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‘When it comes to bulk-billing, the difference between GPs and non-GP specialists is stark,” says Tim Woodruff

The debate on specialist fees continues to rage.

Dr Tim Woodruff, a rheumatologist and president of the Doctors Reform Society, makes it personal saying many specialists have become blind to the concept of the common good.

“Why don’t more non-GP specialists bulk-bill? Because of a sense of entitlement and a dissociation from, or ignorance of, the lives of patients,” he writes. 

The need for some specialties like general practice and paediatrics to understand the patient and their families and their personal circumstances may explain why they tend to bulk-bill more.

Read his argument below.

The Federal Government has flagged that it may look to restrict Medicare rebates to specialists who charge patients large co-payments.

That’s fine, but it will almost certainly be painfully slow to implement, probably involving a constitutional challenge by one of the doctor groups in the High Court.

As we know, the wheels of the law grind slowly.

There are alternative solutions to what is a hugely important issue.

Some years ago, the Doctors Reform Society suggested dedicated funding for an increase in salaried specialists, both in public hospitals and in the community.

Health Minister Mark Butler could set up publicly funded bulk-billing non-GP specialist clinics, similar to the 137 urgent care clinics for general practice the government has established since 2023.

The non-GP specialists involved would be salaried just like they are in public hospitals.

Those who have completed their training would no doubt be very pleased to remain in the public sector in the short term as they look at private practice. And I suspect many would stay, as doctors often do when it comes to public hospitals.

Such a move could be seen as a return to a recognition of the concept of the common good.

This concept, which doesn’t get mentioned much in the current access debate, provides the rationale for creating public services and infrastructure along with the redistributive taxation system to pay for them.

It is under constant attack by those who either don’t believe in the common good or believe only in a limited form of it.

The health of people across society would seem to be a major part of the common good, given the deep miseries that illness, particularly untreated illness, can bring.

Access to high-quality, culturally appropriate healthcare has suffered as the neoliberal dream is pursued with an emphasis on private, profit-driven operators.

Medicare as an institution is here to stay in Australia, despite the best efforts of neoliberals to dismantle it.

But it continues to be denied the resources it needs, convincing many that the public hospital system is the safety net, with a massively publicly subsidised private system when possible for those with the means.

Medicare was set up, not as universal healthcare, but as universal public health insurance, run by the Health Insurance Commission (HIC).

To limit people’s awareness that, as taxpayers, they had health insurance, a cynical Joe Hockey eliminated the name HIC and just called everything Medicare.

Thus, for neoliberals, this created a mindset that if someone expected to have access to high-quality care, they needed to go with private health insurance, albeit heavily subsidised at taxpayers’ expense.

In this world, the common good has no value.

There is a major roadblock to promoting the common good. It is a sense of entitlement combined with a disconnect from those without power and privilege.

The word “entitlement” was frequently used in the healthcare context during the days of the Tony Abbott government and its co-pay disaster.

Ministers would often talk about how co-payments were preferential to bulk-billing because they deterred “entitled” patients from seeing the doctor too often.

Here, however, I am suggesting the presence of an entirely different form of entitlement, which affects those doctors who charge large — sometimes extraordinarily large — co-payments.

The majority of GPs bulk-bill the most needy. Most non-GP specialists charge co-payments for about 70% of their patients, many for all their patients.

While Medicare rebates have never kept pace with inflation, the difference between GPs and non-GP specialists is stark.

Patients who cannot afford these non-GP co-payments can go to a public hospital specialist clinic, of course, but specialists know that the wait times there can be years long.

Despite this, too many still choose income over patient access.

The question then is why don’t specialists bulk-bill more of their patients?

From my observations over 40 years as a specialist in a ‘marketplace’ of provider shortage, it would seem to be because of a combination of a sense of entitlement and a dissociation from, or ignorance of, the lives of patients.

Surgeons and procedural physicians might see a patient only three times before discharging them back to the care of their GP. Even those who see them repeatedly are seeing them for a particular issue.

GPs see them for everything and usually over a prolonged time scale. That exposure to patients and the reality of their lives is important.

It may explain why paediatricians and oncologists are the highest bulk-billing non-GP specialists. Both specialties require their doctors to have deep understanding and knowledge of the family.

For non-GP specialists, the work is itself a reward, intellectually stimulating, and you generally go home every night knowing you have helped individual patients.

It is privileged work. But many specialists can be unreflective about that privilege.

If you are born with a smart brain, into a stable family, comfortably or very well off, with every encouragement to use that smart brain, and surrounded by powerful role models, it is hardly surprising that you will work hard to become successful in whatever career you choose — such as medicine — and continue to work hard throughout your career.

Even those minority of elite doctors who were, say, brought up by one parent in a housing commission flat, like our prime minister, often struggle to recognise that their intelligence and character were present in infancy and early childhood, and that their conscious decision as a teenager to strive hard was born from unconscious personality characteristics.

While due credit for success is expected, it should not lead to that sense of entitlement, not just to the luxuries in life but also to privileged access to healthcare and education.

The reverse of this thinking is that people who do not strive and become successful do not deserve the same care as those who do.

For many who think this way, a safety net for the unsuccessful, rather than a system of equal care, is sufficient for ‘the others’.

Entitlement pervades the thinking of many of those in power, severely limiting the concept of the common good.

But it only requires a moment to see how brittle the justifications are. Unfortunately, such moments of clarity can be rare when enjoying the fruits of power and privilege.

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UK Health Minister Aneurin Bevan introduced the National Health Service (NHS) pointing out that “Illness is neither an indulgence for which people have to pay, nor an offence for which they should be penalised, but a misfortune the cost of which should be shared by the community.”

Advancing age brings with it infirmity and a much higher likelihood of ill health. People do not choose to become old and infirm.  

Whilst conservatives despise the sentiments expressed by Bevan, particularly the concept of sharing by the community, liberals do agree, but with very variable degrees of commitment. Read more