Con Costa

Dr Con Costa is a Sydney general practitioner and National Vice-President of the Doctors Reform Society.

(This article is based on a paper presented to the 2000 National Conference of the Doctors Reform Society in Melbourne, 21 October 2000.)

The elderly migrant lady was brought into my surgery by her daughter. She had previously had a stroke and there was a problem with her speech and memory. Recently she had developed high blood pressure, raised blood sugar levels and an irregular heart beat.

The consultation took a while. It invariably does with the sick and the elderly. A history and then a medical examination followed by prescriptions - one of which needed a phone call to Canberra to obtain an "Authority script".

You’re already up to 20 minutes. It’s hard to take short cuts and anyway, it’s dangerous to cut corners or give inadequate instructions. Even then the job is only half done. Patients need an explanation and reassurance and this takes time, especially when they are elderly, hard of hearing and anxious.

Many elderly or frail patients are on routine medications (such as arthritis tablets) which can cause life-threatening bleeding from the stomach if taken incorrectly. Or they may need an explanation of how to use respiratory inhalers for a breathing problem (which, if not used correctly, are ineffective or dangerous). Or they are taking several medications (which can be confusing and unsafe).

To decide on whether someone’s chest pain is indigestion or something more serious like heart attack; to assess someone’s depression and give them some motivation to continue with their life; to expose a drug addiction or alcoholic problem, all these take time and cannot be rushed.

Conversely, a patient who is not given adequate time by their GP can leave the consultation feeling more apprehensive, more depressed or just plain angry.

Today, GPs are under stress. They are finding it harder to provide the time patients need. Less time means medicine is not being practised safely or effectively.

The traditional solo or two doctor family practice is assailed on all sides; they have the problems of running a small business, complying with new regulations on accreditation standards, patient expectations for extended hours, the need to modernise and computerise, maintain sterilisation standards and refrigeration for vaccines - even change the light globes.

Restrictions on Provider Numbers for new doctors entering general practice has led to a shortage of GPs. And it is now almost impossible for the GP to find a relief doctor in order to take a holiday or if sick - harder in country areas but not much better in the city.

Most importantly, and on top of all this, GPs see their incomes going backwards under Medicare bulk billing. The Medicare rebate for a standard (non-vocationally registered) consultation has hardly changed in the last 10 years. Governments have not understood that health costs can be best controlled by efficient Primary Care.

As a result, today, General Practice is in turmoil.

Patient care is endangered because of a fee-for-service system with a low Medicare rebate. Doctors no longer seem to have the time to sit with the patient, to think, to be interested - and this is a very dangerous situation.

The elderly, those with psychological problems (arguably the majority) and the chronically ill are the main losers as they are not getting enough time with their GP.

Figures published in the MJA recently showed that 40% of GP’s are clinically depressed, 60% would change jobs tomorrow if they could and very few can manage an ethical commitment towards their patients.

Yet, our Federal Government has ignored criticism of its policies of under-funding of primary care and the public hospitals and the annual diversion of billions of dollars of taxpayer’s money to the private health insurance funds. They are distracting the public from the real problem by the unfair tactic of blaming "the greedy doctors". The real agenda, however, is to privatise the whole health system.

It is true that statistically, some GPs can maintain adequate incomes compared to many others in the community - but they are doing this at the expense of the quality of their service. Bulk billed patients are being "pushed through quicker and sicker" or bulk billing is dropped (as in the recent example of working class Swansea near Newcastle where the GPs suddenly stopped bulk-billing all their patients). Finally, demoralised GPs sell themselves to big business and the stockmarket via the Corporate owned Medical Centres. The Corporatisation of Medical Practice as it is called, is occurring rapidly and without much public debate and is by far the more worrying trend in the health system today.

The Corporate package offered to GPs is now well known - although GPs are bound by their contract not to reveal details to other doctors in the Centres or a third party. There is anything up to $200,000 - or more - as a sign-on fee if they commit to a 5 year contract. GPs are a very valuable commodity for these vertically integrated Centres through their ability to tap into Medicare funds via their referrals to pathology, X-ray and specialists.

GPs are also attracted by the prospect of regular holidays and being able to take time off if they need to (albeit without pay) as there are plenty of others to cover them in the Centre. They can elect not to do house calls and they have a virtually brand new fully equipped Polyclinic situation. The Centres, backed by unlimited investment capital, are even able to offer special deals to particular GPs e.g. childcare.

It is hardly surprising that most independent, bulk-billing GPs do not see it as a matter of "IF" but only of "WHEN" and the common topic of conversation at all the medical dinners is how to get the best deal from the Corporations.

