Medicare

"On the 1st of July, just a few weeks' time, we're going to see the biggest changes to the Medicare Benefits Schedule that we're aware of in the history of Medicare. Over 900 items are changing and this has a significant potential impact on patients. The problem that we're seeing, and the problem that we're calling out today is that Government have only just released these new changes to the schedule in the last week or so, leaving only a few weeks for doctors, health funds and others to determine what their fees are and what the arrangements will be for the future.

Now, the changes to the schedule are quite significant, including very significant cuts to some rebates that patients may expect for their surgery as a result of rule changes within the MBS. But the bigger problem is the chaos that's going to ensue because doctors can't tell patients how much they can expect to receive back from their health fund because they simply don't know. It's not the fund's fault. They haven't had a chance yet to develop their own fee schedules. It's not the doctors' fault because they've just got no information around which to have a conversation with their patients for surgeries that have already been booked post first of July. So our message to patients having orthopaedic surgery, also cardiac and general surgery, is that if you do receive a bill that is not what you're expecting, if your doctor is unable to tell you what your fees are, it's not the doctor's fault. It's not the health funds fault on this occasion, it's the Government's fault." (Omar Khorshid, President Australian Medical Association.) Read more on the AMA's site at "Dr Omar Khorshid - MBS changes and comments on quarantine," 6 Jun 2021.

This article is about the real reason why the medicare rebates don't cover the cost of doctors' services and therefore why the practice of general medicine is increasingly unsatisfactory for doctors and patients.

I was inspired to attempt this article by a letter just published in the Age because it articulated my own concerns. The only thing it lacks is that it fails to give the principle reason for the very high costs of running a medical practice.

The truth is Medicare needs to be reformed

It is particularly galling that Labor has adopted the catchcry "Save Medicare". Apparently Medicare is sacred and untouchable. This attitude prevents any possibility of the reform that it desperately needs. It is also galling that Labor is spruiking that the removal of the freeze on rebates will allow GPs to keep bulk billing and this will "save Medicare". The current rebate for a standard GP consultation lasting up to 20minutes is $37.05. Without the freeze, the rebate would be around $39 and by mid-2018 around $40. If GPs had to depend on such paltry amounts for their incomes, Medicare would have died a long time ago.

The truth is that GPs who do not see a patient every six minutes can continue to bulk bill by supplementing their incomes with various care plans, health assessments, home medicine reviews, case conferences, practice incentive payments etc. These processes allow GPs to generate a reasonable income, but there has never been proof that they improve health outcomes. The lowly consultation rebate, frozen or not, encourages GPs to manufacture incomes from these dubious methods. Some, dare I say it, "dodgy" doctors do more than their fair share of "dodgy"' care plans.

The most important 15 minutes in the health system is the consultation with GPs. It must be valued appropriately so that GPs can take a patient's history, examine them and think about a treatment plan that avoids the current blowout of follow-on costs in investigations and referrals. Medicare must be reformed. Neither Labor nor the Coalition have the honesty and courage to do this. It is more complicated than Labor's puerile and disingenuous sloganeering suggests.

Dr Philip Barraclough, Highett

Why do medical practices cost too much to run?

I'll give you a hint. It's not the insurance costs.

A couple of years ago I went for an interview at a GP clinic in an inner suburb of Melbourne, in the region of Armadale or Toorak. It was explained to me that the practice tried to limit the amount of time spent with patients and to make up costs by running various electronic, self-evaluating programs, to diagnose various mental health issues, such as depression. The hard-faced GP interviewing me was keen to tease out any tendency I might have to spend time on supportive or other psychotherapy and it didn't take him long to detect these.

"That might be alright for a GP practising in the outer suburbs," he sniffed, "But there is no way we are going to cover costs here and make a profit by spending time with patients. Our mental health nurses here have got it down to a fine art. They use self-evaluation forms as a way of interacting therapeutically with the patients and then they use the same forms for their reports. Personally I think you may be a little too one-to-oneish for this practice."

