Aniello Iannuzzi: Copay for specialists

AS is typical at any gathering of doctors since the federal Budget, during lunch with a staff specialist friend we discussed the patient copayment.

He mentioned that is was a good thing to try to curb the Medicare cost blow-out in general practice. However, my friend became somewhat dyspeptic when I suggested that any copayment should also apply to specialist consultations.

Instead of offering him a proton-pump remedy, I thought an explanation of my reasoning might be more helpful.
    
Nobody appears to be contesting the premise that a GP copayment will see more patients attending emergency departments, but few have highlighted the potential shift towards specialist visits, particularly staff specialist clinics linked to public hospitals that almost invariably bulk bill.

For instance, a pregnant patient may choose to attend the hospital antenatal clinic over the GP shared-care model. The patient with diabetes may attend quarterly reviews by the endocrinologist instead of the GP.

If staff specialist clinics are exempted from the copayment it will also keep fuelling what is essentially a cost-shifting exercise by the states, as they generate income from their employees by billing Medicare for consultations, therefore shifting the costs to the federal government.

The copayment debates have also added to the debate of supposedly high out-of-pocket medical expenses. However, the GP Medicare rebate is paltry in comparison with the rebates for specialist consultations, and few other specialties have to suffer the red tape of accreditation and blended payments that GPs have to cop.

If the copayment is applied to GPs and not specialists, it will only accentuate this imbalance.

My lunchtime discussion with my specialist friend also touched on the main concerns within the health sector about the copayment — equity, practice viability for non-corporate medical practices, and a reluctance by nurses and doctors to be seen as “tax collectors”.

But labelling the copayment a tax is ludicrous. When we pay a real tax we don’t receive a specific service, nor do we get to select the provider. And the provider doesn’t have the option of charging or waiving it.

Some organisations now appear to be talking of not supporting the copayment in its current format but we are yet to see concrete suggestions to improve it.

In the $7 spirit, I think these seven modifications would improve the copayment:

1.    Spread the base to all Medicare items. Applying it to everything will make it easier to administer and may allow a drop from $7 and abolition of punitive measures for those who do not charge it.
2.    Exempt the Indigenous Access Program. I have written about this previously and we can afford to exempt our Indigenous patients for the sake of better outcomes.
3.    Overhaul the concession card system. We’ve all seen people with huge assets using concession cards — where a good accountant can be as important as being in genuine need. Only when this anomaly is overhauled could concession card holders be exempted from the copayment.
4.    Exempt residential aged care facility residents. Many of our colleagues are reluctant to visit aged care facilities for many reasons. Having to collect money in this setting will be an even greater turn-off, not to mention nearly impossible to administer.
5.    Exempt children 16 years and under — needs no explanation.
6.    Include all state government non-inpatient services. This will be the only way to prevent further gaming and cost-shifting between state and federal governments. State governments already selectively — and inconsistently — charge for various health services.
7.    Make the copayment either $5 or $10. It will be so much easier to administer with such a simple modification — just ask any bakery or coffee shop.
 

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