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Special Edition: The bulk billing crisis in Australia

I have never seen such an escalation of an issue so central to First Step. Not mental health. Not addiction. Bulk billing! In short, the Medicare rebates have not kept pace with costs and bulk billing clinics are either ceasing to bulk bill or shutting down altogether.

As much as First Step is a multi-disciplinary clinic, GPs are still the central pillar of care. They provide opiate substitution therapies, write care plans and team care arrangements, refer to our other services as well as external services, and see people as often as they need to be seen.

And, like everywhere else, we are struggling to find enough doctors and we are struggling to keep the clinic financially sustainable - precisely because these bulk billing rates are so low.

Medicare rebates $40 for a 19 minute consult. So, that’s $120 for an hour to pay the GP, pay the receptionists and cover the clinics operational costs. Obviously, the more GPs we have the more income we make, but the GP workforce shortage is also at a crisis point.

We know, and there is a strong evidence base to prove, that opiate substitution therapies save lives, reduces harm and improves quality of life. Our GPs save lives.

The issue we have been faced with our whole history, has now become mainstream. Read below as Dr Peter Wright provides brief history on why Medicare is failing to adapt to our changing needs.

And if you know a GP who wants to work with vulnerable people, please ask them to stop what they’re doing and call First Step!

Patrick Lawrence
Chief Executive Officer

As more bulk billing practices charge fees, First Step feels the pressure

I’m one of the newest members of the First Step team and am seeing first-hand the impact the bulk billing crisis is having on medical services to the broader community.

As a registered psychologist, I offer psychological therapy under a GP mental health treatment plan, and often find my clients can’t afford to pay for the essential care they need.

Does that mean a service shouldn’t be available to them, just because they can’t afford it?

I don’t think so.

Personally, I believe access to physical and mental health care is a basic human right that should be available to anyone, regardless of their income.

Unfortunately, in community health services we are seeing an increase in costs to deliver services, and eventually this increase is passed on to the patient - who may, or may not, be able to afford it. A gap payment from the patient almost seems inevitable when you consider the pay cut to practitioners working in bulk billing services versus those in full fee practices. Unless the government puts more investment into general practice care, we will continue to see costs rise, and practitioners opting out of the bulk billing services and into full-fee-paying clinics.

As more bulk billing practices begin to charge fees or aren’t able to meet demand due to staffing shortages, inevitably we see pressure put on remaining clinics like First Step, in the form of increased patient numbers and waitlists. From my viewpoint, it appears like an unavoidable widening of the gap in access to medical services.

Already, after only working at First Step for a few months, I’ve had to put a stop on new referrals and begin a waitlist because demand for psychological services is so high.

While I am so happy to work for an organisation like First Step that opens its doors to everyone and anyone, I am somewhat saddened when I think of the overall system, and how it supports our community’s most vulnerable.

Personally, I wish there were 1,000 more First Steps across Victoria. Where anyone can have access to medical care, and those practitioners were paid as much as practitioners at any other clinic. Because in my experience, the services provided are just as essential.

Siobhan McKenna, Psychologist

Renegotiating our social contract

We have a bulk billing crisis in Australia because Medicare is a monopolised, one-provider, nationalised insurance scheme.

It is not a nationalised medical system.

It was originally introduced in the Menzies era as a financial incentive for doctors to streamline and simplify billing, and not bill privately.

But now, there is good evidence to show that the bulk billing rates of remuneration to doctors have fallen behind the cost of living making it an unattractive alternative.

What this means for patients is that they are not insured for enough. Obviously, they can’t negotiate a deal with a doctor, but they also have no choice of insurer.

It is totally different from the UK or Canadian models, and, in fact, is unusual by world standards because it’s a hybrid system, with hospitals allowed multiple insurers.

People should be angry at this monopolised, national insurance scheme that no longer meets their needs.

The solution is an informal renegotiation of the social contract. That is a broad ranging conversation that needs to happen across many platforms, and will take time.

What percentage of people should we expect to be bulk billed when they go to the doctor? It has never been 100%. At the peak of bulk billing, it might have been around 60%, but it is falling.

There are people in Australia who believe there should be no cost to see a doctor, but that would start to breach the constitutional obligation not to co-opt labour. You cannot mandate a profession to charge a certain amount just as you can’t compel all doctors to bulk bill.

All GPs have the right not to bulk bill. There is no obligation. It’s just a convention and has been a common practice, normally tied to people with a welfare card. At the discretion and good will of the doctor.

So, the best we can hope for is a renegotiation of the social contract – who are the people that should get bulk billed for Australians to feel that it’s right and fair?