I needed the job, so tried to sound very flexible on these issues, but he wasn't fooled. He asked me whether I had any political philosophy and, before I could answer, he told me that I really should get familiar with Ayn Rand. He was the first person I have ever met, outside a novel, with the exception of some 'counter-culture' heroine addicts in the 1980s, who had ever expressed any open approval of this writer. I had heard that Rand's 'objectivist' philosophy had enjoyed a resurgence with US and other neocons, but I admit that I was shocked to find her lurking in a Melbourne GP clinic. I guess that made me naive, however, if I knew my GP was an avid fan of Ayn Rand, I would run a mile!

But, anyway, the thing that most interested me about this job interview was the acknowledgement that the cost of rental and real-estate in Australia, particularly within the inner suburbs, was so prohibitive that a doctor wishing to succeed simply could not afford to spend time with patients and, furthermore, artfully deployed gimmicks and electronic questionnaires to take the place of proper physical and mental examinations and treatment.

Because the major cost of doing business in Australia is the cost of land and rents. A business-owner must pay for two premises: the one he or she sleeps in and the one they do business at. Furthermore, they must pay their staff high enough wages for their staff to be able to afford Melbourne's high rentals and house prices. Australia has some of the highest land prices in the world and that goes a long way to explain why small and medium business enterprises so frequently fail. It also explains why Australian manufacturing is in decline and unable to compete with overseas products which do not have nearly as high costs. And high land prices drive up the cost of everything else, including power and water. Even insurance goes up because it must meet this inflation.

And it explains why medicare rebates are no longer adequate to cover patient visits and why GPs practically give you the bum's rush out of their offices almost as soon as you enter, why they won't let you tell them more than one thing that is wrong with you, and why they won't take time to discuss their diagnosis, and why their diagnosis is so often wrong!

Service quality probably increases with distance from the city as the land and rent costs diminish. Maybe some city GPs tak refuge in Ayn Rand in order to rationalise their increasing exploitation and degrading of social capital in an effort to make ends meet.

Whose fault is it?

And whose fault is this? It is the fault of the growth lobby, which has succeeded in raising immigration rates so high in Australia that there is permanently rising inflation of land-prices. Both major political parties and the Greens are responsible parts of this lobby. The first two have massive investments in land-speculation and financing. The Greens utterly refuse to say anything against the engineering of massive population growth in Australia.

Today the Australian Financial Review carried a surprising and uncharacteristic number of remarks about the high cost of privatisation and the benefits of public provision of vital services.

Energy

"The Energy Supply Association of Australia said falling demand for power meant the Coalition must review its energy and climate change policy if it gains power at the September 14 federal election." (The Financial Review, 24/4/2013, p1 & 4)

It seems that power companies want us all to buy more power, even though everyone talks about cutting down emissions and consumption. But, if your company depends on constantly increasing turnover because it has to make a profit (unlike a public power provider), it cannot afford to promote conservation of resources and significantly lower emissions.

On page 4 the Fin Review opines, "[The opposition] is also likely to consider cutting the 20 per cent Renewable Energy Target if electricity demand remains weak."

In other words, to please the privateers, it sounds as if the opposition is willing to fry or freeze us all - depending on whether Greenhouse plays out before we actually run our reserves of fossil fuels right down.

Furthermore, amazingly, there are admissions that the effects of private 'competition' are RAISING prices:

"The main driver of gas price increases for 2013 was increased retail operating costs, including the costs of acquiring and retaining customers in an increasingly competitive market."

So, folks, not only are you driven crazy by telemarketers and doorknockers trying to talk you into changing your gas provider every three weeks for cheaper services, but all that sales-offensive is driving the prices up, not down. The profit motive raises costs. Privatisation costs us all.

Well, we already knew that, didn't we?

Competition policy in W.A. wound back

Already in 2011, West Australia's premier, Colin Barnett, found that increasing the number of private companies handling power had been counterproductive. He said that the break-up of Western Power five years prior had 'clearly failed'.

“There is absolutely no doubt that what the previous Labor government did in breaking up Western Power has not worked.