And things are getting tougher for the "independent" GPs with the increasing pace of Corporatisation. There is an extreme shortage of casual GPs. This is partly due to Federal cost cutting measures which restrict new GPs as well as the aggressive buying up of doctors by the Corporations. Fewer and fewer casual GPs are able to offer short or long term relief for established doctors, or are willing to join a busy practice or to buy the goodwill of an established practice.

Areas where doctor shortages already existed - country and remote areas, the Aboriginal Medical Service etc. - now find it almost impossible to attract staff. And not just because of the massive reduction in the pool of casual GPs. Their doctors have also been directly targeted by the Corporations with offers of lucrative sign-on fees and the promise of an easier life in the city.

At a recent medical dinner one corporate entrepreneur boasted that 10% of the audience were employed in his Centres and that within a year the figure would be 20% and, combined with the other corporate players, 50% of all consultations in Sydney would be in Corporate Medical Centres!

We should expose the Corporate Centres lack of quality of care. They have a well-earned reputation for fast throughput - treating the quick and simple things and sending the patient back to their family GP for more complicated problems. Unfortunately, the differences are diminishing. Firstly many traditional family GPs are now signing up with the corporations and secondly, the malaise of general practice is leading to perfunctory care all round. And patients like the facilities and the extended hours that the Corporate Centres are able to offer.

Health Insurance Commission figures regarding the Corporate or Entrepreneurial Medical Centres show that GPs fast throughput on their commission basis (it is often around 50% of the rebate) show that they have to work quicker to maintain their income. Doctors who were seeing 6 patients per hour in their own practices try to lift their rate to 8 patients per hour. Doctor profiles thus show that they actually see more people in a discontinuous fashion than was formerly the case. This discontinuity is bad practice and there is a reported lack of documentation from one visit to the next. Doctors may insist on "looking at only one problem at a time" or examine only one system. This results in the "dumbing-down" of doctors to the point where they are not expected to take a blood pressure when prescribing the oral contraceptive pill. Scripts are given with the minimum number of tablets to encourage patients to return for further prescriptions. There is no incentive for prevention and for giving information to empower the patient. Patients are encouraged to leave quickly.

The elderly, the chronically ill, those with sick children or those from non-English- speaking-backgrounds and the psychosomatic majority cannot easily negotiate the Corporate Centre environment. These are the very people on whom primary care should focus.

But the threat posed by the corporations goes much further than the threat to quality care. When doctors becomes the employees of big business, their first loyalty must go to their employer. Doctors working in the medical Centres would be acutely aware of the economic performance of the Centre through regular "briefings" from the managers. Some (or their spouses) will own shares in the Corporation or may even have been given shares as part of their package. Patient care quickly takes a back seat to economic performance.

In a recent legal case in the USA a patient who sued a doctor and his HMO, lost her case when the court ruled that under a Managed Care Plan, the doctor’s duty to maximise profits legally outweighs his or her duty to the patient (MJA Vol 173, 20 Nov 2000 - see also p28 of this issue of New Doctor - ed.).

The Corporations are presently scrambling to gain market share - and that means signing up the doctors. Doctors therefore are getting a reasonable economic deal. The corporations know they can recoup their investment through 50% of the doctor’s rebate as well as the flow on from pathology, radiology and specialist or allied professional referrals, chemist etc. - through "vertical integration". This is why big business can still flourish in primary care when the independent bulk billing GP is "hitting the wall" economically because of the low rebate.

But the Corporations involved in health care are capitalised at fifty times their earnings and that is very high. How long will it be before pressure will come from the investors for more profits and less service? Cutbacks have already started in one of the Corporate Health Care groups which sacked half of its management staff.

Soon medical care will be comparable to banks. There will be less service being given but more profit demanded by the directors and the sharemarket investors.

The present Government is presiding over the corporate take-over of medical practice. The Labor Party has yet to articulate its health policy at the time of writing. We are seeing the beginnings of the full US scenario with health bound to get more expensive (investors will demand 20% to 30% profits) and the community getting less for their health dollar.

In the US this has resulted in the emergence of Managed Care, with rationing of health care and an army of bureaucrats telling patients and doctors what they could and could not have.

Australians are facing the loss not just of Medicare but of their whole health system. When health is taken over by big business there is loss of the doctor-patient relationship, patients losing their rights to good treatment, overtaken by the corporations right to profits. Doctors will lose the wide range of freedoms they have enjoyed in the practice of their craft since the time of Hippocrates.

What we are faced with is not just a defence of Medicare. It is a defence of our health system, and in Australia, as in the USA, it should be supported by all health professionals, community groups, trade unions, health organisations and political parties. Our advantage is that the people still remember a health system that puts patients first.

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