DOCTORS REFORM SOCIETY

 

Address to AMA Meeting Melbourne June 2003

Session: Valuing Your Worth and Fee For Service

 

The DRS formed in 1973 at Monash University, as a group of doctors uniting to support the ALP proposal of a universal health care system with an aim of providing access to quality care for everyone independent of means. This was partly a response to the very fierce resistance of the AMA to the proposal, a response designed to show that there was an alternative doctor viewpoint to that very fierce opposition. Our focus hasn’t changed, Universal health care. The focus is patients, not doctors. So I’m really the wrong person to ask about valuing the worth of doctors.

 

However I will make some brief points. Some doctors are happy to work for as little as $60,000. Some expect over half a million. What’s important is that that diversity of expectations will always exist because we are a diverse group of individuals, ranging from psychopaths to saints, from greedy entrepreneurs to doctors who will give the shirt off their backs. Most of us are somewhere in between.

 

But ultimately the market decides, and it’s a sellers’ market. Health is simply too important to our patients for them to easily say, `well, I won’t buy today’ It’s buy or die for serious illnesses. For less serious illnesses, the onus does come back to them a little. But because of the huge information inequality between us and our patients, they are still very much at a disadvantage when it comes to deciding whether they need to see a doctor or whether to take the doctors advice re investigations and treatment. Add to that the shortage of doctors. It’s even more a sellers market, constrained by many of us by what we think our patients can afford.

 

Which leads me to the far more important questions, how do I value my patients health, how do I value the health of all Australians? The answer for me and for the Doctors Reform Society is easy. It’s our first priority. It’s why our society exists. And to look after the health of all Australians we need to accept that there is this huge diversity amongst doctors’ valuation of themselves, we need to accept that it is a sellers market, and then support a health system which takes those factors into account.

 

So let’s look at the system. We want it to value the health of all Australians, so at the very least, such a system should aim to provide access to quality care for everyone. For individual doctors, its complicated enough looking at the system as it affects our own practice. But I believe we need to do more. We do need to consider that just because a change in the system will help our own practice, it doesn’t therefore mean it will help overall to achieve the aim of providing access to quality care for all Australians.

 

The system introduced to achieve that aim is Medicare. It is Public Health Insurance, funded by taxes and the Medicare levy, funded according to ability to pay.

 

The product of this insurance is supposedly, access to quality health care for everyone: that’s the universal nature of Medicare. Not free, as some detractors suggest, no more free than a policeman coming to your aid when you get mugged, no more free than the replacement car your insurance gives you when it is wiped out in an MVA.

 

Bulk billing was introduced as the hassle free way for doctors to be paid for their services, hassle free for the doctor, no bad debts, no accounts, and hassle free for the patient, just sign the form.

It was hassle free to encourage it to happen, and, when combined with the rebate being adequate, and enough doctors to induce competition, it was so attractive that the bulk billing rate for GPs rose from 50% in 1984 to 80% in 1996 when this Government came to power.

 

Charging any extra was a hassle. It was meant to be a hassle. Bills and bad debts for the GP, and chasing a refund from Medicare for the patient. It was a disincentive designed to encourage bulk billing for as many people as possible.

 

The Government is changing all that by starving the system. It has been quietly introducing a 3 tiered health system but the latest suggested changes are designed simply to set those tiers more firmly in place.

The top tier being those who can afford private health insurance and access to any health care they want, the bottom tier for pensioners and health care card holders who may be bulk billed but who will be even more obviously seen as the `non-paying patients’ and treated accordingly, and the huge middle tier of working Australians who need to look carefully each week and month to decide what they will spend their money on.

 

This middle tier will be faced by ever increasing copayments or hefty payments. The superficial short term attractiveness for patients of not having to go to the Medicare office, will turn to dismay as GPs decide the only way to improve their practice conditions in the absence of an adequate rebate is to introduce or increase these hefty payments.

 

Imagine the scenario: mum needs to see a GP. Hefty copayment $20. On $40,000 per year it’s affordable. But then there is the blood test (another $20), the X-ray (another $20), the prescription ($25), and $30 for the unsubsidised drugs. The two kids’ asthma flares. Another $40. Total this week  $155. Then the GP says to come back for the results and regular Pap smear. How much will that cost? Another $30. But this month’s budget is too stretched. Put it off till next month. And the next. And forget the Pap smear until it’s too late and major surgery is required. Some saving!

 

Next week, another asthma flare for one of the kids. Hope that this mild flare will settle as it will cost $20 to have it checked. And end up in Emergency at midnight. Preventable, but for the copayment.

 

Of course there is a so-called safety net. It comes in two forms

• Doctors'  charity

• Government policy.

The doctor decides to bulk bill certain patients, or reduce the copayment, and then cross subsidise with copayments from the rest.

