Health of the Nation: good and bad news according to Australia’s GPs 

Australia’s GPs believe that mental health is the number one emerging health concern, often related to co-existing chronic health conditions – but more is needed to keep Australians well.

This is one of the conclusions presented in the benchmark report General Practice: Health of the Nation 2017 which gives a unique overview of the general practice sector.

The report is based on various sources, including research commissioned by the Royal Australian College of General Practitioners (RACGP) and the MABEL (Medicine in Australia: Balancing Employment and Life) Survey.

Some of the key messages from the report:

  1. Mental health is today’s biggest health problem and will continue to be an issue in the future
  2. The GP is the most accessible health professional and should be utilised to keep Australia well
  3. Patient out-of-pocket expenses in general practice are increasing and present a barrier to patients accessing the required care

The bad news

GPs report that psychological issues such as depression, mood disorders and anxiety are the most common health issues they manage. Mental health was flagged by RACGP members as the health issue causing most concern for the future, followed by the often related problems of obesity and diabetes.

GPs believe that mental health and obesity are two key health policy issues the Federal Government should prioritise for action.

From the benchmark report: “This is a clear warning of both the current frequency and future potential impact of psychological ailments on individuals, the community and the broader health sector. It is also a stark reminder that the personal and financial health costs associated with obesity and diabetes are expected to escalate.”

However, the number one health policy issue flagged by GPs is the problem of the low patient Medicare rebates. GPs have indicated this requires immediate Federal Government action to make sure that access to high quality healthcare is maintained.

As the cost of providing high-quality health services and running general practices continues to rise, GPs are finding it more difficult to bulk bill patients. Between 2013-14 and 2016-17 the growth of the bilk billing rate has slowed down.

Patient out-of-pocket contributions continue to increase each year as Medicare rebates fall further behind the real cost of providing general practice services.

The good news

Most Australians can see their GP when they need to. Nearly all patients (99.3%) report that they are able to see a GP when they need to and most people are able to get an appointment for urgent medical care within four hours.

Australians access GPs more than any other part of the health system. They report that they visit their GP more than they receive prescriptions, have pathology or imaging tests, and see non-GP specialists.

Eighty-three per cent of patients report that they visit their GP multiple times a year, including 11% who report seeing their GP 12 times or more. The availability of GP services has further increased with extended opening hours.

GPs coordinate care within multidisciplinary teams and Australians report positive experiences with their GP.

More time with patients

The RACGP is arguing for Medicare changes that will incentivise doctors to spend more time with patients – by increasing the patient rebate for longer consultations.

RACGP President Dr Bastian Seidel said: “We believe when GPs are spending more time with their patients, that leads to less prescribing, less pathology, less referrals, enhanced continuity of care, and that would, of course, mean less hospital presentations as well.”

General practice accounts for less than 9% of total government recurrent expenditure. The RACGP, AMA and other groups believe this is inappropriate as more health benefits for Australians can be gained by investing in primary care.

 

Download the report here.

 

Blood tests at the chemist is like getting your car serviced at the lawn mower shop

Pharmacies are the right place to get your medicines and receive medication advice, but they are the wrong place to get a blood test.

AMCAL chemists are offering customers pathology tests at a cost of up to $220.

Ordering a test through a pharmacy chain rather than your local GP creates risks for patients including fragmentation of care, unnecessary duplication of tests, confusion about the interpretation of the results and increased out-of-pocket costs.

It may lead to incorrect, incomplete and unnecessary tests as well as wrong conclusions and false reassurance.

A pathology test should be recommended based on a medical assessment which may include your personal medical history, symptoms and a physical examination. Pharmacists do not have the diagnostic skills required to provide this kind of care safely.

AMCAL customers will be paying out-of pocket and are not eligible for a Medicare rebate. For example, a vitamin D blood test will cost $89.50, a ‘fatigue screening’ $149.50 and a ‘general health screening’ $219.50.

Our Australian Medicare system reimburses patients for a range of pathology tests after an appropriate assessment by a doctor.

The standard packages sold by AMCAL may not include the tests that are required for your unique circumstances or health problems.

We really need better integration of health services in Australia. We need pharmacies to work together with GP teams, not introduce more commercially driven duplication and fragmentation of services.

Ordering a pathology test through the chemist is like getting your car checked at the lawn mower shop. Nothing wrong with the lawn mower shop but it just isn’t the right place.

We told you so: Ignoring primary care is never a good idea

Last night’s undecided election results raise many questions – and doctors will say: we told you so.

Family doctors have made it very clear during the lead-up to the federal election that it’s crucial for governments to invest in primary care to keep Australians well and out of hospital.

But not only that, during the longest election campaign in Australia’s history, GPs around the country have had discussions with millions of patients about the future of their healthcare.

