Lab report and cat scan

This joke was posted by a colleague. He pointed out that the scenario is very applicable to general practice. Indeed, it nicely illustrates the cost benefits of a good doctor who can often make a diagnosis without many expensive tests…

A woman brought a very limp duck into a veterinary surgeon. As she laid her pet on the table, the vet pulled out his stethoscope and listened to the bird’s chest.

After a moment or two, the vet shook his head and sadly said: “I’m sorry, your duck, Cuddles, has passed away.”

The distressed woman wailed: “Are you sure?”

“Yes, I am sure. Your duck is dead,” replied the vet.

“How can you be so sure?” she protested. “I mean you haven’t done any testing on him or anything. He might just be in a coma or something.”

The vet rolled his eyes, turned around and left the room. He returned a few minutes later with a black Labrador Retriever. As the duck’s owner looked on in amazement, the dog stood on his hind legs, put his front paws on the examination table and sniffed the duck from top to bottom.

He then looked up at the vet with sad eyes and shook his head. The vet patted the dog on the head and took it out of the room.

A few minutes later he returned with a cat. The cat jumped on the table and also delicately sniffed the bird from head to foot. The cat sat back on its haunches, shook its head, meowed softly and strolled out of the room.

The vet looked at the woman and said: “I’m sorry, but as I said, this is most definitely, 100% certifiably, a dead duck.”

The vet turned to his computer terminal, hit a few keys and produced a bill, which he handed to the woman.

The duck’s owner, still in shock, took the bill. “$150!” she cried, “$150 just to tell me my duck is dead!”

The vet shrugged. “I’m sorry. If you had just taken my word for it, the bill would have been $20, but with the Lab Report and the Cat Scan, it’s now $150.”

The problem with ‘record-high’ bulk billing rates

According to government data, bulk billing rates are at an all-time high: around 85% of GP services are bulk billed. This figure is often used to justify the lack of investment in general practice, including the freeze on Medicare rebates patients get back after a visit to their family doctor.

Why is this figure so high? Not surprisingly, the issue is more complex than politicians want us to believe.

According to the government it is a matter of supply and demand. In other words, they claim that GPs will not be able to introduce a fee because their patients would go to a bulk billing practice down the road.

This argument, as well as the government’s focus on record-high bulk billing figures, is misleading and doesn’t tell the whole story.

The truth about BB rates

The reality is that we don’t exactly know why bulk billing levels are high. There are several possible explanations, such as:

  • GPs have been billing compassionately to provide access to all their patients
  • GPs have been absorbing the costs of the government’s freeze on patient Medicare rebates
  • Doctors have increased their services to compensate for the low Medicare rebates
  • As a result of the ageing population more people are bulk billed.

The explanation given by the government that market forces are the reason GPs bulk bill does not do justice to the work of GPs around the country. Besides, as a result of government policies, out-of-pocket expenses for patients have been rising over the years.

Why out-of-pocket costs go up

notice
Image: As a result of the Medicare freeze on patient rebates, GP practices across Australia are getting ready to introduce fees. Source: Twitter

GPs are genuinely concerned about their patients first and foremost and, no matter what politicians say, GPs have been bulk billing a large proportion of their services because they know that many patients would not seek medical care if they had to pay a fee of $15-$20 per visit.

Unfortunately the government has indicated it will not further index Medicare patient rebates, and as result of the government’s long-term Medicare freeze, practices across Australia will be forced to introduce fees.

This was the whole idea behind the government’s original co-payment plan and the reason the Medicare freeze has been dubbed a ‘co-payment by stealth‘.

The short-term ‘savings’ created by the Medicare freeze will likely result in more health problems due to delayed GP visits, and drive up costs in the longer term. A typical case of a penny wise and pound foolish approach.

Downward spiral

What if practices don’t introduce a fee? A bare-bone, high-turnover model is one way bulk billing practices can sustain themselves: doctors may decide to see 7-8 patients per hour instead of 4-5. The question is of course: how safe is this and how long can they keep doing this?

High bulk billing rates, yes – but is this the health care system we want for Australia?

Out-of-pocket costs comparison
The focus on high bulk billing rates is misleading as it only tells part of the story. At the same time Australians pay more out-of-pocket for medical care than many other countries, which creates barriers to visiting a family doctor. Source: RACGP

The bulk billing statistics tell us what percentage of services is bulk billed, not patients. We also know that Australians already pay more out-of-pocket for their care than many other countries, which creates barriers to visiting a family doctor. These figures are rising, so clearly the bulk billing statistics only tell part of the story.

Instead of looking at bulk billing rates as a measure of success, we should be carefully monitoring the out-of-pocket health expenses in Australia.

