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12 Sep 2018

BY AMA VICE PRESIDENT DR CHRIS ZAPPALA

This issue will not go away. 

The shrill voices of opposition and those zealously defending their own turf (by blaming doctors) will only get more stentorian and insistent. The health funds, all hatching plans for managed care, are desperately trying to preserve their $1.8 billion profit. The politicians want to claim victory in increasing bulk billing rates without having to pay as much as they should either. The Government must be delighted with the emerging public expectation that bulk billing is a fair price for medical care – it is lamentable that we have not been more effective at changing this view. Our medico-political strategy perhaps needs to change here… 

Dr Linda Swan, Chief Medical Officer for Medibank, recently made the point in The Australian that cost is not an indicator of quality (in health care). This is not true though, is it? While high fees might not always correlate with high quality (but absolutely can correlate), you can be fairly certain that low cost will always put quality in jeopardy. The saying ‘cheap and nasty’ has real meaning. If Government designs a budget, no frills, ‘free’ healthcare system it will necessarily produce a budget health outcome – as occurs in everything else in life. We have no problem generally accepting this truth and moreover, paying for quality when we perceive it elsewhere – the same should also apply for health care. 

The extension of this observation is that we should not be ashamed to value ourselves properly. We work long hours, get woken in the middle of the night to come into work, accept significant responsibility and continuing education (which is costly), and so on…   While in theory we can charge whatever we want – as can any other professional, business, sole proprietor etc – it does not mean we can obfuscate when it comes to explaining our fees. Patients should always have a choice not to proceed and an appropriate ability to ask questions.  Regretfully, this does not always occur and I do not think anyone really regards this as appropriate.

There are three points that need to be underlined in this discussion and that we must find a way to have Government and our patients clearly understand.

  1. If we keep wanting a bargain basement health service (i.e. bulk billing) we must expect quality cannot be achieved in all circumstances.
  2. Bulk billing and health insurance rebates are not designed with the true costs of medicine – rather, funders wish to pay the least they can to preserve profits or for Government to spend money on something else (it really would be refreshing if Government and the health funds cracked open the AMA fees list and took heed).
  3. You get what you pay (or don’t pay) for.

Having said all of this, there are some doctors’ fees that do seem excessive, i.e. many times above the AMA fees (which have kept pace with inflation over time and better represent fair value and the cost of practice). Quite clearly, we need to be honest with patients about the full costs of their care before it happens when they still have time to opt out and ask questions. The huge majority of the profession agree that booking/administrative fees are not appropriate. Even if we were wavering on this issue, we must realise that patients (plus Government and funders) are going to be increasingly derisive of this practice. Let’s please deal with all of this now in our own way rather than have to endure an imposed solution from one of the funders who remain conflicted by their desire to pay as little as possible.

There are four initial solutions that we, the profession, should consider implementing immediately.

  1. Administrative/booking fees must go. Bill honestly and up front.
  2. Obtain informed and signed financial consent from all patients (if you cannot give an exact price give a reasonable range and stick to it).
  3. Allow an appropriate ‘cooling off’ period for the patient to consider options and opt out if they desire.
  4. Let’s develop a definition of what is unequivocally ‘egregious’ billing and develop a credible strategy of how we deal with this.

Health funds and Government are going to define their own version of what is appropriate or not, so the profession should take the lead. We must preserve a system that rewards increased effort or superior skill, otherwise everyone just regresses to the mean where there is no incentive to do anything other than the bare minimum. We cannot strike this happy medium that preserves ‘fee for service’ medicine if the few outliers do not realise the harm they are doing to us all.


Published: 12 Sep 2018