Interview - AMA President, Dr Kerryn Phelps, with Sandy McCutcheon, Radio National 'Australia Talks Back'. Discussion: Decline in bulk billing; Medicare rebate; medical co-payments
"The reason that we have seen such decline in bulk billing, and it is unlikely to reverse, is that the Medicare rebate is only half the value of providing a service. And if you look at the real value of a standard consultation in general practice, it's about $50 on average per consultation, and that's a conservative estimate. Medicare rebates for bulk billing doctor or a patient who's privately billed, $25. "So it's that difference that has made it impossible for doctors to maintain bulk billing and to stay in practice," said Dr Kerryn Phelps.
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COMPERE: Before we go to calls, let's bring in Dr Kerryn Phelps, National President, of course, of the AMA. And, Kerryn, good to talk to you again. Welcome.
PHELPS: Hello, Sandy.
COMPERE: Now, you argue the decline in bulk billing warrants a doubling of the Medicare rebate?
PHELPS: Well, I don't.
COMPERE: You don't?
PHELPS: What I'm saying is that the reason that we have seen such decline in bulk billing, and it is unlikely to reverse, is that the Medicare rebate is only half the value of providing a service. And if you look at the real value of a standard consultation in general practice, it's about $50 on average per consultation, and that's a conservative estimate. Medicare rebates for bulk billing doctor or a patient who's privately billed, $25.
So it's that difference that has made it impossible for doctors to maintain bulk billing and to stay in practice.
COMPERE: But, Kerryn, isn't the implication of what you're saying is that the Medicare rebate needs to be doubled?
PHELPS: Well, that's one solution. I mean, really it comes down to what the philosophy of Medicare is, and that is do we want to have it as a universal payment for health care? Or do we want it to be a safety net for people who are disadvantaged? And the question really is around whether it is appropriate for every person to be able to, no matter what their wealth or otherwise, go to a GP or other specialist and expect to be treated for no charge out of their pocket?
COMPERE: So where does the AMA stand on that?
PHELPS: Well, the AMA stands on a very firm platform of the relationship should be between the doctor and the patient.
COMPERE: So a co-payment?
PHELPS: The issue of a co-payment is yet another issue again. But where the AMA stands is that we believe that the relationship should be fundamentally between the doctor and the patient and that the patient pay the doctor's bill and their insurance situation is between them and their insurer. Now, Medicare has set itself up as the universal monopoly insurer so that no other insurer is able to be involved in that transaction. And, as the monopoly insurer, it has not kept up with the cost of running a practice.
If you're talking about a co-payment, there are different ways of instituting that. If somebody is privately billed they are, in effect, paying a co-payment. But they pay the whole fee up front and then they get back as a rebate their Medicare rebate. The gap is what's left out of that equation.
PHELPS: The other way of looking at this, and it would need a change to federal legislation to do this, is to enable what is called a co-payment at the time of the service. So that would mean that the doctor would be able to electronically lodge your Medicare claim which would be payable to the doctor, and then you just paid the gap. What was between the Medicare rebate and what the doctor's fee was.
COMPERE: So if the rebate was adequately increased, doctors should they still be able to charge what they feel is right above that rebate?
PHELPS: Well, I think that it's very important that we do always have the ability to charge what is appropriate for the cost of providing a particular service. And it really is a balance at the moment between what the taxpayer pays.
Health care has never been free, and anybody who thinks we had free health care in Australia was seriously mistaken. Tax is always paid for health care in combination with household incomes.
What we have seen, over the last decade or so particularly, is a shift in the balance between how much comes from taxes and how much comes from household incomes. And the debate for the future is how much should that balance be from household budgets.
COMPERE: Yes. We're speaking with Dr Kerryn Phelps, National President of the AMA.
Kerryn, rural doctors and others favour a differential rebate, where a higher rate will be paid to country areas or the outer suburbs. What's your view on that?
PHELPS: I think that's very open to political pork barrelling, so that if you live in a particular postcode if the guy across the road is in a different postcode they've got to pay more for their health care, that doesn't work. The reason it doesn't work is that it doesn't pass the social justice test.
If you've got people who are living in, let's say an outer urban area, you might have one cohort of patients who are extremely wealthy and another cohort of patients that are very disadvantaged. And you see this to some balance in every postcode in Australia.
Now, if you are to give a higher rebate - that is more tax dollars - to people living in that particular postcode no matter what their means, then you're actually subsidising people who don't need it.
I don't think that passes the social justice test.
COMPERE: Yes. Kerryn, just one final thing and it's something that worried me and I mentioned it in the introduction, and that's the latest statistics point to a decline in the number of visits to a doctor in areas where bulk billing is lowest. Now, first of all are you getting that kind of feedback from your members? And, if so, what are the implications of that?
PHELPS: I am getting that feedback and it's a concern I've been expressing for quite some time. But I think we need to tease those figures out a bit more, we don't know yet why the attendance figures are lower in those areas. And I think that there is a possibility that there it's an access problem as well.
COMPERE: So you don't think it's just that (a) going to the doctor is too expensive therefore you don't go to the doctor?
PHELPS: No, the average co-payment for patients is around 11 or $12, which is, I think, most Australians would find affordable.
PHELPS: I do think...
COMPERE: But if it was that, then it would be a matter of great concern, wouldn't it?
PHELPS: If it was that, it is a matter of great concern because we know that if people are going to be making decisions about whether they go to the doctor, particularly for preventive health checks like blood pressure checks, cholesterol checks, diabetes management, that sort of thing, if they don't manage those diseases well and they wait until they're sick to see the doctor, then our health outcomes are going to be worse.
That is, people are going to be sicker. We are going to see deaths. We are going to see unnecessary illness because people perceive that they can't afford to go and see the doctor. That's a real shame.
Now, the co-payment is one way around that because even if people have to pay something of a gap over their Medicare rebate they don't have to come up with the full amount up front.
COMPERE: Yes. Dr Kerryn Phelps, thank you so much for your time.
PHELPS: My pleasure.
COMPERE: That's Dr Kerryn Phelps, National President of the AMA.
Published: 26 Feb 2003