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THE Royal Australian College of General Practitioners has been active in the copayment debate, not least with its #CoPayNoWay campaign.
The Senate inquiry into out-of-pocket medical expenses put the Royal Australasian College of Surgeons (RACS) under the spotlight, particularly when the RACS suggested that GPs should advise patients of surgeons’ fees before referring. It’s fair to say GPs were not impressed.
Over the years there have been other examples of the learned colleges buying into discussions about doctors’ fees — the RACS and RACGP are not alone.
In medicine we enjoy status, privilege and good incomes. To protect and maintain these there are the checks and balances to avoid conflicts of interest, such as scripts being dispensed only by pharmacists, the referral systems, and the colleges providing education that is independent of government.
When we went to university we were never taught about doctors’ fees and how to bill patients. It was also understood that the learned colleges were bastions of standards and knowledge for each craft group. It was then up to individual doctors to decide on the best way to practise and earn.
Until recent times, deliberations about incomes and fees were always left to the associations such as the AMA.
I am quite sure the public and politicians regard specialist college qualifications as defining clinical skill and knowledge. However, in the profession change seems to be under way.
Do we need to ask what the current role of colleges should be?
In my discussions with grassroots and senior members of various colleges there is a mixed response.
Some support the push by colleges to be more active in the political sphere. These doctors feel that colleges should provide members with more services and value for money beyond the traditional role of education, training and standards. They argue that quality and cost are linked and cannot be separated, justifying the colleges’ role in discussions about fees.
One argument put forward by those who believe the colleges’ roles should be expanded is that the Health Practitioner Regulation National Law Act opens the door for government to bypass the colleges in specialist training, thus creating this need for colleges to expand their functions.
A more cynical view is that colleges that do the one-stop-shop of academia, politics and finance mean doctors only need to join a college, making associations redundant (of course, like death and taxes, we will never be able to avoid our registration fees). Let the AMA beware!
The opposite side argues that when money is factored into clinical education and credentialing, clinical judgement is clouded if not sidelined altogether. For example, in some RACGP exams questions are asked about how to write chronic disease management plans. Is this really a key to specialist education, or something you learn on the job?
Perhaps learning how to bill Medicare, charge patients, set up practice and manage a business should be left to the associations, or even other organisations. After all, these are also the domain of practice nurses, allied health practitioners, managers and secretaries.
“Give back to Caesar what is Caesar’s” usually applies to church–state relations, but I think it is also relevant to our colleges.
I prefer colleges to be apolitical and focused on the highest levels of knowledge and practice. They should leave the grubby stuff to others.
Dr Aniello Iannuzzi is a GP practising in Coonabarabran, NSW.
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Of course the Colleges (Cs) must reserve and retain the right to lobby. In fact, it is not in the Public Interest for the Cs to relinquish that fundamental right. Naive to do so. AMA is not omniscient and omnipotent. Simply put, AMA does not have the resources and exquisite knowledge of details to defend and offend in the Public Interest on a daily basis. The Cs provide—as their most important service—in theory, protection of the Public Interest. Our collective Oaths to Hippocrates dictate we must preserve the Public Interest above all others. It is the Cs sacrosanct societal duty to ensure the qualifications of Australia’s medical and surgical providers comply with International Gold Accreditation Standards. The Cs duty to monitor Australia’s medical and surgical providers is a non-delegatable duty. Patients can’t be allowed to assume the responsibility of judging providers’ capabilities. If one is “medically unqualified”, then by implication and inference one is surgically unqualified. How difficult is it for the AMA to persuade Parliamentarians that the medically unqualified are medically unqualified? Care to consider the “Oklahoma Land Rush” opportunists and Squatters’ Rights advocates that comprise the fiasco that is AHPRA? Where was the AMA in policing AHPRA’s “starting line”? Let alone “finishing line”? Where is the evidence that Australia adheres to any International Gold Accreditation Standards? All of Australia’s Colleges have a duty to actively engage and align themselves with the Aust Gov’s advocacy for the highest standards. AMA, by itself, does not possess the specific subject expertise to catch and pivot on a dime.
Everything on Earth is related to politics. If the learned Colleges are only concerned about standards and academia, they should not comment or have a say on matters such as the organisation of health services, the number of specialty doctors needed in the community, government policies on new initiatives such as Medicare locals or capitations or population based funding for services, number of hospital beds, number of medical students, liberation of medical services to be provided by non-medical persons, etc. There are so many things that can affect directly and indirectly medical services other than medical knowledge, its training and research, etc. Should the Colleges ignore them?
