The building contractor chatted pleasantly while I checked his blood pressure, waist circumference, recent cholesterol levels, fasting glucose and urine protein. We discussed screening for bowel cancer with “the poo test” versus colonoscopy, with reference to his family history. We talked in detail about prostate cancer testing and I offered to provide written information as we were out of time. As I signed his script for the blood pressure medication he winked at me. “That was easy money for you, wasn’t it?” he said as he walked out.
Thirty-seven dollars and five cents is the value this government places on up to twenty minutes of my time. This figure, the amount a practice receives from Medicare for a standard consultation, has not changed in four years, and under the current arrangement, will not change for another three. I myself receive sixty five percent of that. But are the pennies well spent?
0830 Nineteen year old homeless girl slouches angrily in chair while I explain why she needs the daily medication that keeps her alive and out of hospital. After about nine minutes her body language changes. “Oh,” she says, “If someone had just told me that I would’ve taken it. Can I get a chlamydia check while I’m here?”
0846 Eleven minutes assessing a toddler with fever. Are you dying of meningococcal septicaemia, or do you have a cold? Repeat this consultation six times today.
0901 Stoic man, whose wife of forty years is in hospital again, vaguely says he wants a “check up.” That’s not like him. After ten minutes of probing chat, he mumbles something about a funny feeling in his shoulder, but it’s probably nothing. Ask the nurse to do an ECG. Thank God the nurse is here today.
0914 Talk for fifteen minutes to a young man who just lost his leg. Together make a list of the things he will think about when he can’t take his mind off the gun in his uncle’s garage.
(0932. Check Stoic Farmer’s ECG and send him in an ambulance to hospital. Three hours later he is flying to Sydney for heart surgery. Lives to fight many more days and continues to care for his wife at home.)
0940 Spend three minutes in silence with a woman with finger marks on her neck to see if today is the day she wants to talk. Nope. Talk about her migraine management plan instead. Maybe next week.
0953 Insert contraceptive implant into giggling, chaotic eighteen year-old, saving everyone three years worth of unplanned pregnancies.
1004 Attend to eighteen year old who has now fainted. Answer phone call from nursing home – three new urinary tract infections, someone is delirious and Bert’s family are here from Perth and would like to talk to me about that magnesium. Can I come by at lunch?
1010 Determine whether eighty nine year old is fit to drive, waving the lives of the public around in my hand.
1027 Explain to young man that, contrary to what Dad tells him, men as well as women can carry sexually transmitted infections, and that discharge should be tested and treated. Screen him for depression. He’s not depressed, yet, but he is injecting testosterone into his butt and has a secret abscess he’ll let me see.
1045 Explain to woman with nine years of abdominal pain unresponsive to dry needling, pyrrole supplementation, crystal healing and zinc replacement that her basic bloods show she probably has coeliac disease.
1056 Reassure first-time mum with post-natal depression that she is not evil. Organise support.
1115 Shout at ninety two year old that she has gained four kilograms of fluid, and her medications need jiggling or she will end up in hospital again. Receive beatific smile and cheek pat in return. Jiggle medications. Stop the four least useful of her fifteen medications. Arrange to review tomorrow for more jiggling.
1132 Repeat child with fever consultation.
1148 Repeat child with fever consultation. Notice child has stopped growing. Rebook to investigate.
1203 Advise local butcher that she should invest in Hepatitis A vaccine prior to Thailand trip, for all our sakes.
1212 Take phone call from lab – this blood count from yesterday’s man with the night sweats looks weird. It looks like cancer. Call haematologist. He’s busy.
1218 Repeat child with fever consultation.
1230 Notice suspicious looking lesion on bricklayer’s forearm while taking blood pressure. A notorious no show, I probably won’t see him for six months. Biopsy today.
1254 Lunch! Call the haematologist again. Call the patient with the weird blood to request he come in this afternoon. Do some quick reading to brush up on weird blood. Paperwork. Go to the nursing home.
