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AUSTRALIAN Medical Association fees are expensive, and many GPs and specialists charge higher than the recommended rate for their services.
Medicare rebates are relatively low until a patient meets the safety net thresholds. It is not viable for most clinicians to bulk bill everyone, and many reserve this for concession card holders. Bulk billing is on the decline as well (here and here).
In my experience, many of my colleagues, especially psychologists and psychiatrists, believe that people don’t value their services unless they pay for them.
I argue that this is patently wrong. While it’s possible some patients may feel paying for a service is contributing to the therapeutic relationship, public patients and bulk-billed patients can be extremely grateful for care they receive for free. Being bulk-billed saved my life, and it has saved others too.
I am a psychiatry registrar and support my family on a single income. Like many who began medicine in Australia as an international student, I have an unfathomable amount of debt related to being a student in a capital city and paying full fees.
Although the salary of a registrar in my state is nothing to scoff at, I often struggle financially. I have rescheduled medical appointments and investigations to be able to buy everyday essentials or pay other bills on more than a few occasions over the years.
In late 2021 and well into 2022, I experienced a severe major depressive episode and at one stage had a quite lethal suicide plan. I finally recognised this as depression and sought help from psychiatrists and psychotherapists.
It has taken many months to find a psychotherapist, but I got lucky to find my psychiatrist relatively soon. When my psychiatrist learned I was having financial difficulties, they bulk-billed me for several months until I was really getting back on my feet.
The act of bulk billing took an immense weight off my shoulders. I did not have to choose between bills piling up and getting treatment. This enabled me to focus on my recovery and to not be afraid to reach out because I might have another bill to pay. I don’t know where I would be without this gesture. My psychiatrist bulk billing me saved my life, and I can’t think of another medical service I’ve received that I have valued more.
Imagine finding out someone stopped seeing you because it cost too much, only to not have that cancer screening and subsequently not be diagnosed until it was too late. Imagine finding out a patient has died by suicide because they couldn’t pay for psychiatric care.
While some may say that these patients could have accessed public services, that’s not always the case.
Public services may not be able to provide ongoing treatment outside of emergencies and crises or could deem someone low risk compared with others who have imminent risks. This can especially be the case in regional settings, which often face under-resourcing and staff shortages while covering large catchment areas.
I urge my colleagues to consider their bulk-billing policies and to actively ask patients about their financial situation. We often don’t ask this outside of a psychosocial assessment, but patients may not spontaneously disclose their financial worries. It can be embarrassing, or they may view themselves as somehow failing.
I have been there, and bulk billing saved my life.
Dr Israel Berger is a Child and Adolescent Psychiatry Advanced Trainee at Goulburn Valley Health and is involved in medical and public health education at the University of Sydney and Monash University.
If this article has raised issues for you please reach out to any of the following resources:
DRS4DRS: 1300 374 377
- NSW and ACT … 02 9437 6552
- Victoria … 03 9280 8712
- Tasmania … 1800 991 997
- Queensland … 07 3833 4352
- WA … 08 9321 3098
- SA and NT … 08 8366 0250
Medical benevolence funds
- NSW … https://www.mbansw.org.au/
- Queensland … https://mbaq.org.au/
- Victoria … https://www.vmba.org.au/
- South Australia … http://doctorshealthsa.com.au/resources/medical-benevolent-association-of-sa
AMA Peer Support Line … 1300 853 338 or 1800 991 997
Hand-n-Hand Peer Support … www.handnhand.org.au
If you or someone you know is having suicidal thoughts, there are people here to help. Please seek out help from one of the below contacts:
- Lifeline | 13 11 14 — 24-hour Australian crisis counselling service
- Suicide Call Back Service | 1300 659 467 — 24-hour Australian counselling service
- beyondblue | 1300 22 4636 — 24-hour phone support and online chat service and links to resources and apps
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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Thank you for your brave and candid piece Israel, and never mind the nay-sayers! Your contribution is a valuable reminder that disadvantage (or conversely, advantage) doesn’t necessarily lie where we think it does. I completely agree that a patient’s individual financial situation should be considered in billing practices. There are many people who fall in the grey zone of experiencing financial stress but not qualifying for a concession card. The reality of their situation should never be a barrier to accessing timely health care. I wonder how this approach could be put into practice. I’ve seen signs in some specialist rooms encouraging patients to discuss their bill if they are experiencing financial hardship, which I think is a great start. Experiences such as yours give us all important food for thought.
Not billing one’s medical colleagues is a proud ethical tradition which goes back to Hippocrates.
We don’t bill each other, we don’t bill colleagues for the use of our intellectual property if we devise a treatment (you don’t need to send Barry Marshall a dollar every time you treat peptic ulcer disease), we don’t bill our trainees for our pearls of wisdom. We are ‘family’, as Hippocrates so clearly stated.
But as Evan Ackermann points out, the shortage of GPs is at least partly due to bulk billing. If doctors don’t make a decent living from work, then there will be no doctor available for any emergency – many rural areas are already facing a total lack of doctors.
The irony of Israel’s opinion is that he recognises the scarcity of “public services” (i.e. Government funded) but wants 100% government funded bulk billing. The people from the government (State or Federal) really aren’t here to help you, they’re trying to cut their budget.
“Bulk-billing saved my life” is emotive fallacy.
Another perspective is that it was the psychiatrist who saved the authors life. Bulk billing transferred the financial strain from the patient to the psychiatrist. Perhaps the psychiatrist could afford it, but its a limited strategy. Who alleviates the psychiatrist when they suffer financial strain? No-one.
“Bulk-billing saved my life” – is a type of thinking that ties ourselves in knots of guilt for financing our work. Ask everyone about their finances – they are all experiencing financial problems. Why is it expected that doctors should take personal responsibility for patients financial status?
In a universal health system the Government takes responsibility to patients to adequately (not completely) cover their health costs. They have been doing this by shifting costs to other entities and by using government pressure to reduce professionals income rather than financial assistance in rebates. Criticising doctors about bulk-billing is the wrong approach.
In GP , the pressures to “bulk-bill” have been raised too high, and the rebate reductions have gone too far. We are in a position where GP work is considered unattractive to new graduates, the workforce is not renewing itself. The media say doctors are rorting the system. All the result of bulk-billing being the norm.
Raising emotive arguments does not solve the problem. A dispassionate assessment of bulk-billing would accept that it is a control mechanism that has had both beneficial and harmful effects on health of individuals, health professionals and the health system. That there is a push against it is unsurprising.
I work in a RARE fully bulkbilling GP Practice of 8 GPs in a MMR 3 Rural area
I have experienced mixed billing in the past and I PREFER bulkbilling, if I am honest.
It means when I tell patients i need to see them again in 1 week or 1 month, they are more likely to come back – cost is not a consideration.
I am the only member of the AMA in the Practice too – all the others seem to think being a RACGP member is enough.
This I regret.
I have been a GP for 44 years and am not ‘BURNT OUT’ yet
So be it
A day when I see or learn something new, I celebrate!
Dr Israel Berger, I salute you. It must have been extraordinarily hard for you to write this article. Thank you for this deeply moving account of why in a first world country those with the deepest need for the most urgent care should not be denied access by a health finance system that is in conflict with the model of care. As a member of our profession please never feel alone. We do need to ensure that all members of our community in serious need, can access the care they need, when they need it, and not have their financial circumstances get in the way.
It is quite sad to me that some of my colleagues do not routinely bulk bill other medical doctors, even more so when they are in training. I thought this was the unwritten rule of being a doctor and I personally find it a mark of respect and kindness to bulk bill my colleagues. Obstetricians seem to be the worst offenders.