Issue 6 / 9 August 2010

“You don’t see geriatricians driving around in Porsches,” a member of that profession once said to me.

He had a point.

Findings from the largest ever survey of Australian doctors’ earnings, covered by InSight two weeks ago, put geriatricians near the bottom of the list.

The outright winners are diagnostic radiologists, followed by orthopaedic surgeons, while GPs, psychiatrists and paediatricians cluster towards the end of the list.

GPs’ average personal income is $178,000, while specialists across the board average $317,000.

Of course, there are lots of reasons why members of one specialty might earn more than those in another – length and complexity of training, supply and demand, and the level of copayments patients are prepared to pay, to name a few.

But the bedrock underlying our medical fees system is that unwieldy beast, Medicare, and the rebates it establishes for particular services as provided by particular groups of doctors.

This strange mish-mash of empirical evidence, politically motivated decisions and historical accident has more impact on the make-up of our medical workforce than any incentive program designed by government or a professional body.

You can’t blame a debt-burdened new medical graduate for thinking the specialist sports car might be a better bet than the general practice station wagon.

But you have to wonder about some of the rarely questioned assumptions that underlie the schedule.

Why, for example, does procedural work tend to be valued more highly than other services?

And do we really want to perpetuate a system that may be discouraging young doctors from going into fields such as general practice, geriatrics and paediatrics?

Genuine reform of the Medicare schedule would be a courageous endeavour. It’s hard to imagine any of the current crop of lacklustre politicians having the guts to do it.

There’d be winners and losers. And you could expect the losers to make a lot of noise about it.

Just look at the furious response of ophthalmologists when the government last year reduced the Medicare rebate for cataract surgery, claiming new technology had made the procedure simpler and quicker.

I’m not making any judgement about the rights or wrongs of that particular decision, but you can imagine the uproar if a government tried to fiddle with hundreds of item numbers across every specialty in the country.

Still, maybe it would be worth it.

Shouldn’t the publicly funded remuneration for medical services be just as evidence-based as the medicine it provides?

Jane McCredie is a Sydney-based science and medicine writer. She has worked for Melbourne’s The Age and contributed to publications including the BMJ, The Australian and the Sydney Morning Herald. She is also a former news and features editor with Australian Doctor magazine. Her book, The sex factory, on the science of sex and gender will be published by UNSW Press later this year.

7 thoughts on “Jane McCredie: Are Medicare rebates skewing the system?

  1. Peter Bradley says:

    (Dr)Michael Wooldridge was the Minister for Health of the previous Howard Govt, who moth-balled the Relative Values Study.

    A study which set out to correct the very anomalies this article raises, and which cost the taxpayer (via the Govt), and the AMA, millions – only to be wasted. It did not suit them politically to do the hard but right thing then, and see where that has got us.

    If only they had bitten the bullet then…. we might not need to be having this conversation? One would have to be mad to enter general practice in today’s climate, so maybe we should remind ourselves of this, before we decide in haste, only to maybe repent at leisure, if we allow our distaste for the present Ministers plans (for GP anyway, much as I dislike them myself), to overly colour our thinking – and our vote – in 2 weeks time.

  2. Bill Pring says:

    Jane is correct, and the direction of the problem is going to break Medicare in the end. The current Government may deal with this by redfining Medicare to be a National Health Service if it gets into office. Liberals do not seem to have policy on this, but Tony Abbott’s secondary safety net was helpful for disadvantaged people (which the current Government has been steadily and paradoxically been dismantling). We should not bash our procedural colleagues because they demand to be paid what they are worth. In fact, without their strength, we would be even worse off. There was an enquiry into fees called the RVS, but the pollies did not implement it. Current AMA fees roughly represent the current RVS value. I think it is harder for a doctor who sees their patient a number of times, to charge them too much if we know they are not well off. Because a proceduralist sees patients briefly usually, it is easier to set a fee, and the patient can decide whether to accept. For the patient too, it is hoped to be a one off expense, and they will often rise to the occassion. From Bill Pring

  3. Dr Gamani Goonetilleka says:

    I agree with many of the points raised by the writer. There are certain aspects which no political party/Government of the day appears to be aware of OR unwilling to admit knowledge of. This is the fact that far more specialists are now performing minor procedures under local anaesthetic in their rooms ably assisted by a nurse assistant in most cases. I believe the Medicare rebates for these procedures need to be far higher and in line with the AMA fee levels than the paltry amounts paid back to the patients.These procedures keep a very large number of patients away from waiting lists of Hospitals and need to be adequately supervised and encouraged.The fact that such procedures need to attract a far higher Medicare rebate is an essential part of good and effective health policy. The Libs proposed policy of increasing the rebates for GP’s who work longer hours or work after-hour sessions having had a reasonable break, is to be praised. This will benefit the Public far more than the ALP’s proposed GP Mega clinics which will ultimately do little if any to proportionately alleviate the needs of the Public at large nor will it reduce waiting lists in Hospitals. Medicare rebates seem to increase so slowly and by miniscule amounts.

  4. Anonymous says:

    Absolutely agree. Well written article. Also, perhaps a limit could be set on the number of procedures per year eg 100 knee arthroscopies per surgeon. This would make orthopaediac surgeons save those procedures for those that really need it rather on every body who walks through the door complaining of a sore knee.

  5. Ray Taylor says:

    The ground with Medicare rebates has shifted unevenly over the years. In the late 1970s and the 1980s, as a Psychiatrist, I was doing reasonably well, though not as well as procedural specialists were.

    I did own a couple of (second-hand) Porsches during that period. That had changed by the early 1990s, and in fact the last car I bought was a second-hand 1995 Audi sports in 2002. I still have it.

    By 2005 the changes had been profound and young doctors were aware. In Victoria, in 2005, there were only 25 applicants for 56 available Trainee Psychiatrist positions.

  6. Dr Mike. says:

    Laywers charge by the 7 or 12 min intervals. Why should there not be a similar charge made by doctors – And according to their training the amount would be different. EG specialists (all) $200/hr. GP’s/VR $150/hr. Registrars $100/hr. RMO $80/hr.

  7. Oliver Frank says:

    Jane McCredie said: “But you have to wonder about some of the rarely questioned assumptions that underlie the schedule.”
    Jane, GPs and others have been questioning these assumptions every day for many years. The Commonwealth ran and then ignored the findings of a huge inquiry into this, called the Relative Values Study:
    It would be good for you to ask and find out why the findings of the Relative Value Study have never been implemented.

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