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Speech to the ADGP Summit, Melbourne - Dr Kerryn Phelps, AMA President

"RVS - Climb Every MoUntain, Ford Every Stream"

Thank you for the opportunity to address the Summit today.

I am very pleased to see this effort at engaging grass roots organisations in the debate on the future of our specialty.

At a critical time for medicine in this country - especially for general practice - the AMA has been very active in its advocacy for a better deal for doctors - all doctors - and a better deal for our patients.

I found it curious to hear Nick Demediuk from the RACGP talk earlier about 'corporates delivering health outcomes for governments'. It sent a chill through my bones. When did doctors stop delivering health outcomes for patients?

And his comments on super payments presume that there is an employer-employee relationship.

With GPs under enormous pressure to continue to provide quality affordable health care and patients confronting bigger and bigger gaps, I could quite easily have turned up today with a one-line speech with a simple message.

That speech would have read, "Walk away from the MoU".

My message to you today is the same - "Walk away from the MoU" - but I will spend a bit more time explaining to you why I think it is the right thing to do - the right thing for GPs and the right thing for our patients.

I understand the Department has floated some figures on what would be available under the MoU for RVS restructuring if the MoU was extended.

I will comment on these figures later.

As you all know, the AMA spent almost seven years working with the Government to produce the RVS. It was a tough job, a job not free of controversy, and a job whose result - on the surface - is not exactly what everyone was after down to the last dollar, the last cent, the last dotted i, and the last crossed t.

Despite the quibbling around the edges, the body of work that is the RVS represents the best possible outcome - for the longer term - for GPs in Australia.

Sure, the modelling may need some tweaking here and there, but it does provide a foundation and a framework to reassess realistic fee levels for all specialties, including general practice, for decades to come.

Poll after poll - by the AMA, the RACGP, and the independent medical press - shows that GPs want the RVS and they want the profession united behind it.

You were asked this morning to ignore not only rhetoric but also ideology. That we must never do. Our ideology as doctors underpins everything we do.

GPs do not want more blended payments.

No fundholding.

GPs do not want fundholding.

GPs want proper remuneration for all their study, training, hard work and commitment to their patients.

But the bottom line is this: what we are really talking about are the patients' rebates. Increasing gaps will come out of household incomes.

We don't want our patients to be further out of pocket for their health care, but GPs will no longer continue to subsidise the shortfall in the Commonwealth Medicare Benefits Schedule, which simply serves to protect government from meeting its obligations to patients' rebates.

We want the Government to be genuine in its commitment to Medicare.

This commitment has to be seriously questioned when you look at the 'new' RVS modelling released by the Health Department last week.

What happened to the open and frank public discussion and debate about the original RVS outcomes?

Why has the Minister and his Department chosen to ignore the fruits of almost seven years scientific and forensic study of the Medicare Benefits Schedule of fees?

Why is the Department suddenly championing some back of the envelope calculations prepared overnight to cover the Minister's obviously fading Medicare commitment?

The AMA believes the Minister's token gesture at 'implementing' the Relative Value Study in the Budget was tantamount to running up the white flag on Medicare and the long-term stability of the health system.

By failing to adequately respond to the RVS, the Minister has ensured he will be remembered for three things:

Record low morale and greater insecurity for GPs

Bigger gap payments for patients, and

A rapid acceleration in the decline of bulk billing.

    Strong advocacy on behalf of GPs and their patients has been needed and that is what the AMA is all about.

    The AMA has led the charge for a better deal for general practice.

    Sadly the other GP groups have not been as enthusiastic, choosing instead to follow other, less appealing and less rewarding paths - much to the disappointment of their members.

    Yes, the ADGP has been guilty in this regard. Now is the time for the ADGP to heed the call of the members and join the AMA on the RVS path which has a positive outcome at the end. The MoU is a dead end.

    The RACGP, too, went weak at the knees over the RVS. Now we hear that the College is planning a move to Canberra to step up its lobbying capacity - despite the fact that they have only about 8 per cent support from GPs for any sort of industrial role.

    I have to say that successful GP advocacy requires financial independence from government, leadership that heeds its members, a strong secretariat and a strong policy base - not just a change of address.

    In a positive move, the RDAA - previously distracted by issues close to the hearts of its rural constituency - can see the benefits of RVS implementation and is now making noises of discontent about the MoU. RDAA members will be applauding this shift.

    The Minister delivered a poor Budget for GPs because the GP groups were splintered.

    Three hundred million dollars ($300 million) over four years represents about 70 cents additional on the standard consultation.

    It has already been swallowed up in increased costs from the GST and accreditation and with the promise of a whole lot more red tape and bureaucracy to come.

    Let's not be in any doubt, this Minister is trying to control and break the spirit of General Practice.

    What he is clearly saying is GPs are not worth more and if they want more, they will have to dance to the Minister's tune. He can whistle Dixie as far as the AMA is concerned.

    According to AMA modelling, a 15 minute GP consultation should be worth $45.21 as at November 2000.