“When that was put in place, the promise from Eric Ripper at the time was that it would lower electricity prices.

“It’s had the exact opposite effect.”" (Source: Gareth Parker, "Premier plans electricity overhaul," The West Australian September 20, 2011

And Public medicine does keep costs down

In "Saving the budget and Medicare,"AFR, 24/4/2013, p.42, Alan Mitchell writes of the Australian medical benefits system:

"Medicare and the public hospital funding agreements with the states are designed to keep the lid on healthcare spending, and even its critics accept that it has been crudely effective."

and

"An unrestrained private market, the Medicare apologists warn, is an invitation for monopoly pricing and over-servicing. That's what America's private healthcare market has produced. In the US almost 18 per cent of nominal GDP is spent on healthcare, compared with just over 9 per cent in Australia."

And what about the Private Property Development and Housing Industry?

This lesson should be applied to the property development lobby. For many years France and most continental European countries have kept housing prices down by running public land development and housing as a major competitor with private property development and housing. It works very well.

Whitlam tried to bring in the same system with DURD. I've always wondered if that was the real reason that he was dismissed. (See Chapter 7 of The Growth Lobby and its Absence. )

Gail Graham's 17 year old son, Jimmy, was brain injured when his car ran into a tree in Queensland. The accident was unwitnessed and Queensland has fault-based law and insurance for traffic accidents. Because Jimmy was too injured to say what had happened and no witnesses came forward, he was uninsured. You might expect that medicare would pick up his medical bills, and it did, but the care it subsidised was hardly care at all. In a sublimely logical response to an utterly absurd situation, Mrs Graham came close to murdering her son's doctor.


Gail Graham's 17 year old son, Jimmy, was brain injured when his car ran into a tree in Queensland. The accident was unwitnessed and Queensland has fault-based law and insurance for traffic accidents. Because Jimmy was too injured to say what had happened and no witnesses came forward, he was uninsured. You might expect that Medicare would pick up his medical bills, and it did. The problem was that the medical fraternity failed to recommend Jimmy for any significant rehabilitation and seemed to collude to neglect him so that he would die. Moving from Queensland to Victoria to be closer to his parents made little difference. His mother, Gail, who was a journalist, soon got the message that he was being allowed to die without ordinary rehabilitation services because he only had Medicare. Pure bad luck meant that he fell through the holes in the private accident insurance net and therefore was judged by a series of doctors to be too costly to treat and a drain on the public purse. His mother put Jimmy's pension away every fortnight until she had saved up enough to employ a private physiotherapist. The hospital tried to dissuade her from using a private therapist and pointed out the cost. When Gail told them that she had saved up his pension, they sent her a bill amounting to the total for the use of his hospital bed. Read on:

The End

"It was the end.

There would be no money for occupational therapy, no money for any therapy at all. The administrative officer had been right when she pointed out that occupational therapy cost far more money than the average family - or even the above average family - could afford. And that was just occupational therapy. What about physiotherapy? What about speech therapy?

Frantic, I rang the Mont park Brain Trauma Unit and asked to speak to Diane McLachlan. She'd helped Jimmy once. Maybe she could tell me what to do now.

Diane was sympathetic, and surprised that the hospital would actually do such a thing. But they were quite within their rights, she said. There was nothing she could do about it. There was nothing anybody could do about it. The best thing for me to do would be to stop fighting XX Hospital and either put Jimmy in a nursing home or take him home. Perhaps I could appeal to some of my local charitable organizations for help ...

You keep saying that there's nothing you can do! I screamed at her. Everyone keeps saying that there's nothing they can do! There's nothing the Health Commission can do! There's nothing the politicians can do! There's nothing the lawyers can do! There's nothing the media can do! The doctors can do anything they like and there's nothing anyone can do to stop them!

I'd finally lost control. But I couldn't help myself, couldn't stop myself. I just kept screaming at her.