Looking at the outcome of the election night, it seems that voters have taken the message to the polling booths.

Wealth should not affect our health

The day after the federal election date was announced, the Royal Australian College of General Practitioners (RACGP) launched the You’ve been targeted campaign, warning people about the looming higher out-of-pocket costs, which have already become a reality.

The aim of the campaign was not to increase health corporate profits or fill doctors’ pockets, it wasn’t even a political campaign – it was all about the message that the Australian people must be able to visit their doctor when they need to.

Doctors called on a newly elected government to invest in quality and sustainable general practice to strengthen patient services.

“Our first and foremost responsibility is to our patients,” said RACGP President Dr Frank Jones, “and this is really the message from the College in the campaign, because this is about the fact that we cannot sustain quality general practice under the present Medicare freeze.”

Posters went up in GP surgeries, messages were printed at the bottom of prescriptions, TV ads were aired and there were 2340 syndicated media stories featuring the RACGP on national TV, print and radio, and in medical and consumer media outlets across all formats.

The Australian Medical Association (AMA) followed suit and threw its weight behind the issue, and shortly after many political parties made health a key focus during the election campaign. The policy shift by Labor to lift the Medicare freeze and fund chronic disease management by general practice teams was welcomed by many.

What should happen next?

Whatever the outcome of the election will be, the new government would do well to sit down with GP leaders and develop a long-term plan to strengthen primary care. The message is simple and supported by abundant evidence: strong primary care keeps people well and out of expensive hospitals. Investing in general practice patient care pays off!

Dr Frank Jones: “The RACGP is seeking progressive health reform and a genuine commitment to the future of our healthcare system from our political leaders and we are committed to discussing funding models for a sustainable and effective primary health care system.”

As GPs around the country are moving away from bulk billing, health minister Susan Ley has already indicated she is prepared to look at a medical home model. The proposed appointment of a National Rural Health Commissioner and commitment of the Coalition to pursue a National Rural Generalist Training Pathway is another positive sign.

However, the medical home is more than a hospital avoidance project. “In a patient-centred medical home, patients have a stable and ongoing relationship with a general practice that provides continuous and comprehensive care throughout all life stages,” said Dr Jones. “This model is the most cost-effective way to address the needs of patients, healthcare providers and funders.”

There are many versions of the medical home or healthcare home. The ‘gold standard’ version is outlined in the RACGP’s Vision for General Practice and a sustainable healthcare system.

Part of the future plan should be the continuation of high quality primary care research and the introduction of non-face-to-face patient services such as video consultations to improve access to family doctors and to transform Australian primary healthcare to the digital age.

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.

Why doctors will stop bulk billing

Patriotism is supporting your country all the time, and your government when it deserves it ~ Mark Twain.

Although federal health bureaucrats seem to think bulk billing rates will increase, about 30% of GPs say they will stop all bulk billing soon. In a previous post I explained why. As a result of government policy to freeze patient Medicare rebates, doctors are faced with three options. They can:

  1. take an estimated $50,000 pay-cut;
  2. see more patients more often;
  3. charge more.

Some will choose option 1, because they don’t want to or cannot charge their patients more, and are also unable to work more. The reality is however that most GPs will not be able to afford this option.

Others will go for option 2: they may, for example, see 7-8 patients per hour instead of 4-5. They may decide to work more days and longer hours. The question is of course: how safe is this?

Can doctors continue to offer good care when they are churning through high patient numbers? It will certainly feed the epidemic of burnout, depression and suicide among doctors and medical students.

What the Medicare rebate freeze is all about
Medicare is shaping up to be a major election topic. Still, the freeze on the patient Medicare rebate is a complex topic for many. It was a lot easier to understand when Medicare was called the Health Insurance Commission, but the principle is still the same: Medicare pays a contribution towards the doctor’s fee on behalf of the patient. Many GPs have accepted this contribution as a full payment, which is called bulk billing.
The ‘indexation freeze’ everybody is talking about means that this Medicare contribution will not be increased annually, in line with the increasing cost of living. The shortfall will have to be made up by patients which means that the out-of-pocket expenses will go up as doctors stop bulk billing. The freeze on the patient Medicare rebate was introduced by the Labour government in 2013, and will continue under a Coalition government until 2020 and possible longer. The rebate has not kept up with costs and inflation for a much longer period.

3-tier system

Then there is option 3: doctors will charge more, which will increase out-of-pocket costs for patients. As RACGP president Dr Frank Jones mentioned in this interview, we may see a 3-tier system in Australia soon:

“Dr Jones warned poorest patients would feel the impact of the freeze hardest, while there was a risk doctors would churn through appointments more quickly.