    This is based on a two doctor General Practice where the practice is open 1960 hours per year and the GP works 1840 hours per year in direct patient care.

    In other words, it is based on quality and safety.

    It is based on a reasonably modest and realistic professional remuneration to the GP of $134,374.

    It is also based on a 75:25 face-to-face/non face-to-face ratio.

    In other words, a 15 minute face-to-face consult will involve 20 minutes of total doctor time so you can do three per hour. Safety and quality.

    According to the Department analysis, what is a 15 minute GP consultation worth? It is worth $29.30 as at December 1999. What is a 10 minute consultation worth? It is worth $18.50 as at December 1999.

    You don't have to be an economist to work out that a GP could attain a higher hourly rate under the Level B structure operating as at December 1999.

    The Level B at December 1999 was $25.85 and the Department's RVS 15 minute consult is $29.30 and you can do three per hour.

    You only have to do 4 Level Bs to be ahead per hour.

    In fact, a GP doing 15 minute consults at $29.30 with the Department's practice cost figure will have net hourly remuneration of $29.98.

    If you bulk bill, your net remuneration will be $16.78 per hour.

    If you do 10 minute consultations, the figures are $25.33 and $12.95 per hour respectively. This is what the Government thinks you are worth.

    The independent consultants doing the remuneration rates study said you were worth $70 per hour in net professional remuneration. I think you are worth more.

    The Government said the AMA results were too generous to other Specialists. So what did good Government do? It widened the gap.

    At the 15 minute consult level, AMA modelling had Specialists 33% ahead of GPs and Consultants 36% ahead of GPs ($45.21, $60.11 and $61.46 respectively).

    The Department has Specialists 48% ahead and CPs 42% ahead ($29.30, $43.30 and $41.55 respectively). We can find no basis in RVS methodology for this outcome. It is not in the practice costs and it is not in the intensity factors.

    This is, after all, a comparison of consultation with consultation, not consultation with procedure.

    GPs cooperated with the RVS process in the reasonable expectation that their relatively poor remuneration would be redressed. If the Department's modelling can be taken at face value, then we must assume that the Government does not understand, and does not value the contribution that GPs make to health care in Australia.

    Amazingly, at 7 of the 11 points in their new structure, the Department has the Specialists ahead of the Consultant Physicians in what is one of the most counter intuitive aspects of their report.

    They have just got it wrong and seriously so.

    Their methodology involves GPs working between 58 and 109 hrs per week in order to earn the so called fair income figure the Department has plucked from the air.

    A GP doing all 10 minute consults who bulk bills will have to work 109 hours per week to make a net $112,000 on these rates. That is well over 5000 hours per annum. Safe? No. Quality? No thanks.

    The annual hours implied in the modelling for the other specialties is all over the place. Dermatologists and Cardiologists need to work 3000 hours per annum under their profile. Renal Physicians need to work 3500 hours.

    The Government has said it wants to reduce medical gaps. In fact, a greater level of Schedule Fee compliance was a specific term of reference for the RVS. But if the Government's schedule is anything like the Department's modelling, gaps can only go one way and that is up.

    This will not be the fault of doctors; it will be because the Government has not demonstrated a commitment to Medicare. It wants to get the credit for it but not put in the money.

    The Department is clearly saying to GPs you're not worth what the other professions are paid. Lawyers in salaried employment are paid more than the Department's modelling has allowed. Accountants in salaried practice are paid more than the Government has allowed.

    The Department is also saying you're not worth what salaried doctors in public hospitals are paid. Salaried doctors doing work most similar to General Practice were on salaries of $150,000 to $160,000.

    The Department has rejected this evidence and chosen $112,000 as the annual professional fee for service remuneration for General Practice.

    But even this is a con. Before you can earn this figure, you have to work massively long hours.

    If you are a GP doing 15 minute consults billing at the Department's proposed fee, you have to work

    58 hours per week in clinical activity to net $112,000.

    If you bulk bill, this rises to 91 hours per week to earn $112,000. If you do 10 minute consults at the Department's rate and bulk bill, you have to work 109 hours per week.

    This does not leave a lot of time for CME, running the business, keeping up to date etc, let alone a private life.

    The modelling is not based on safe, quality practice.

    A proper resource based study must have regard to community norms.

    One of those norms is weekly hours consistent with safe high quality General Practice. The Department has totally ignored this aspect.

    To earn even the Department's bargain basement figure, you have to work their profile of clinical activity that involves nearly 7,300 services and annual hours that move us in the wrong direction in terms of community norms, safety or quality.

    For one of the more counter intuitive outcomes, let's look at obstetrics. If a complicated delivery item remains in the Schedule, the fee for item 16519, normal delivery, comes down to $388.20.

    The average cost of indemnity premiums per delivery is now around $600.

    So in the context of rampantly rising medical defence premiums, large patient co-payments and across the board acknowledgment that the current fee is seriously inadequate, the Department's intention is to drop the schedule fee to $388.20.