GP Leaders have warned that we’re facing a downward spiral – which is a risk for the nation’s health and leads to higher overall costs. Even if the freeze on Medicare patient rebates is reversed – which is an absolute must – we’re not out of the woods.

We need well-resourced, sustainable primary care funding models that support high quality care for our patients and are easy to implement at grassroots level.

Minister, please don’t ruin our holiday again

Before Christmas – just as I was about to pack my suitcase – Prime Minister Tony Abbott dropped a bomb.

Together with the Health Minister he announced that the Government had introduced a policy to stop 6-minute medicine – or ‘sausage machine medicine’ as he called it. As a result the Medicare rebate would be reduced in January by $20 for GP consultations of less than 10 minutes.

Battle won, but not the war

This cut to Medicare patient rebates was meant to deliver $1.3 billion in savings over four years. However, as a result of the backlash by GPs and health consumers, the proposal has now been scrapped.

The other 2 components of the Government’s revised co-payment plan are still on the table: $873 million saving from a $5 Medicare rebate cut, and $1.3 billion saving by a four-year freeze of Medicare fees for GPs, medical specialists, optometrists, and others.

Expect more fireworks in the coming months.

6-minute medicine

Was Abbott right about the sausage machine? Are bulk-billing doctors churning through patients in six-minute sessions?

Most GPs felt Abbott’s argument was a sham as the issue was never raised in the budget. The real agenda was obviously to save health dollars. The timing – just before the Christmas break – as well as the one month’s notice before the measure would kick in, added insult to injury.

Some said it was a case of attempted political suicide.

Research shows that the average GP consultation lasts 14 minutes, not six. Some consultations may only take 5 or 6 minutes, but that’s not necessarily a bad thing. Here’s an example:

Someone comes in with a painful wrist after a fall. An efficient, experienced GP can take a history, examine the wrist and, if needed, organise further investigations within 6 minutes. The GP-in-training may take 20 minutes to do the same, should she be paid more? Probably not.

Abbott’s argument is of course not coming out of the blue: ‘6-minute medicine’ has a bad reputation because some business models of larger corporate GP clinics are purely profit-driven, and it is thought that this can lead to a high patient-turnover.

If Abbott has a problem with this practice, his Government should deal with those clinics, and not punish all GPs and their patients. But there’s more to it.

The real problem

The real problem is the increasing gap between the Medicare rebate and the costs of running a practice. While business expenses are going up every year, Medicare has only slightly increased the rebates over the years – barely covering inflation, and for the past 1.5 years the rebate has been frozen.

As a result, doctors need to see more patients per hour or work more hours, if they want to continue bulk billing. Another option is to retire (not recommended). Or they can choose to charge a gap fee or co-payment. This has happened before.

In 2003 bulk billing rates were at an all-time low of 66%. This didn’t make the Howard Government very popular, so the health-minister – Tony Abbott – had to increase the Medicare rebates. As a result, bulk billing went up again.

The solution

At the moment bulk billing rates are at an all-time high, about 85%. If the planned $5 rebate cut and freeze per the 1st of July 2015 go ahead, it is likely that less clinics can afford to bulk bill. History tends to repeat itself: If voters start to complain at a level of about 66% the Government may feel there is room to play – that is if they can get their proposals through the senate.

The new Health Minister Sussan Ley indicated after the backdown last week that she will continue to look for ways to make Medicare ‘sustainable’ and introduce a price signal by way of a co-payment. At the same time she wants to protect bulk billing and maintain and improve high quality healthcare.

I just hope that whatever the solution will be, private insurers are kept at a distance.

It’s good to hear that Minister Ley will talk to doctors – she seems genuine. Many GPs have already started the debate about ways to cut red-tape and increase efficiency in primary care. I’ve heard some excellent suggestions.

A bottom-up approach to health reform takes longer, but is more likely to succeed.

The Dutton promise

The Dutton promise
Image: peterdutton.com.au

The quotes below are taken from a speech by the Hon Peter Dutton MP, addressed to the Royal Australian College of General Practitioners’ Conference in Hobart, 2011.

“Today I want to announce a priority of the first Abbott Government will be to re-build general practice. To restore respect to general practice after four years of Labor’s attempts to undermine our country’s 23,000 general practitioners.”

“So today I want to start a debate again, this time around general practice. The Government does need to be goaded into further support of GP’s and to rethink their attacks on general practice. The fundamental pillar of our health system is our doctor and in particular our GP. I said this in my very first speech in this portfolio. With the might of Government we should be working to build on this strength, not to be pulling it down.”

