Doorstop Dr Mukesh Haikerwal, AMA Vice President - Paying to jump the doctor queue

Haikerwal:  Regarding the community sustaining a medical practice.  What we are seeing is one way somebody has thought of trying to maintain some degree of bulk billing in the community for some of his patients.  What we now know is that Medicare bulk billing is around 70% or less across the country and more people are charging fees and gaps, and there is less access to no fee, in other words no bulk billing.  The Government's own study has shown that the fee for doing a 15 minute consult should be around $50.00, so the listed fees that they use for Medicare benefits schedule is completely out of date.  If somebody is bulk billed on that Medicare listed fees, you are getting a 50% discount.  Now if your giving a 50% discount on every consult that you are doing, that is not sustainable long term and that is why we are seeing the situation now of avoiding bulk billing rates and different ways of trying to at least have some access to some bulk billing for some patients.

Question:  Doctor, first in relation to the case in this mornings press how do you feel about that, what is your response to seeing a case of that type.

Haikerwal:  My response is that people are free to do what they like, I don't think it hangs well, for the practice because people will start resenting the way in which they are being treated.  As far as I'm concerned it is important that people are treated fairly, that there is equal access to consultations and that people actually can see a doctor and have to wait more because they happen to be charged a different rate.  So, in a nutshell what I am saying is that when somebody has been admitted or taken into the practice, into the waiting room, it should basically be on a needs basis thereafter, not a can pay basis.

Question:  These are first and second class citizens according to the size of their wallet.

Haikerwal: The concern here is that we have a two tier in fact a three tier in this particular case, Medicare system, and AMA is constantly concerned about the two tier system that is being developed.  We think our system has truly been fantastic, because we have a balance between private and public and we had Medicare system which give a good subsidy rebate for us, the patients when we go see the doctor, so that we are not charged much out of pocket or anything out of pocket.  Because of the way the Medicare list has not kept up to pace with costs, there has been a big gap and this gap has increased, we would like to see a system where the gap is address and kept to a minimum.

Question:  Do you believe this case is a rarity?  You suggested it is just one response out there in the Community, do you believe there other surgeries doing similar things and if so how many.

Haikerwal:  I couldn't give you a figure but I know there are other people trying different methods, for instances some previously bulk billing clinics will charge for weekends, other bulk billing clinics will charge after a certain time in the evening, so there are variety of different charging mechanisms that are out there, and it basically shows the facts that there is a limit to the amount of access that people have to bulk billing and that is because the schedule of fees that the government uses and the rebates that are being given to us as patients aren't getting up to date.

Question:  Do you believe other surgeries are discriminating between bulk billing and full paying patients.

Haikerwal:  My hope is that once people have come in through the door and are accepted as patients they are all treated the same and that there is no difference in the quality or standard of care that they are receiving and that to us as an organisation, and that to us as a group of doctors is paramount.

Question:  Who is to blame for this, who is the blame for the fact that this system has occurred?  The Surgery? The Federal Government?

Haikerwal:  I think the combination of facts is plain on this, I think that the Federal Government both Labor and Coalition, over the last 10 years have allowed Medicare to decline.  It is now in a diabolical state and we are see less than 70% of people currently getting access to bulk billing.  Bulk billing on its own is not the measure, the measure is access to care and what we are seeing is some surgeries shutting down in certain parts of town and that is partly because of the rate of rebate that we get as patients, it is also partly because of lack of supply of doctors anyway.

Question:   One would think that the AMA has enough influence with its members to stay to this particular member, you shouldn't do this, don't do this.

Haikerwal:  The AMA can advise members on what is and isn't legal things to do and can advise members of what is and isn't ethical, it is then obviously up to the member to make up their own mind which way to go.  I believe that they have to be careful because we have ethical obligations, not only under the AMA code, which is voluntary, we are a voluntary organisation, but under the Medical Practitioners Board, they can mandate it.

Question:  Ethically, with the ethical argument you must have some sympathy for this doctor, you have just outlined out tough it is for doctors, she is just trying to survive.

Haikerwal:  Absolutely, I can not say that things are not tough out there and it is very important that we make sure that people understand, that when you are bulk billing you are actually getting a 50% discount, and that is one of the first things we have said to the Government, is that it come clean, your schedule of fees boggy, lets have a decent schedule of fees, and then come clean to the public and say that the rebate you get is not 85%, the rebate you are getting is 50% and that is all we are prepared to pay.  Come clean.

Question:   We have spoken to patients, out at that surgery this morning and they have accepted it, would accept it if patients seemed to be accepting it themselves.

Haikerwal:  Look, I think that patients are very understanding, especially in areas in the outer suburban parts of capital cities, because there is a very great problem in accessing doctors, we have a workforce crises, this side of town of Melbourne is actually the second lowest number of doctors per population, after the (indistinguishable).  That is how dire things are in the outer suburbs, so I can understand why people understand they are having to charge a gap, my concern is not so much of having to pay a gap, but I would like to see Medicare address on that particular aspect.

Question:   (indistinct)

Haikerwal:  People have a choice, they have a choice to walk, and I think that what we are finding in our practice for instance, is that people are prepared to pay a gap because they understand, that whether they pay a gap or are bulk billed they get a good level of care, but in order for to maintain a service in the area we do have to charge above Medicare, that is the gap, because Medicare does not allow us to continue to practice where we would like to on the current rates the Government is making available.

Question:   And what can you tell us about the future of Medicare.  What does this tell us about where Medicare is headed if there aren't fundamental changes in the next couple of years?

Haikerwal:  The big concern I would have, Medicare is very much under the gun.  We would like to make sure that there is equity of access to patients and that access is on patients needs, and I think that if we don't address the short fall between the cost of providing medical service and the cost, and the rebate that patients get for seeing the doctor then we are going to run into trouble.

Question:  Again, for us if you would, what does this tell us about Medicare in the next couple of years, is this a sign of disintegration, what is it?

Haikerwal:  Medicare is very much under the gun.  As a system as it was conceived it was an excellent system, and it still can be an excellent system, it gives access for us the patients to a rebate, for medical services that we can afford and it allows a much greater distribution of services.  If this Medicare system is not addressed we are going to see more and more people not being able to afford services, and that is inequitable and totally rejected by the AMA.  We have to make sure people can get access, not just to medical services, but also to prescriptions that they would have to take as a result of medical services and the pathology that they would have to have and the x-rays that they have to have.  What is going to happen is that each one of those (indistinct) the whole system is going to become unaffordable.

Question:  Finally, you are saying that you would expect to see a lot more this kind of charging, extra charging and initiative in ways that doctors charge as the months and years go on.

Haikerwal:  There is no doubt people are moving away from universal bulk billing, and there is a real cost imperative to do that, if they don't do that their business is going to have great difficulty in surviving.  In order to reduce the slug the patient will feel from that, they are trying to find other ways of reducing that costs, some practices cross subsidies other have at least some access to bulk billing for those who most need, those on very low incomes and age pensioners for instance.  It is not just a situation restricted to Medicare consulting in doctors rooms, it also involves aged care facilities which have gone to a very low level with only 16% of GP's visiting older people, because the same problems occur there.  We are having people say in hospitals because the homes which cater for outpatients can not get a GP to visit them.  This is really, as you said, something. This is really the beginning of the end if we don't act now and act decisively.

Ends