The Guardian July 26, 2000


The doctor's dilemma:
Corporatisation of general practice

When I saw the elderly frail patient, brought in by her daughter,the 
story unfolded slowly.  She had a history of stroke and long standing 
problems with speech and memory, and more recent problems, including 
uncontrolled high blood pressure, high blood sugar levels and an irregular 
heart beat.

The consultation took a while.  It invariably does with the sick and the 
elderly. Taking a patient history and then medical examination is 
essential, followed by prescribing, which may need a phone call to Canberra 
to obtain an "authority prescription" for more costly medications.  

You're already up to 20 minutes. It's hard to take short cuts and dangerous 
not to give proper instructions. 

Patients need an explanation and reassurance and this takes time, 
especially when they are elderly, or hard of hearing, or are parents 
anxious about a sick child.

Time is always important. Many elderly or frail patients are on routine 
medications with serious side effects if not taken properly,or on multiple 
medications, which can be confusing for them.

To decide whether someone's chest pain is simply indigestion or something 
more serious like heart attack, to assess depression and give patients 
motivation to continue with their life, all these things take time and 
cannot be rushed.

Our GPs under stress

For today's busy GP it is becoming harder to provide the time patients 
need, yet less time means less safe medicine.  

The solo family GP has to carry the problems of running a medical practice 
on their own. They need to meet patient expectations of extended hours, 
struggle with computerisation, purchase and maintain medical supplies, 
employ staff, maintain sterilisation standards and a cold chain for 
vaccinations (even change the lightglobes). Such a GP has no guaranteed 
sick leave or holiday leave.  

Federal governments, keen to make Medicare budget savings, have restricted 
the number of new doctors entering general practice by restricting provider 
numbers to access Medicare bulk billing. Less doctors entering general 
practice means existing GPs are even busier and that it is almost 
impossible to find a locum doctor so the GP can take a holiday. This is 
even more difficult in country areas.

GPs see their incomes as going backwards under Medicare bulk billing. The 
Medicare rebate for a standard consultation has not changed much in the 
last 10 years  around $24 a standard consultation for up to 25 minutes. 
Medicare has worked "too well" in controlling health costs, as far as GPs 
are concerned!  

The result is that many GPs are being attracted to the bigger bulk billing 
Medical Centres. They are given a one-off goodwill payment for their 
practice (paid over five years), and the opportunity to work in modern up-
to-date facilities. They keep 45 percent of the fees they generate from 
bulk billing.

Medical Centre GPs have nurse support, fixed working hours, with all 
administration provided by the Centre. In return the Corporation keeps 55 
percent of the doctor's billings as well as profiting from doctors' 
referrals to the pathology service, x-rays, specialist services, chemist 
and other services within the Centre.

GPs in Medical Centres can pre-plan their holidays and there are plenty of 
other doctors to cover them if they are sick.

It is estimated that almost 45 percent of GPs in NSW now work in the big 
Medical Centres and in Victoria the figure is around 35 percent. These 
proportions are steadily increasing, and would be higher if we excluded 
rural areas.

Many of these Medical Centres are owned and controlled by big corporations 
that have interests in radiology and pathology companies, as well as in 
private hospital services. This is known as "vertical integration". Doctors 
working in these Medical Centres have a reputation for rapid throughput and 
of practicing "quick" medicine.

Patients value the benefits of one-stop shopping and extended hours 
provided by the Medical Centres and perhaps they balance this against the 
rapid throughput, and the vertical integration factor, which is the 
possible loss of independence of the doctors' decision-making within the 
Medical Centres.

Would my elderly female patient have been treated differently in such a 
Centre? Quite possibly.

For a start I would not have had as much time to spend with her and the 
temptation may have been to refer her for a chest xray or a CT scan of the 
brain  neither really necessary but an easy way to temporarily terminate 
the consultation and move on to the next patient. Or refer her to one of 
the in-house specialists who "could afford to spend more time with her".