The other problem is because of the high fees or extra fees paying to belong to AMA, the percentage of doctors belonging to this organisation is likely to get less and less. However, belonging to a College is essential for making a living properly and legally. So, the Colleges practically have 100% representation or majority of their specialty doctors. I came from NZ and there the Government refused to talk to the NZMA because it said it did not represent the majority of the doctors concerned. It only only talked to the RNZCGP on matters affecting GPs. Think hard and look at all scenarios before making up your mind that Colleges should only attend to standards and academia.
With regard to the recent stance of the RACS on excessive fees (which Dr Ianuzzi seems to be referring to) Dr Iannuzzi is confused. The RACS has not and is not planning to come up with a recommendation regarding fees. As he states quite rightly this is the domain of organizations like the AMA.
He is quite correct that the principle role of the RACS is in standard setting. Standards need to be set across all 9 RACS competencies. One of these is Professionalism. The RACS believes that charging excessive (or exorbitant) fees in situations where there is little opportunity for a patient to obtain a second opinion is unprofessional behaviour. The RACS encourages GP’s to assist their patients in obtaining second opinions in this situation.
As Dr Ianuzzi states Colleges should be “focussed on the highest levels of knowledge and practice” – the latter of course includes Professional Behaviour.
Aniello, organising doctors politically is like herding cats and long may that continue. After the Cotton reforms the AMA is, for all its faults a reasonable umbrella for the whole medical profession in political matters. I agree with you that learned colleges should stick to education and professional standards. They are fairly secure in this role as the barriers to entry for other providers of education are significant given the bureaucratic strangle hold AHPRA and the AMC have on the medical education industry.
I agree with Dr Iannuzzi and the other physicians who have commented. The colleges should concentrate on being learned colleges, and be very careful about entering advocacy that crosses the boundary of comment that directly relates to the standards of professional practice into political debate. There are a number of reasons for this.
The political opinions expressed by colleges may reflect the views of the office bearers, rather than the views of the members and although the office bearers may consider that they are right, or even righteous in expressing those views, they should be mindful of their responsibilities to the primary goals of the college and the platforms of committment to professional excellence on which they secured their election.
The views of the college office bearers may not take the whole policy question into consideration. For example, the campaign against the co-payment assumes that universal welfare, ie the right to medical care at not cost to the consumer is better policy than targeted welfare, ie support for those who cannot afford proper care becuse of poverty or chronic illnees and that there is an unlimited fund to pay for universal welfare. In fact the cost of universal welfare is either covert rationing or a reductionin the quality of care, both of which are ocurring as a matter of fact.
It is difficult to win the political game. Professional people, such as doctors, do not win the political game agisnst politicians, who have massive resourcess, including the tax exempt status of the colleges.
Agree with both Dr Iannuzzi and “Physician”. The Colleges should confine their roles to education (including continuing education) and training – this should enable some trimming of their increasingly bloated bureaucracies which we are expected to support with increasingly bloated fees. Regrettably, I doubt that the RACP (or other Colleges) read MJA Insight.
I agree with “physician” the RACP has lost it’s way and seems to be running without the interests of it’s fellows.
The number of disenchanted fellows is large and the attendance at meetings of Fellows (independent of the College itself) to discuss this lack of direction and the observation that the College is being run by administrators
is a cause for serious concern in numerous areas.
It would be wrong to say that all political lobbying is about the money. The colleges have a mandate to maintain and defend standards of care, not just for individual patients, but also for the community as a whole. This can be extended to a variable extent by the interpretation of community health, to cover advocacy for such broad ares as smoking, alcohol fuelled violence, the obesity epidemic, road safety etc. While advocacy in these areas is properly also the business of the AMA, the colleges should be encouraged to participate and contribute, so long as we don’t work at cross purposes.
The government has an obligation to provide a cost effective model for the health care of the nation, and the extent to which this means financial assistance for patients to pay whatever fee the doctor may choose to charge is rightly their business. Obviously this does impact on provision of quality care, and that is the AMA’s business, because the colleges cannot be seen to be protecting doctors’ financial interests.
Dr Iannuzzi is correct. The RACP has also entered into politics, agitating about refugees and climate change. These are political positions that Fellows may or may not support, but we have no choice but to be Fellows and put up with the politics and the costs of policy staff. Joining the AMA is voluntary and we can be as active as we like, or resign and join other groups such as the doctors reform society or doctors for the environment if we wish. It is completely inappropriate for the Colleges to be actively involved in politics – the question is how can Fellows stop them? My correspondence to the RACP was simply ignored.