What are you all so afraid of? I wanted to know. Why are you all so afraid? Doctor F. is afraid of Doctor H. and so are all the rest of you! Why are you all so afraid of Dr H.? I'm not afraid of Doctor H.! I screamed. I'm not! And I'll tell you what I'm going to do! I'm going to kill Doctor H.! I'm going to take a gun, and I'm going to go down to his house and wait for him to come home tonight, and then I'm going to kill him! And I' going to tell everybody why I killed him! I'm going to tell them that I killed Doctor H. because he refused to let my brain-damaged, eighteen-year-old son have any therapy at all, because he's letting my son die like an animal and because I can't stand to watch it any more! and then the media won't have to worry about defamation suits, because it won't be defamation. It'll be murder! There isn't a jury in Australia that'll convict me, and even if they do, all that will happen is that they'll say I'm crazy and lock me up for a couple of years. But Jimmy will get a bed in a rehabilitation hospital, and that's all that matters to me! Do you understand? That's the only thing that matters to me!

I was gasping for breath, almost choking. Diane was saying soothing, reasonable things, but I wasn't even listening to her. In the midst of that uncontrollable burst of anger and hysteria, I'd stumbled on the answer. I would kill DoctorH. And then I would tell the whole world exactly why I had done it.

I'd tell them what it was like to watch my son turn into a living skeleton. I'd tell them what it was like o watch his arms and legs fold up and become useless. I 'd tell them what it was like to beg for the most minimal maintenance physiotherapy, only to be told that he wasn't worth the effort. I'd tell them what it was like to look at his eyes and know that he understood everything that was happening to him. I'd tell them what it was like to be powerless to do anything but watch him die.

If I could tell my story to the public, Jimmy would get the care he needed. I knew that.

Georgina wouldn't approve of murder, but Jimmy was running out of time. He was dying. Already, he was little more than shriveled flesh and bone. He was so weak. All it would take was the slightest germ or virus or infection, and he'd be gone. He couldn't' wait for a miracle, and neither could I. [...]."

Gail Graham's book, Staying Alive HarperCollins Publishers (Australia) Pty Ltd (June 1, 1985), ISBN-10: 020715189X
ISBN-13: 978-0207151897 is a very well written, readable work that grips you from beginning to end with its truth. The author paints a humanistic picture of the moral frailty of health profession teams and the unwillingness of any to break out from the 'just following orders' excuse for standing by and allowing unnecessary suffering. Her account is memorable because she also shows how professionals will not only stand by, but actively defend the indefensible.

The book was written in 1983 but nothing much in the way people with serious brain injuries are undertreated when their injuries occurred outside an insurable situation.

One thing has changed, however, and that is Australia's laws of defamation, due, as I like to point out, since it seems so surprising to many, to the intervention of that much hated 1990s Australian immigration minister, Philip Ruddock.

When this book was written, it was almost impossible to name names even if you had proof and truth on your side. In 1983 Australian defamation laws meant that you could be dragged into court and sued several times over for one document if a party objected to a term used more than once in that document. And it didn't matter if you had right on your side, if the other party had more money, they could drag the matter out and bankrupt you. In 1983 our defamation laws were so bad that even newspapers would not name doctors because it is relatively easy for a doctor to claim large sums in loss of livlihood if the public are alerted to a mistake. So Gail Graham, when she was writing, could only refer to doctors as DrH., Dr F., etc and to specific hospitals as X and XX hospital. If she had written today, with the evidence she had, she could name those doctors. I wish that she would republish and do so. They deserve to be named. Graham does name a couple of politicians, Mr Roper and Mrs Hill, both Labor politicians, describing how she approached them with detailed information and begging for help dealing with the hospitals and doctors in question, yet both Roper and Hill failed miserably to help her. They were not the only ones.

Gail Graham wrote a sequel, which I have not read but have ordered as an interlibrary loan. She has also written several novels and other books, including a biography of Chairman Mao. Her blog is at http://www.gailgraham.net/3.html, and she has just brought out a new novel, which is digitally available.

This article, which is a book review, is the first in a series we hope to invite contributions to, about brain injury. The Australian Government currently has a project to publicly insure all seriously disabling accidents, called the National Disability Strategy.