The complicated or time-consuming patient can be sent on a continuous merry 
go round of "more tests", the depressed patient sent off to the 
psychiatrist and the complex patient "flicked" to the public hospital 
emergency department. More hassle for the patient; more cost to the health 
system but faster through-put for the entrepreneurial GP.

Some doctors may not be comfortable in this situation, with the pressure of 
time meaning that corners often have to be cut. The outcome, though, is the 
role of the GP as the primary care doctor and his/her function as an 
efficient and cost saving element in the health system is being eroded.  

Corporatisation  what can be done to stop it?

It is important to oppose this corporatisation of primary health care. It 
represents big business taking over the small business GPs, all 
underwritten by Medicare bulk billing. To do so requires primary care 
receiving more funding and support  in return for better outcomes.

We should oppose the corporate Medical Centres for the following reasons:

1) Vertical integration  Doctors in the medical centres are expected to 
refer to the in-house radiology, pathology, specialists, and the like. 
There is loss of doctors' independence to refer patients in the patient's, 
rather than the business's, interest. That is the principle of arms-length 
referrals has been lost.

2) Sweat shop conditions in the Medical Centres  doctors are employed as 
"sub-contractors" being paid 45 percent of the bulk billing fee. (This is 
probably illegal as the Medical Centre in fact controls the doctor-pay 
cheques and the GP is made to look like a sub-contractor in name only).

As a result of this arrangement the Medical Centres do not have to pay 
doctors any holiday pay, sick leave or superannuation benefits.  

3)  GPs in Medical Centres have economic imperatives to turn patients 
through faster and faster  because the Centre is extracting its share of 
profit from the GP's rebate.

The GP thus has to pay for the luxury and convenience of the Medical Centre 
by faster throughput of patients.

Monopolisation

For various reasons, some patients shop-around. They sometimes use the 
Medical Centres for out-of-hours convenience, but see their family GP for 
more serious problems.

However, this may not be an option in the future as more and more of the 
smaller GPs join the Medical Centres. They do so because they are fed up 
with the Medical Centres "creaming off" the easier work, leaving them to 
deal with the more complex medical problems.

Once monopolisation is complete, GP wages and conditions within the Medical 
Centres will be set for a fall and so they will have to work even faster. 
No time to waste  no time to talk to the patient. No time to think. And 
then the easiest thing to do is to send the patient off for yet another 
"test".

What should be done?

Nationalisation of the Medical Centres is not a likely option at this point 
in time!  

Alternative forms of payment for GPs are available. At present most GP 
practices earn five percent to 10 percent of their incomes from a salaried 
component paid to them directly by the government and which is tied to 
their overall practice size.

Another alternative is the proposal to revamp the Medical Benefits 
Schedule, so that the rebate is more directly tied to the time spent with 
patients. 

The revamp will be cost-neutral to the government and would reward doctors 
spending time with their patients. Although it might sound like a big 
increase to doctors' incomes, it is designed as a cost-neutral arrangement. 

If this proposed fee schedule goes ahead there will be cost savings because 
the number of prescriptions, tests or referrals to a specialist made by a 
GP is inversely proportional to the amount of time a GP spends with the 
patient.  

Better funding of GOOD primary care may be better than cost-neutral to the 
government  it can be argued that the more spent on primary care, 
especially building in time for preventative care, the cheaper the overall 
health system becomes.  

We would get much better value if the Federal Government put the $2 billion 
it now wastes every year on the private health insurance rebate into our 
public hospitals, and towards better primary health care.

Appropriate remuneration for GP consultations is an important way of 
winning their support for the Medicare system. The majority of GPs rely on 
Medicare for their incomes, so their support is important in the struggle 
to maintain it.

Contrary to the statements of incoming AMA President Karen Phelps, bulk 
billing will be vital for patients if GPs are to be remunerated in a way 
which disencourages quick through-put, and pays them fairly for their time.

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