as high as I think I can get away with for all other patients – probably $50 to $60, so that this covers the 25% drop for the no-co-pay patients and covers the administrative burden too.
    (2) Have a $7-filled envelope at the front desk that we donate to concession cardholder patients, then they use it to pay us the co-payment. This way I get $37.30 (the $31.30 rebate and the $6 bulk billing incentive), which is better than the $31.30 I come away with if we waive the $7 copayment.
    (3) Do care plans for everyone I can possibly get away with.
    (4) Do something else entirely or retire if I could afford it.

    I am so angry that GPs bear the brunt of health reform time and again. WE are doing the heavy lifting. I’d like to see Joe Hockey face the choice we’re making: 25% pay cut or deny someone the medical care they need. Not only am I about to face a pay cut, my job is also about to become worse than ever: patients bringing longer lists of problems (to “justify” the cost of the consult), patients expecting medical care over the phone (because they can’t afford the visit to the doctor), patients being unable to afford medication so going untreated, patients refusing to attend follow up appointments, patients dropping out of preventive health activities, and selecting which of the tests on the blood test request form they want to have done. Not to mention the awkward conversations where the patient has to tell you their financial woes and convince you to waive the co-payment.

    Where are our specialist colleagues? They need to back us on this.

    Thanks for letting me have my rant, and a note to any medical students or junior doctors reading this: DO NOT go into GP training. Most registrars are lured in by the “lifestyle” – part time training and part time work for reasonable pay. Don’t do it. Train in a more lucrative specialty, sacrifice 5-8 years of your life working 2.0 FTE if you have to – it will pay off in the long run, you can drop to part time later.


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