5 reasons why the Medicare rebate freeze is bad policy

When I tweeted about the Medicare freeze last week, someone asked “Care to explain other than meaning you get less money?”

I thought it was a really good question as it highlights the complexity of the issue. Most people seem to think that it’s all about doctors’ income – but it isn’t. The Medicare rebate is also about the money patients get back from Medicare.

As we speak, around Australia GP practices are adjusting their fees as a result of the government policy. Our practice increased the fee of a basic consultation with five dollars for people without a concession card. Other practices have decided to charge a once-off $30 payment to previously bulkbilled patients.

I expect that if the freeze is not lifted these amounts will have to go up again soon.

Greedy doctors?

Everything gets more expensive over the years, including the cost of running a medical practice – think for example about rent and employing receptionists and nurses. If GP practices would not up fees, their Medicare rebate income would drop with 7.1% by 2017-2018!

Over the years more and more services will require an out-of pocket payment by patients, including pensioners and healthcare card holders. Rural doctors expect that bulkbilling in the bush will soon be a thing of the past.

But the freeze has also affected urban areas. That’s why the the RACGP and AMA have labelled the government policy a ‘copayment by stealth’.

Five arguments

The freeze is bad policy and should be reversed for five reasons:

1. Many practices will stop bulkbilling. This means higher out-of-pocket costs for patients. As a result fewer people will visit the doctor in the early stages of a disease. This will often make treatment later on more difficult, more stressful and more expensive.

2. The policy disproportionately affects disadvantaged people who cannot afford a copayment. Research shows that increased out-of-pocket costs stop people from going to the doctor.

3. The freeze undermines important Australian values such as equity of access and therefore encourages a two-tier health system.

Some argue that a copayment would cut unnecessary use of medical services. But higher out-of-pocket-costs will not weed out unnecessary visits. Many of my colleagues know that often their sickest patients will not seek medical care if it becomes more expensive.

4. Research indicates that areas with poor access to GP services have higher hospital costs. It is likely that more people will visit places where healthcare is free, such as already overloaded public hospitals and emergency departments. Dr Google will become more popular too!

5. Practices continuing to bulkbill will have to change their business model: doctors need to see more patients per hour, or practices will have to hire less staff which will affect service. Some practices will close their doors – such as Dr Adrian Jones, a Redfern GP who decided to close his practice as the margins were getting too small.

Is the freeze a necessary policy?

Medicare is not unsustainable. This is a false argument by the government. In fact, Federal Health Minister Susan Ley admitted at the national AMA conference: “The Government is not claiming we’re in a healthcare funding crisis.”

Australian healthcare performs well in comparison to other countries. The increase in health expenditure in general practice has been slow, and in line with overall economic growth and GDP.

Freezing the patient Medicare rebate will not make healthcare more efficient or reduce waste in the system.

Medicare freeze

The video that made doctors cry

The first video of a national awareness campaign by the Royal Australian College of General Practitioners (RACGP) highlighting the value of general practice, has brought tears to the eyes of many GPs.

The clip starts in the seventies, when home pregnancy tests were not widely available. The young, fresh GP is visibly happy to bring the good news to a couple in his consulting room (“You have a baby on the way”). There is no computer in the room, lots of paperwork on the doctor’s desk, and we see furniture and filing cabinets from times gone by.

As we follow the couple and the doctor over the years, the consulting room changes too. If you look closely (admittedly this may be of interest to medicos only) you will see a beautiful old mercury sphygmomanometer on the trolley. Computers begin to appear on the desk. Time flies in the video; in a matter of seconds the GP and his patients age and new family members enter the consulting room.

The lifelong journey

Towards the end one of the children has become a mother. The GP, now with grey hair, says to her “we have quite the journey ahead of us,” as he gets up from his chair with the visible difficulty of an older man.

Indeed, sharing the journey through life is one of the aspects that sets the GP apart from other disciplines. And just like in the video we’re there for the minor ailments – the nits – as well as the big and often emotional life events, such as a cancer diagnosis or the death of a spouse. I think the video brings this message across very well and that may be why it triggers an emotional response.

But the video also contains another message. Observant viewers will have noticed that the GP has two framed certificates hanging on the wall at the beginning of the clip and, as time moves on, more certificates follow.

The importance of education and learning gained through fellowship of the RACGP is a key message of the campaign. A voiceover at the end tells us: “The good GP is with the Royal Australian College of General Practitioners, because the good GP never stops learning.”

Criticism

There is of course, as always, criticism. Some have commented that telling patients they have to do something may not be the most effective way to encourage change – like smoking cessation. Good GPs have a conversation with their patients. Others have mentioned the video doesn’t reflect our multicultural society or the gender diversity in medicine.

Fellows of the Australian College of Rural and Remote Medicine (ACRRM) may rightly say that they too are good GPs. And lastly, there seems to be a disconnect between the clip and the message about lifelong-learning at the end. It may be easier to brand general practice than a GP college.

I believe some of the criticism will be addressed in future campaign material – but it is also good not to lose sight of the bigger picture. The campaign aims to improve the recognition of GPs and general practice. If it’s as successful as the RACGP’s You’ve been targeted campaign, the promotion of general practice will benefit all those working in primary care, and more importantly, our patients.

Strong general practice

Personally I hope the campaign opens the eyes of some politicians. Australians rate their doctors in the top-3 of most honest and trusted professions and they visit the GP on average 5-6 times per year. GPs are good value when it comes to spending tax payers money: The average GP consultation costs $50, compared to for example $400-600 per service in a hospital emergency department.

It is a good idea to reduce waste and duplication in healthcare, but poorly targeted cuts and freezes will do more harm than good to the health of Australians. We must also reduce the amount of red tape and stay away from more bureaucracy, like NHS-style revalidation – so doctors can look after their patients instead.

The success of a campaign depends on the people who support it. In a video message directed at doctors RACGP president Dr Frank Jones said: “Talk to your patients and key people in your community about the importance of general practice. Our training and the accreditation standards are why the good GP never stops learning.”

The video touched the hearts of many GPs, but in the end it’s the impact on patients that matters most. I hope its positivity will be contagious.

The Medicare freeze: A storm is coming

Health Minister Sussan Ley said at the annual AMA conference in Brisbane that the Government is not claiming we’re in a healthcare funding crisis.

At the same time dark clouds are gathering as the frustration about the patient Medicare rebate freeze rises.

The Medicare rebate is the amount patients get back from Medicare after they visit their doctor. This amount is supposed to go up every year to compensate for inflation and higher costs. The government has frozen the annual indexation for four years.

The Consumers Health Forum said in its analysis of the latest Budget: “The retention of the $1.67 billion freeze in Medicare payments to doctors may mean many patients are likely to face higher medical bills.”

The Guardian reported: “The AMA president, Brian Owler, used his opening address on Friday to call for both sides of politics to lift the ‘damaging’ freeze which could force GPs to start passing costs on to their patients, amounting to a so-called co-payment by stealth.”

And: “The federal government could face another fierce campaign from one of the nation’s most powerful lobby groups if it does not lift its freeze on doctors’ rebates before the next election.”

The RACGP has also indicated that it would consider a new campaign. It looks like we’re going to get some fireworks again.

Why the ‘You’ve been targeted’ campaign against the co-payment was so successful

“We don’t have to engage in grand, heroic actions to participate in the process of change. Small acts, when multiplied by millions of people, can transform the world.” ~ Howard Zinn

Not many people know that the main message of one of the most successful campaigns of the Royal Australian College of General Practitioners (RACGP) against government policy was largely inspired by one patient.

At the height of all the commotion about the co-payments, patient advocate Ms Jen Morris posted a message on Twitter suggesting a different response to the government proposals: Instead of focusing the campaign on doctors, she said, we should be focusing on the consequences of the policy for patients.

We’re sorry

I used her simple but powerful message in a leaflet (see image). It said:

We’re sorry to hear your rebate will be slashed. (…) It’s not that we haven’t tried, but the Government doesn’t seem to listen to GPs. They may listen to you.”

We are sorry
The original design inspired by Ms Jen Morris.

Not long after I posted it on my blog and social media channels, the RACGP President contacted me. He wanted to include the message in a national campaign. I thought it was great that the RACGP was using social media and that they took notice of what was being said. Not long after, the You’ve been targeted campaign was unleashed by the college. The message was similar to the original, inspired by Jen Morris:

“Your rebate from Medicare will be CUT (…). We have been vocal with Government but it’s falling on deaf ears. They haven’t listened to us but they will listen to you.”

The RACGP had listened to patients and many of their members who wanted a patient-focused campaign. The You’ve been targeted approach showed that every GP surgery in Australia can be turned into a grassroots campaign office if necessary. After other groups, including the Consumers Health Forum and the AMA, increased pressure on the government, the co-payment plan was dropped.