“As the most common health system interaction for patients, providing nearly 120 million services each year, general practice is ideally placed to address the future burden facing our health system from demographic changes and chronic disease. The management of lifestyle and chronic disease is going to require all hands on deck. We all know that we need to do more successive interventions before patients reach hospitals if we are to have any chance of alleviating the growing burden on our health system.”

“Building up remuneration, addressing scope of practice, supporting training and genuinely strengthening general practice must be the first steps we take to making general practice the first choice for our graduates.”

“Governments should work with general practice to ensure the right resources are being provided in the most productive ways, without increasing the bureaucratic burden, without stifling innovation or becoming a competitor in the provision of services.”

“So with one eye on the history and one eye on the future, I hope that we can work together to rebuild general practice, to again turn a job into a noble vocation.”

“Doctors and patients across our great country deserve nothing less.”

[ends]

9 reasons why GPs are being screwed by government

GPs screwed by government

The government’s revised co-payment plan is a dog’s breakfast. Here are 9 reasons why the proposal has angered Australian GPs.

#1

Prime-minister Abbott’s reference to sausage machine medicine is insulting. If the government is unhappy about the way some clinics churn through patients, they should do something about it, but not punish all Australian GPs – and patients.

Besides, it looks like the government didn’t do their homework properly: A recent report debunked the myth that GP care is ‘6-minute medicine’. The authors of the report: “If people feel they must ignore the wide range, and refer to the length of GP consultations in one phrase, it would be far more accurate to call it ‘14 minute medicine’.”

#2

The revised co-payment plan will not make healthcare more efficient or reduce waste in the system. It unfairly targets a part of healthcare that is operating in an efficient and effective way. RACGP president Dr Frank Jones: “If the Government is serious about this move, it is reasonable to ask the question: why not across all healthcare services?”

#3

Medicare is not unsustainable. This is a false argument by the government. The increase in health expenditure in general practice has been slow, and in line with overall economic growth and GDP. Professor Jeff Richardson, Centre for Health Economics at Monash University said this:

“Public spending on health as a percentage of GDP is among the lowest in the OECD. Only Chile, Estonia, Hungary, Israel, Mexico, Poland and the Slovak Republic channel less of their GDP into health via the government.

#4

Yes, research shows that increased out-of-pocket costs stop people from going to the doctor. This is not rocket science. Research also indicates that areas with the fewest GP services have higher hospital costs.

It’s not rocket science either to figure out that more patients will attend the free, but more expensive emergency departments of public hospitals, thus increasing overall health expenditure.

#5

Unfortunately, out-of-pocket-costs will not weed out unnecessary visits. The extra expense will also deter people with a serious illness from going to the doctor – especially people on a low-income.

#6

If the revised co-payment plan will cut the amount of visits to the doctor, a highly skilled, expensive medical workforce will be doing less work. The revised co-payment plan does not change the opportunity cost of medical care.

#7

The government wants GPs to work longer for less. Up to ten minutes of work now pays $37.05, but if the revised co-payment plan goes ahead, the government will only pay $11.95 – a drop of $25!

Note that $11.95 is not doctor’s income: After practice costs (staff wages, rent etc) and tax are deducted about $4 will be left for the GP to spend.

#8

Look at the chart and it is clear that the expected drop in revenue, in combination with ever-increasing costs, will make GP practices unsustainable – unless fees go up. The fees will need to cover the before mentioned $25, and will continue to rise each year as the rebate will not go up until at least 2018.

Medicare
The expectation: If the government’s alternative co-payment plan goes ahead, Medicare income will drop and not change until 2018, while the costs of running a medical service will continue to climb. Note: this is a forward estimation only, not based on empirical data.

#9

The revised co-payment plan may stop certain clinics from bulk billing, but it will not prevent these clinics from undercutting more comprehensive GP services. The gap fees of those clinics will likely still be much lower.

In summary: This plan will alienate GPs, shift costs instead of making real savings, and not improve care in any way – it will only make things worse.

In her open letter to Tony Abbott and Peter Dutton, Dr Sally Cockburn wrote:

“Your government is taking advantage of GP benevolence with your cut to Medicare rebates. We’re sick of being kicked around. While most of my colleagues are too busy looking after patients to play political games, this time I think you may have woken a sleeping giant.

Sally, you are right!

Follow me on Twitter: @EdwinKruys

Sources:

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.

 

Everything you always wanted to know about bulk billing (Video)

My patients often ask: “Doctor, do you  bulk bill?” and “Why do I have to pay a gap?”

Although there are certainly circumstances where I bulk bill, it has many risks. Lowering the quality of Australian Family Doctor services is one them. In this video I have tried to explain how it all works.