    Overall, procedures of all sorts are said to come down by 8%.

    But, according to our calculations, procedures will come down by 14%.

    One wonders whether such serious errors constitute misleading the Senate given that the report was tabled before the Senate Estimates Committee.

    I understand there is a Government session this afternoon. The Minister will be here and senior Departmental representatives. You need to ask them some hard questions.

    For example, can a GP earn higher hourly rates now under the current structure than is available under the Department's proposed RVS structure? If the answer is No, they are not being truthful.

    What is the hourly net professional remuneration rate for a GP doing all 15 minute consultations who bulk bills. If the answer is not $16.78, it is not true.

    What is the hourly net professional remuneration rate for a GP doing all 10 minute consultations who bulk bills. If the answer is not $12.95, it is not truthful.

    Finally, you should ask the Minister if he completely repudiates the Department's modelling. If he won't, we are all in trouble.

    The MoU Group is a symbol of disunity.

    I understand the Department on behalf of the Minister has floated some figures of what might be available for RVS implementation or restructure if the GP groups can be lured into extending the MoU.

    I remind you that this document appears just three weeks after the 2001-02 Federal Budget.

    You need to ask the Minister if this document has Government or Cabinet approval. If not, will there be another backflip?

    It identifies $80 million as available for "restructure" in 2001-02, $198 million in 2002-03, $291 million in 2003-04 and $387 million in 2004-05.

    It does this firstly by only allowing for an unrealistically low 0.5% growth in the base level of MoU funding for volume growth. Secondly, it also allocates what has already been announced in the budget as available plus what it describes as full indexation (in reality, only about 1.6% per annum) as being available for restructure.

    As you know, full indexation (or more accurately) very partial indexation, is required to meet rising medical practice costs. It is not available money at all. It is not available for restructure. The additional funds allocated "if the MoU is extended" totalling $201 million over 4 years is really just money reallocated from the base grant by adopting unrealistically low volume growth estimates.

    If volume is up by more than 0.5%, you will not see any extra money for restructure. The document is a massive pea and thimble trick to try to get you to extend the MoU. It is not a basis for a genuine partnership.

    When it comes to industrial and financial negotiations, it is crucial that GPs are represented by organisations totally independent of Government funding.

    We have seen too many Government funded organisations threatened with de-funding if they don't toe-the-line. This creates sycophancy and poor results.

    The ADGP has an important role in assisting local Divisions to support and enhance GP services - but the ADGP should allow the AMA to provide the national advocacy on industrial and medico-political issues.

    In doing so, the AMA would welcome a partnership with the RDAA.

    Of course, the RACGP's core business is to deliver quality education and training and to develop and promulgate evidence-based clinical standards.

    When we start talking and working like this, we will all be better off.

    We should start by rejecting the MoU and further additions to the blended payment scheme.

    The Government has seized the opportunity, through the MoU Group, to attempt to control the income and professional life of GPs and to claim consultation and the support of the profession. The recent Budget, with its hotch-potch of incentives, is a perfect example.

    The Budget purports to improve the "level" and "effectiveness" of GP care but it has only added complexity to the MBS system and failed to take into account extra costs incurred.

    GPs will have to jump through hoops to receive payment for providing asthma care, diabetes care, cervical cancer screening and mental health care - when that is part of our core business.

    We do not need politicians and bureaucrats to tell us how to practice medicine. Whatever happened to professional independence?

    We know that only one-third of GPs think that the PIP has improved the quality of patient care.

    These incentives must be re-formulated into an appropriate fee-for-service - the RVS fee.

    But bear this in mind. GPs in private practice are not employees of government. The MoU should never have been about remuneration for GPs. Rather, it should have been about rebates for patients.

    As a profession, we must guard our independence, not sign up for more red tape and Government control.

    The RVS process is essential because the current role of the GP is becoming unsustainable without the sort of increase in the fee-rebate equation recommended in the RVS.

    Because of the RVS, GPs around Australia now know what they are worth and what they should be earning.

    The solution does not require complicated GP incentive programs.

    But it does need your total and unified support for the RVS outcome - the real RVS outcome, not the version the Department has concocted.

    A strong united GP voice will be listened to by Government and respected by patients for doing all that is possible to revive Medicare.

    When you listen to the Minister's address this evening, think of this:

    Despite the MoU - or more likely because of it - GP morale is at an all-time low

    GPs are subsidising Medicare, and

    The MoU is a distraction that enables the Government to shift blame to the MoU signatories.

    I urge you all to consider this in your deliberations this afternoon on the RVS outcomes.

    There is unlikely to be another opportunity like this in our professional lifetimes. I urge you all - the grassroots GPs of Australia - to send your leaders a message: support unity for general practice by walking away from the MoU.

    Thank you.

    _______________________________________________________________________________________________

    CONTACT: John Flannery (02) 6270 5477 / (0419) 494 761

    Sarah Bucknell (02) 6270 5472 / (0419) 440 076

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