John Dwyer. Medicare changes – why on earth would a young doctor want to be a GP?

Jan 15, 2015

In case you missed it, this is a repost of a blog that I posted on 12 December last year.  It is highly relevant to the continuing debate about copayments and general practice.  John Menadue.

The most distressing feature of the government’s determination to have us pay more for a visit to our GP is its the total lack of vision for the structural reforms we should be discussing to provide Australians with Primary Care services that meet contemporary needs, are equitable and more cost effective. Instead of focussing on new models of care that around the world have been shown to achieve better health outcomes than we enjoy in Australia, the  $5 reduction in the remuneration for a standard GP consultation will make matters worse. The logic associated with this latest initiative is seriously flawed. Placing the money saved into a research fund means that the proposed reduction will do nothing for the budgets bottom line, the imperative presented to us in the May budget.

The Government wants to send a “price signal” to Australians to remind us that no longer can we expect Medicare to be free. Australian taxpayers provide every cent of the 19 billion dollars we spend each year on Medicare. If you pay to join a tennis club but do not pay extra for having a game of tennis you don’t consider that game to have been free. There is in fact plenty of evidence that current additional expenses associated with Primary Care see many delay seeking help and unable to afford prescribed medicines. Our out of pocket expenses for health care top 29 billion dollars a year, on a per capita basis, second only to the United States.

Australians on average, make five visits per year to a GP.  That does not suggest that we are abusing our entitlement to Primary Care services such that we need to be discouraged from visiting our doctor. With health expenditure at 9.3% of GDP there is no health budget crisis and there is time to make structural reforms that would achieve better outcomes and continue to make our expenditure sustainable.

The truth is that many of us need to visit a GP more frequently if we are to avoid the pain and suffering associated with chronic disease, the problem that is eating up the majority of our health care dollars. Many rural Australians, whose health outcomes are disgracefully inferior to those of their city cousins, would willingly consult a GP more frequently if there were GPs to consult. If Rural Australians accessed Medicare funded services as frequently as urban Australians the cost to Medicare would be an additional two billion dollars.

The future availability of sufficient numbers of general partitioners is already problematic. Only 13% of young doctors express any interest in becoming a “GP”. Only one percent are contemplating a career as a rural GP. Primary Care training is rigorous and GPs are true specialists. How does all the rhetoric from Canberra about the pivotal role they play sit with the proposed $31 fee for a standard consultation? Given the training required and the responsibility associated with medical care this fee is frankly insulting. The discrepancy in the income potential for GPs when compared to that of other specialists is now huge. No wonder young doctors considering career options are increasingly ruling out Primary Care. The ability of GPs to consider “bulk billing” the majority of their patients is only possible if the total remuneration they receive is satisfactory. Bulk billing doctors will not be able to absorb the five-dollar cut in the Medicare rebate and are appalled by the added levels of bureaucracy and paper work that the new arrangements will entail.

Young doctors looking at the professional life of our GPs are uncomfortable with the current “fee for service” model which encourages “turnstile” medicine that is so professionally unfulfilling. Many GPs join corporate Primary Care providers preferring a salary. In New Zealand the government has facilitated 85% of the nation’s GPs moving away from “fee for service” payments. The same is true for 65% of US Primary Care physicians.  Throughout the OECD health systems recognising the perverse incentives associated with fee for service remuneration are exploring changes that increase a GP’s remuneration for keeping people well.

Were it not for the destructive division of health care responsibilities shouldered by State and Federal governments, Canberra would not be looking at Medicare as if were in isolated from the rest of the health care system. Hospital expenditure, at more than 50 billion dollars per year, dwarfs Medicare spending and is increasing more rapidly. There is now abundant international evidence that we should be spending more on Primary Care services to reduce the spiralling cost of hospital services and at the same time achieving better health outcomes for the community. Just this week the UK government has been presented with a review that concluded that an extra 72 million pounds spent on improving Primary Care in the community would save the system 1.9 billion pounds by 2020! The future of quality hospital care in our country is totally dependent on reducing demand for hospital services through better Primary Care.

A competent government would be looking at the way we can introduce the highly successful “Medical Home” model of Primary care where teams of health professionals populate a practice and are available to enrolled patients. The infrastructure is available to help people avoid illness, have potential problems recognised earlier, offer coordinated “in house” care for people with chronic problems and care for many in the community currently sent to hospital. But no, all we discuss is this five-dollar impoverished initiative. The Abbott government should abandon this latest plan and start a dialogue with health professionals and the community about needed structural reforms that would extract far more health from the available dollars.


Professor John Dwyer is Emeritus Professor of Medicine UNSW.

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