He predicted it would lead to a three-tier billing system: doctors would bulk bill their most disadvantaged patients, charge other health care cardholders a concessional rate, and private patients would be charged the Australian Medical Association’s recommended fee.”

In 2015 the RACGP surveyed GPs on how they planned to manage the patient rebate freeze. Of the 566 members who responded, the majority (57%) said they would have to increase out-of-pocket costs for patients.

GPs said they would have to do this either because the practice would stop bulk billing and begin charging a gap or co-payment (30%), or the practice would increase out-of-pocket costs for non-concessional cardholders (27%). Only 8% indicated that they would not increase out-of- pocket costs for their patients.

How fees will go up

It is to be expected that many practices will start cost-cutting: staff levels may be minimised and investments in new equipment, training & education, IT or buildings may become a lower priority. This is a risk for the quality of care.

Practices will determine a fair and equitable fee based on their increasing practice costs, professional time and services. The RACGP and AMA support GPs to set fees that accurately reflect the value of the services they offer, such as the recommended fees in the Australian Medical Association’s List of Medical Services and Fees.

Practices will review their patient demographics and billing profile and optimise the utilisation of MBS items. Pensioners and/or health care card holders may be charged an extra fee which will be much higher than the bulk billing incentive of $9.25.

Practices may decide that certain services will attract fees, for example dressings and other consumables, treating doctor’s reports, off-work/off-school certificates, phone/video consultations, data entry or certain surgical procedures.

Updating practice management software to streamline Medicare claims and EFTPOS payments may be required in some cases. Expect notices to go up in surgeries across the country to tell patients about the changes in billing policies. Unfortunately there will also be some practices that will have to close their doors.

How safe is the patient safety net?

In the ‘Blogging on Demand’ series you get to choose the topic. If you have a great idea you want the world to know about, feel free to contact me. Perth GP Dr Jacquie Garton-Smith proposes a change to the PBS safety net to protect vulnerable patients.

“One thing that my patients with chronic disease on lower incomes find difficult,” says Dr Garton-Smith, “is that they have to pay for all their medications until they hit the safety net. Even if people are only paying the lower rate for scripts, it adds up if they are on a number of medications. I have seen it affect compliance at the beginning of the year when they have to decide which medications they need most.”

The general patient safety net threshold is currently $1,453.90, and the concessional threshold $366. When someone or their family’s total co-payments reach this amount, they only have to pay the concessional co-payment amount of $6.10 until the end of the calendar year. Concessional card holders get standard PBS scripts for free after they reach the threshold.

The PBS co-payment and safety net amounts, effective from 1 January 2015:

General patient co-payment: $37.70

Concessional co-payment: $6.10

General safety net threshold: $1,453.90

Concessional safety net threshold: $366.00.

A safer solution

Garton-Smith: “Loading the costs into a few months of the year and then being free the rest of the year for concessional card holders is concerning. My patients tell me the safety net is supposed to help them but doesn’t – until it kicks in. For someone who has diabetes, hypertension, hypercholesterolaemia, arthritis, reflux, depression and sometimes osteoporosis, asthma or COPD, you can see the impact. This is not an unusual scenario.”

“It would be so much easier if the cost could be spread out over the year for people likely to hit the safety net. It would also prevent people attempting to stock-pile at the end of the year. I realise most people don’t get more than 5 scripts a month but those who need to are often managing serious health problems.”

Medication adherence 

Research has shown that when co-payments for medications increase, more people stop their treatment. This includes essential preventive medications, and as a result more visits to the doctor and hospital may be required.

Associate professor Michael Ortiz said in Australian Prescriber: “Some have argued that greater cost sharing does not undermine overall patient health because patients facing rising costs will reduce their consumption of perceived non-essential medications more than their consumption of essential drugs. However, ‘preventive’ drugs are different, because not all patients understand the long-term benefits of taking medicines for conditions such as hypertension and hypercholesterolaemia.”

“Some of my patients need to delay filling scripts they see as less essential

Garton-Smith: “A patient I have seen needs to buy more than ten medications every month at a cost of $85. Sometimes there are extra costs, for example if he needs antibiotics. On a single disability pension he gets $840.20 per fortnight, so approximately 5% of his income is spent on scripts until he reaches the safety net threshold, generally by May. Even though he gets a lot of prescriptions filled just before the end of December, he usually needs to delay filling scripts that he sees as less essential at the start of the year.”

Professor Michael Ortiz in Australian Prescriber: “The current approach to PBS savings is that the Government takes most of the cost savings, but increases co-payments and safety net thresholds each year in line with inflation. Increasing co-payments reduces medication adherence and ultimately may compromise the care of some patients.”

Thanks to Dr Jacquie Garton-Smith for the topic suggestion.

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: