Issue 43 / 14 November 2011

SHOULD more doctors be salaried? It seems to have become an age-old debate in the medical profession.

Recently, the MJA featured “opposing views” for and against salaried doctors.

Every time I read or hear this debate it is a procedural specialist pitted against a hospital staff specialist. Surely this is something bigger than operating theatre lists and teaching hospitals?

As a rural generalist, I see things from the outside (as a referring GP) and inside (as a hospital doctor). And as a training supervisor, it is a discussion I have with all prospective GP registrars, who have the choice of working under either formula.

I predict that employed GPs of the future are more likely to take up salaried positions as GP funding becomes less service based.

The job of apportioning blended payments from Medicare, universities and other bodies in general practice is becoming increasingly complicated. For instance, the Practice Incentives Program (PIP) is currently made up of 13 components which have to be divided up among all the doctors in a practice ― a herculean task.

For those not familiar with working in general practice, it goes something like this: “How much of the Pap smear PIP do I give Dr Felicity Jones? She did 17 of 43 smears in this quarter’s payment, but she only works 0.3 full-time equivalents”.

Now, multiply that by 13 incentives, and then by the number of doctors in the practice — and this is just the PIP! Some of these incentives may be worth only a few dollars, while others may be worth tens of thousands of dollars.

And how on earth does Dr Jones verify that she has been paid correctly?

With the advent of Medicare Locals, and all the fundholding, capping and blending that will go with it, GPs will become so bamboozled that salaried positions may be the only way to avoid financial paranoia, tax audits and breakdowns in employer‒employee relations.

So what will be the impact of this evolving new world on general practice if most GPs are on salaries?

In the MJA debate, fee-for-service doctors were depicted as merchants peddling their wares while salaried doctors were able to spend more time with their patients, rather than churning them through.

The problem with this argument is that GPs are not standing at their front door looking for patients to “churn”. I don’t know of any decent doctor — in any craft group — who doesn’t have a waiting room full of patients seeking care.

We work long hours, seeing patients because they need to be seen, not because we want to see as many as possible in one day.

You only have to look at what has happened as more specialist services convert to salaried positions. Appointments are harder to make, letters take longer to come back, “criteria for referrals” are invented, and referral letters are requested before an appointment is confirmed to “ensure” the specialist is “happy” to see the patient at all.

The only reason why the system doesn’t collapse is because GPs are in the community triaging, treating and reassuring while patients wait for the specialist.

In the meantime, waiting lists still blow out, patients and referring doctors get more frustrated and the “outcomes” that the occupants of the ivory towers demand get harder to achieve.

This debate is about more than just doctors’ incomes and the “quality” of a consult. It is just as much about access, workforce distribution, rationing of hospital services and discrimination.

So far, these inefficiencies and anomalies have only been a feature of the hospital specialties.

Thankfully, general practice has been spared, but for how much longer?

Dr Aniello Iannuzzi is a GP practising in Coonabarabran, NSW.

Posted 14 November 2011

3 thoughts on “Aniello Iannuzzi: Not sold on salaries

  1. Amanda McBride says:

    Thank you Aniello for well thought and observed comments as ever. It is wonderful to open the discussion. It should acknowledged that different payment systems and fee for service can co-exist in our society. Patients are different in their needs for health care and in their willingness and ability to pay for it. Coordination of care does not have to include only non-fee for service medicine and allied health. What we need is for governments to stop trying to start afresh and see what is in front of them – doctors and allied health all wanting to care for patients effectively and efficiently.

  2. Bill McCubbery says:

    An excellent presentation of the issues! As new, bureaucratically-generated “plans” are developed problems arise. The Procrustean view that, because some people have specific problems the solutions must be applied universally; and the “one size fits all” approach causes more troubles than it resolves. The generalised procedure becomes blunter in its effect the more widely it is applied. The specific solution is a “one-off” which makes for a better fit. Ultimately, fee-for-service works best because the patient (or guardian) is self-directing and makes the decisions. Those who are incapable of managing their affairs need guardians appointed by due process. Programs devised by bureaucrats are not adequate substitutes.

  3. Chris Mitchell says:

    Aniello makes some good points
    The job of apportioning blended payments is becoming an increasing challenge
    The new DVA Coordinated Care Program is another example – though this is a wonderful program and will make a difference to our veterans’ quality of life, trying to work out how to fairly compensate practice owners and practitioners will be a challenge
    The new initial Video consulting support is another one
    As Aniello says – a herculean task awaits us – as we work through these issues.

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