I spoke to Ms Jen Morris and RACGP President Dr Frank Jones about the role of patient input, the use of social media and what we can learn from the remarkable campaign – as there is still a lot of work to do (for example to reverse the freeze on indexation of Medicare rebates)

A pay cut for wealthy doctors?

Morris: “I opposed the co-payment, but was concerned that the original approach adopted by doctors’ organisations misjudged the public’s values, as well as public perceptions of doctors’ wealth and social position. In the initial stages of the campaign against the proposed co-payment, doctors’ organisations, and thus media coverage, were framing it as a pay cut for doctors.”

“Misframing the situation like this made it harder for those of us opposing the changes to explain the various proposals, including Medicare rebate freezes, in a way which the public could understand. It also made it easier for the public to write the problem off as not their concern, but rather a pseudo ‘workplace relations’ issue between doctors and Medicare.”

“At the time, the public were reeling from a budget widely touted as disproportionately impacting the most vulnerable and disadvantaged people. In a social context of widespread public perception that doctors of all stripes are wealthy. So there was little public sympathy when the doctors’ lobby cried foul because the government was trying to ‘cut their pay’. There was a sense that as well-off professionals, GPs should take their fair share of the fiscal blows and ‘cop it on the chin’.”

“The government played perfectly into the combination of these two problems. By later touting the co-payment as ‘optional’, they painted GPs who chose to charge it as opting to squeeze patients rather than take a pay cut.”

‘Extremely poor policy’

Jones: “The RACGP repeatedly raised its concerns with government over many months regarding the impact of a co-payment on the general practice profession and its patients. As GPs we have an obligation to speak up and oppose any policy that will impact on our patient’s access to quality healthcare. We know that poor health policy drastically affects the ability of GPs to deliver quality patient healthcare, and this was extremely poor health policy.”

“When it became apparent the RACGP’s concerns were not gaining the traction required to influence change, we decided it was time to increase pressure. While advocacy has always been a major component of the RACGP’s work, it has recently taken a more public, contemporary approach to these efforts.”

“In the case of You’ve been targeted, this meant ensuring patients were also included in the conversation and encouraged to stand united with GPs to protect primary healthcare in Australia. We collectively see hundreds of thousands of patients a day and knew that a campaign bringing GPs and patients together would present a strong united voice.”

You've been targeted
The succesful RACGP You’ve been targeted campaign

The strength of the campaign

Morris: “Like most public policy debates, successful campaigning against the co-payment was contingent on securing public support in a political PR contest, which means getting the public on side. I believed that re-framing the issue around patient interests was the key to changing public perceptions, and winning the PR battle.”

Jones: “The RACGP took notice of what patients were saying about the co-payment and listened to our members who were telling us they wanted a campaign that focused on how their patients would be impacted. This is what led to the creation of You’ve been targeted.”

“The response to the RACGP’s change.org online petition was a big step for the campaign, with more than 44,800 signatures obtained in less than one week. While the campaign gained momentum through protest posters, use of the social media hashtag and sending letters to MPs and this allowed for concerns to be heard, the online petition was a collective demonstration of the sheer extent of those concerns.”

“A campaign’s strength is intrinsically connected to how powerfully it resonates with its audience and You’ve been targeted hit all the right buttons in this respect campaigning on an issue that affected every single Australian, young and old.”

Novel approaches

Morris: “If doctors and patients can capitalise on common ground and present a united front from the outset, the weight of political force will rest with us.”

Jones: “In terms of closer collaboration on advocacy campaigns, the RACGP feels there will be significant opportunity to work with health consumer organisations, given the mutual priorities of better supporting patient care.”

“The RACGP has already partnered with consumer organisations including the Consumers Health Forum (CHF) with whom it produced a number of joint statements. Most recently, the RACGP and CHF partnered in a joint submission regarding the deregulation of pharmacy locations and ownership.”

“The RACGP has consumer representatives on its key committees and boards. We have a history of working with consumer groups on important issues, and will continue to do so moving forward.”

“In light of the RACGP’s recent campaign successes, we will increasingly use social media as a platform to act as a voice for Australian GPs and their patients. Social media is new age media and the RACGP is committed to keeping pace with technological advances to ensure its members are effectively represented.”

The untapped power of the patient-doctor alliance

Traditionally campaigns against poorly thought-out Government policies have predominantly been doctor-centric, and the usual Government response is to divide consumer and medical organisations.

Jen Morris is a patient advocate and researcher in healthcare quality and safety at the University of Melbourne. She feels strongly that cooperation is required if we want to make more impact in Canberra.

This makes sense. It looks like the time is right for a novel approach – and it is much needed too, as the discussion about healthcare so far has been about dollars instead of quality. What are the benefits of a patient-doctor alliance and how do we overcome our differences?

Jen Morris
Jen Morris: “If doctors and patients can capitalise on common ground and present a united front from the outset, the weight of political force will rest with us.”

The numbers game

“At a strategic level, it’s a numbers game,” says Jen Morris. “There are approximately 26,000 GPs in Australia, and about 82,000 registered medical practitioners. But there are over 23 million patients. That is an enormous bloc of voters and lobbyists to leave untapped.”

“When campaigns are too doctor-centric, that leaves this bloc ‘in play’ – sparking a spin and PR war between doctors and the government, vying for public support. But if doctors and patients can capitalise on common ground and present a united front from the outset, the weight of political force will rest with us.”

“More importantly, putting patients and their care at the centre of pro-healthcare campaigning recognises healthcare exists wholly for, and because of, patients. Sometimes, public debates amplify some of the worst features of traditional hierarchies in clinical healthcare. Authority figures argue over who knows what’s better for patients, and best represents their interests.”

“All the while, patients pushed to the sidelines quietly await a chance to speak for themselves. If we’re serious about changing the culture of paternalism in healthcare, and empowering patients, that change in approach needs to permeate right through from the consulting room to the campaign platform. ”

What if we disagree?

There may be topics where patients and health providers don’t agree, such as certain aspects about the PCEHR. This can really paralyse a project. How should we approach this?

Morris: “It is important to remember that disagreement doesn’t only pose an obstacle in ‘patients and providers’ scenarios. Neither patients nor providers are homogeneous groups, and we do well to remember that. It is worth asking how providers approach the problem when they disagree on an issue or project, and source lessons from that.”

“It’s worthwhile looking for points of common ground, and building upon those

“The possibility that some parties may disagree is not, for example, a reason to exclude likely dissenting practitioners from a committee of doctors. In the same way, it is not a reason to exclude patients from healthcare policy discussions. Moreover, the fact that patients and providers may not always agree is not a reason to close our minds to collaborating when we do.”

“We should approach such disagreement on policy and projects the way we should in any sector. That is, give relevant stakeholders of all perspectives a fair opportunity to be heard. And, where possible, try not to speak for others in lieu of them speaking for themselves first.”

“It’s worthwhile looking for points of common ground, and building upon those. More often than we acknowledge, patients and doctors are really advocating for the same outcomes. But too often we don’t take the time to really analyse where the crux of disagreement actually lies.”

“So it’s worth trying to identify when disagreement is about what the end goal should be, and when it’s about how we should best get there. That helps to clarify how the points of difference, and points to potential solutions.”

“In cases where viewpoints really do differ substantially, all parties should have the opportunity to make a case for their proposal, then let the policy and law makers evaluate those on their merits.”

Is there a will to cooperate?

Morris: “Because I don’t work for or represent a consumer organisation, I can’t speak for them with any authority. However, I will say that in my experience, there is reflexive and entrenched suspicion on both sides.”

“If we find that the aims of doctors’ and patients’ organisations are so distinct as to be deemed incompatible, we should be re-evaluating those aims urgently

“Patient organisations are concerned about being seen to endorse a situation in which doctors’ organisations dominate and speak ‘on behalf of’ patients. Because such situations hark back to unhelpful, dictatorial hierarchies which have traditionally silenced the patient voice.”

“On the other hand, doctors’ organisations have expressed concern that patients do not understand the complexities of health policy and systems, the challenges faced by practitioners, and the broader potential consequences of proposals.”

“But in my experience, if and where these issues exist, it is in working together that parties learn from each about about how they can all do better. And the result is stronger organisations, and a more robust campaign.”

“It is healthy for organisations to remain vigilant about being faithful to their purpose and mandates. However, if we find that the aims of doctors and patient organisations are so distinct as to be deemed incompatible, we should be re-evaluating those aims urgently.”

“As a patient advocate, I would be delighted to have the opportunity to campaign alongside doctors and their organisations when appropriate. And indeed, on several issues I have done just that.”

“I have the privilege of working alongside many doctors in my role, who have taught me a great deal about the everyday realities of being a doctor. And I am a better advocate as a result. I hope that working with patients and advocate affords doctors similar insights.”