 

And here we have to remember how diverse we doctors are in terms of our belief in charity, and our capacity to judge other people. Some of us would give the shirt off our back. Some are so tight fisted a bilateral amputee would be told `you’re lucky, you’ve still got arms, go and get a job’, and most of us are somewhere in between. We decide. Some of you are very happy with deciding who amongst your patients deserve your charity. Some, like me, are distinctly uncomfortable making that decision.

 

How do I really know who is struggling? Some of my patients are upfront and say they are struggling (and some of those will be lying). Some just give hints. But what of the ones who feel ashamed, embarrassed, just private, about their personal financial circumstances? What if I miss them? Will they be taking their tablets? Will they simply forget to have the test? Will they just not return until they feel desperate?

Or will they demean themselves in the interests of their health and reluctantly tell me about how they are struggling? Will having me and my office staff know that they require charity help them to have the confidence in themselves which we know helps them to better deal with illness and adverse circumstances.

 

So much for the very well intentioned and heartfelt charity. Then there is the second rate charity that we doctors bestow. The kind where people are treated differently if they receive charity. Thus the example of the patient with the broken arm who noted a patient who entered the surgery after him but was about to be seen before him. I quote the Medical Board of Victoria Bulletin’s report on the complaint, “the receptionist indicated that the other patient was private and it was the clinic’s policy to put these patients first as they paid cash”.  Another patient related his experience to me recently, of attending a clinic, and being told he could be seen at 10 am if he paid a fee, or wait in the queue if he wished to be bulk billed.

These stories are a reflection that some doctors believe patients who pay more have a right to better access to their services. It is inevitable that such an attitude will, in some cases, manifest not just as better access, but as better care for the so-called paying patient.

 

The second kind of so called `safety net’ is the Government one, where for example there is a limit to how much out of cost payments one has to make in a year. This assumes of course, that the most needy budget their health care costs over the year, and ignores the fact that many of them have trouble budgeting for a week.

 

So much for so called safety nets. They are full of holes and they sag.

 

So patients are faced with copayments. They may reduce so called frivolous visits amongst those with not much money (but probably not if you live in a mansion in Toorak) but they also reduce visits which save lives. The Commonwealth Fund surveyed sick non institutionalised Australians in 2002 and found that 16% had, in the last 2 years, failed to attend a doctor when sick because of costs, 16% had failed to have the treatment, test, or follow up recommended because of costs, 14% of below average earners, failed to fill out a prescription due to cost. Or, a much more local perspective from George Santoro, a Richmond GP and 8 years a Federal Councillor of the AMA, in an MJA article said `the system before Medibank encouraged underservicing, as many people presented late in their illness, hoping that nature would heal them so that they could avoid the fee.’

 

One hears that copayments may be necessary to make patients value their visit. So do I return the bottle of Glenfiddich I received last week and tell my patient `my service was free so you can’t value it that highly’. Wrong. What most patients value is the feeling that they are getting good service.

 

Copayments and a so-called `safety net’. That is what is being promoted by this Government not just in relation to GP services, but also for hospital services, and the PBS. And restricted access to quality care is already apparent, and increasing.

 

But for those of you who don’t buy the equity arguments, and for those who do but are concerned about the costs, consider the facts. We spend about 8.9% of our GDP on health care. The US, where the majority of care is private, spends 14.5%. They spend more than twice as much per person on health care. They die younger. And the commonest cause of personal bankruptcy in the US is failure to pay medical bills.

 

Our costs are not out of control. Costs in some parts of the system are increasing rapidly for example Government spending on private health care, or the cost of the PBS, but most are not. The surest way to blow costs out to US figures is to strengthen the sellers market. Promoting copayments does just that. Promoting private hospitals does just that.

 

In addition, a total reliance on fee for service promotes cost blowouts through overservicing. Consider the following. Figures on coronary artery angiography following an infarct at hospitals throughout Victoria show that private patients in private hospitals are twice as likely to have angiography as their public counterparts. Private patients in public hospitals are one and a half times as likely to have angiography. Some doctors overservice. The size of the problem is impossible to determine. The alternative to fee for service, salaried doctors, brings with it the dangers of underservicing and inefficiencies. The principle of some combination of the 2 does seem like a reasonable alternative to control costs and, where appropriate outcomes can be determined, patients may even benefit.

 

Can we afford universal quality health care? No problem, if we want to. The money is available. We can go the US way and take it out of the pockets of the sick through copayments and private health insurance, or we can spread the cost burden across the community and get the money from one of 3 tax sources, our current budget surplus, an increase in the Medicare levy, or the Public Health Insurance rebate. Funding from taxes is cheaper fairer, and more efficient.

 

It is possible to have a universal health care system providing quality health care to everyone, irrespective of means. Whatever the value such a system grants to doctors, it’s most important value is that which it gives not just to our own patients, but to all patients and to their health

 

Dr Tim Woodruff

President,

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