Ruth Armstrong: Something of value

IN his regular piece for the Guardian last week, whimsical cartoonist “First Dog on the Moon” wrote a love letter to Medicare.

“For almost 40 years we have watched as everyone gets treatment whether or not they can pay for it; the desperate and needy (and the middle class as well). You are the Australia we claim to be in action.”

Although simplistic, the cartoon was read, enjoyed and shared by many in what turned out to be a tumultuous week for its celebrated subject.

Changes to Medicare effecting a reduction in the rebate for some General Practice consultations were due to be enacted in Australia today. All consultations of less than 10 minutes duration were to be billed as “brief” (level A) rather than having an option to be billed as “standard” (level B), which attracts a $20 higher rebate. Patients seemed likely to be liable for the difference.

But on Thursday, the federal minister for health, Sussan Ley, called a press conference to announce that the changes were now “off the table”. General Practice Medicare rebates as we know them are saved (for now)!

Australian GPs are not known for their political machinations. Most go about the challenging, engaging and exhausting business of patient care, leaving policy negotiation to the “experts”, and responding adaptively to funding and organisational changes.

But this time was different: following the announcement of the rebate changes late last year, rank and file GPs urged the RACGP and the AMA to protest, enthusiastically participating in an advertising campaign to warn patients of price increases and garnering 44 000 signatures on a petition. The fight was set to continue with plans for lobbying in the Senate and mass rallies. The proposed changes had touched a nerve.

Feeling undervalued is not a new thing for GPs, and the rebate change was undoubtedly another blow to both those who bill privately and those in bulk-billing practices. The ease and swiftness of the change also gave a sense of urgency for both doctors and patients to protest the relentless erosion of funding for primary care. The magnitude of the response certainly suggested that something widely valued was under threat.

A recent analysis by the Grattan institute shows that, in terms of income earned per minute in practice, short level B consultations are the best remunerated, attracting a rebate of up to $9/minute compared with $2/minute for a 20-minute level B consultation.

While GPs who have inappropriately exploited this should be readily identifiable by correlating billing data with the number of consultations; a more likely cause for the widespread outrage is that the flexibility of the level B consultation actually meets a need for GPs and their patients, making it something they value.

For doctors, the flow of General Practice is notoriously unpredictable. The broad brush of the level B rebate means that, in terms of both time and income management, shorter consultations — the well known patient who is seen briefly for a single problem, the extra child, or the acutely unwell person from out of town who is squeezed into a busy session — compensate for the more complex appointments, where 19 minutes feels like 30, paperwork mounts up, and anxiety about running late begins to build.

Seen from the patient’s perspective the same thing applies. Consultations of different lengths and complexity, responsive to need but with predictable fees, can enhance the rich tapestry of an effective therapeutic relationship.

The current General Practice funding arrangements are far from perfect but GPs across the diverse practice arrangements that exist in Australia have learned to make them work.

Susan Ley has vowed “to pause, to consult, and to listen” before developing the next round of policies for General Practice. In this, and in other areas of health policy, she would do well to follow the advice of Russell and Leeder in this issue of MJA InSight, by picking up the phone and talking to some of the many internationally renowned Australian health policy experts.

She should also spend time with practising doctors and ordinary Australians: the people who’ve realised recently just how much they love and value Medicare.
 

Dr Ruth Armstrong is the medical editor of MJA InSight. Find her on Twitter: @DrRuthInSight