General practice costs 7% of Medicare’s budget (1). Seven percent. The frontline of medical care, the majority of doctors and the whipping boy for most governments, is consistently under attack, and the latest genius conclusion, that we can build a tower to Mars with the money we will save by starving the frontline further, is madness.
Keep two patients per week out of intensive care, ten patients per week out of hospital, rather than skimming the top off the rebates so that GPs see eight patients per hour to make their practices viable, rather than five. But don’t tell me that general practice is not worth investment. Of course, in addition to the big stuff, I see my share of coughs, colds and medical certificates demanded by, ironically, mostly government employers. But I also start a dialogue, about malaria prevention on the trip to Africa, about those amphetamines, that sedentary job, this obesity. These are the things making a lot of us unwell, not a shortage of three-hundred-dollars-a-bottle lolly water from the natural therapist with the most Swedish furnishings in their Surry Hills space. We talk about the free stuff, the bang for your buck stuff that changes lives and saves money – fibre, exercise, alcohol reduction, community involvement instead of long work hours.
I invest time in saving Medicare money. I do this by listening to the actual problem, examining the patient and explaining why most often a blood test or CT scan isn’t going to change what we know or what we do. The more I get squeezed, the less time I will spend. A study in 2014 showed that doctors are more likely to prescribe antibiotics at the end of the day(2). Obviously. It’s much more draining to examine the patient, explain a viral versus bacterial infection and reassure the sullen face of the millennial accustomed to instant gratification that antibiotics are not the right treatment, than it is to just print a quick script for Amoxyl and get them out the door. It saves me money, time and energy to just shut up and order the test or prescribe the drug. That way Medicare or the Pharmaceutical Benefits Scheme (i.e. the taxpayer) pays, not me. But I spend the time because I believe 1) in universal health care remaining sustainable and 2) that I’ve invested eleven years and over a hundred thousand dollars in my own eyes and ears and mind, and utilising these tools before a multinational pharmaceutical and/or pathology company seems both wise and cost-effective. Also, I would like antibiotics to still work when my children have children, and my colleagues in Infectious Diseases tell me that at this rate, they won’t.
One of the most important ways that GPs save Medicare money is by keeping people out of that economic sinkhole, The Hospital. I spend eleven minutes each assessing at least three to four infants per day who don’t need a bed in the emergency department, and I send the quietly declining asthmatic that does. I jiggle cardiac medications to take the load off failing hearts. Last month I saw a socially isolated man who had decided to quit the cannabis that was destroying his life. I saw him every second day for a fortnight for four to seventeen minutes, encouraging him through withdrawal, using medication judiciously and making plans for how and why to stay off it. I can only imagine what an admission to the local Mental Health Unit for a drug induced psychosis costs, but it’s probably more than $185.25.
Here’s thirty seven dollars and five cents well spent – talking to people about end of life care. Then if the last illness comes on in a nursing home we know what the person’s wishes are – far and away most commonly to stay in the nursing home. That $37.05 will save Medicare $500 on an ambulance, a six hour spell on an emergency bed involving probably four nurses, two to three doctors, a cleaner, wards-person, clerk, three or four lab technicians, one radiographer to take an x-ray, a radiologist to interpret it, a catering assistant to bring a tray of food which will be thrown out, and buckets of equipment for drips, antibiotics, catheters, oxygen tubing, sheets (let’s not even get started on the environmental impact). If they make it out of emergency to the ward while the hospital tries to contact their interstate children, the price tag will skyrocket. With any luck you’ll snag an ICU stay at $1500 per day, before everyone agrees that this eighty nine year old woman with advanced dementia has been trying to die for months. If we’d talked about it, it would have cost a GP visit to the nursing home, a couple of vials of morphine, a subcutaneous needle, and the comforting presence of a familiar carer.
Rather than strangling the greedy GPs further, how about a campaign encouraging people to sit down with their GP and talk about what they want as their health begins to decline? If they want to be actively treated in hospital, let’s do it, no worries. But if they don’t (as the vast majority of ninety year olds don’t), let’s not send them kicking and screaming and then sedated, in a freezing ambulance, because no one knows their wishes or is confident enough in the inexorability of death to let it happen. That could save some money.
1430 Repeat child with fever consultation. Notice he is quiet, not the good quiet. Something’s not right. Send this one to hospital.
My paediatric friends tell me there’s pretty much nothing more depressing than seeing parents rocking up to emergency departments with kids with snotty noses or an eighteen month history of picky eating. This stuff just doesn’t need to be jamming up emergency, consuming huge amounts of resources, slowing down the care of the truly unwell. Lowly GP though I am, I can recognise a dangerously sick kid. Not the good quiet. Send them to the GPs and we will part them like wheat from chaff, at a fraction of the cost. It’s also a good way to keep the snotty kids away from the immunosuppressed kids with cancer.
The consumer has one of the most important roles in valuing and preserving Medicare. The other day someone asked me to order an x-ray for a sore foot. It would have taken me a minute to order it, but I took seven minutes to examine her, explain why it wouldn’t be helpful, describe the problem and explain that she needed supportive footwear.
“The x-ray’s free isn’t it?” she asked.
“Well, Medicare pays.”
“I may as well get it then, if I don’t have to pay.”
It never ceases to amaze me what people will not pay for. A woman recently asked me about the cervical cancer vaccine for her teenaged daughter. I explained the benefits and cost, and she looked at me in dismay when I explained that it would not be provided under Medicare. Despite having a family history of cervical cancer, seeing a close family member die of the disease, and having the opportunity to drastically reduce her daughter’s risk, the woman was visibly offended at the prospect of paying and told me she’d think about it when they returned from their trip to Europe.
In the end, the government doesn’t want to pay me and neither do the people. The government froze indexation on Medicare rebates three years ago (though they do kindly continue to index my HECS-HELP debt each year). So while rent, fees, insurance and the cost of living goes up, my income doesn’t. I also receive no superannuation, maternity, holiday or sick leave. Can we all stop looking surprised when we have to pay to see a GP? Each fortnight I look at my bank account and decide to start doing Botox injections so I can get a car made after 1995. Last week I told a chiropractor what I get paid and she gasped and laughed.
1410 Have a very unpleasant conversation with a man about weird blood.
So why do I bulk bill? Because I believe people should be able to see a doctor, regardless of income, and we are all better off if this is the case. I do it because I want to help catch the people wandering near the cracks, like the chaotic teenager and the octogenarian with seven chronic diseases. However, a purely bulk billing practice will inevitably also attract people who can pay, but don’t want to – those who will spend money on cigarettes, eyebrow waxes, alcohol, smashed avo, private school fees or gentrified suburban rent, but not on healthcare.
When someone in a Saba jacket complains to me that “the last crap doctor” didn’t explain anything, I inwardly reflect that it’s like whinging that eating McDonald’s gave you reflux. It’s one or the other – a gap payment, or eight patients an hour. I give good care, but I haven’t burnt out yet. Soon I’ll start either charging a gap, doing that Botox of an evening, become a “crap doctor.” If you want better care, either pay a gap, or write a letter to your member of parliament. Preferably both. You get what you pay for, because your government won’t.
1740 Prescribe some antibiotics for a viral infection.
If I had billed the building contractor the private fee of $70.00, $37.05 would be refunded directly into his bank account by Medicare. Of that $70.00, thirty-five per cent goes to the practice for rent, insurance, the receptionist and nurse, software, electricity and equipment. Of my $45.50 I would pay around 37% tax plus the Medicare levy (total $17.75), and 7% for my HECS-HELP debt ($3.19). So for eighteen minutes of my time I would take home $24.56. I bulk billed him, and therefore made $13.01 after tax. That dizzying sum has to cover sick leave, holiday and maternity leave, superannuation, and around $8,000 per year in registration fees, indemnity insurance and continuing professional development.
So no, it wasn’t easy money.
- Health Expenditure Australia 2013-14: analysis by sector. AIHW. http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129553773
- Linder JA, Doctor JN, Friedberg MW, et al., Time of day and the decision to prescribe antibiotics. JAMA Internal Medicine. Published online 6 October 2014. doi:10.1001/jamainternmed.2014.5225