 Dr Peter Wright, GP


A crisis of epic proportions

The trickle of media stories about Australia’s General Practitioner (GP) shortage has turned into a flood. In fact, I think it is the first time an issue so critical to First Step has received sustained media focus.

We have gone mainstream!

The media focus is affirming but doesn’t get us any closer to solving the problems.

And what are those exactly?

1) Medicare rebates are so low that GP clinics are abandoning bulk billing en masse. As a result, millions of Australians are struggling to access free GP care, the cornerstone of universal health care.
2) There is a serious shortage of GPs nationwide, and it’s much worse in the country.
3) Trainee doctors are choosing general medicine at record low rates, down from approximately 40% twenty years ago, to 15% now.

Put those things together and you see the result of years, perhaps decades of neglect of one of the things that defines us as Australians: a nationwide belief in universal health care.

As bad as the general GP situation is, it is much worse with Addiction Medicine GPs.

It’s probably worth a quick explainer here:

The medical intervention for opioid (including heroin) addiction is the prescription of daily doses of methadone or buprenorphine. These medications have been proven to reduce the amount of heroin people use (often to zero), reduce harms such as overdoses, accident and injury, crime, hospital admissions, and deaths, and reduce the impact on families and society.

These medications are prescribed by doctors called Opiate Substitution Therapy (OST) prescribers, just ‘prescribers’, addiction doctors, or methadone doctors. We call them Addiction Medicine GPs.

At First Step we believe that everybody deserves every chance to turn their lives around. Without the workforce, this is unachievable.

To our enormous frustration, we turn multiple people away every day because we have a 3-month wait list to see a GP. And we have, what is generally considered in the sector as a large GP team – 4 doctors equating to just over 2 full timers.

We have been in active recruitment for GPs for as long as I can remember. We’ve used recruiters, advertised, made noise in the media, and in the last 6 years successfully recruited only one – the wonderful Dr Niall Quiery.

In addition to the systemic shortage of GPs, this kind of coalface, gritty, life-saving and challenging work . . . well, I suppose it’s not for everyone.

Then there is the general societal stigma around drug use, and lack of understanding of underlying childhood trauma’s that often predict co-occurring addiction and mental illness. And to add insult to injury, and this is said with the greatest of respect to our own GPs, they are aging and retiring.

These factors have ramifications not only for our clients, but also for our financial feasibility. Like in any GP clinic, GP billing forms a percentage of our income. With year-by-year government grant funding, contracts that are not indexed, and this GP crisis, it gets harder and harder every year just to keep our doors open.

We are trialling an Alcohol and Other Drug Nurse Practitioner program on behalf of the federal government; we’ve formed a recruitment partnership with Star Health and the Salvation Army, and we are pioneering programs to increase the scope of practice of pharmacists in addiction medicine.

All these things might help, but they are long term incremental improvements to a current and epic problem.

 Patrick Lawrence, CEO              

Please remember, we are here to help

It’s no fun telling a client we don’t have a doctor available.

Clients have said to me, ‘well, aren’t you a doctor’s surgery?’ Yes, we are. But we don’t always have GPs available. The majority of our doctors work Monday, Tuesday and Wednesday, with limited availability on Thursday and Friday.

I understand their frustration. We’re frustrated too. We wish we had more doctors, but we don’t.

One way to alleviate this pressure is to make sure clients book their appointments in advance. And keep their appointments!

We know that for many of them, forward booking appointments can feel overwhelming, and unavoidable circumstances force them to miss their appointments, but we encourage them at the end of each appointment to book for the next one.

Sometimes, I print a list of all the clients that have attended in a week, cross check what medications they are on, and if they don’t have an appointment booked before their script ends, book them in. This is a really time consuming process.

Inevitably, we always receive those last minute, urgent calls from clients on a Thursday or Friday, needing a methadone script.

We really do go out of our way to find a solution and to help. But I once had a client say to me, ‘you guys are the reason I’m going to have to use.’ I know it’s not true, but that was hard to hear. After all, I didn’t get into this job to say ‘no’ to people, I want to help.

Thankfully, that is rare as our clients know that rude or aggressive behaviour is not welcome at First Step.

For most of our clients, when they arrive and see a welcoming smile, their face lights up. And it’s the same for us. We get to know them and want to have meaningful interactions. For some, we might be the only interaction they get all day, so we want that to be positive.

We know that our clients are appreciative of the care and support they receive. We want to remind them to be patient, to book their appointments in advance and remember we’re doing the best we can.

And of course, the clients that really make us happy are the ones that bring in their dogs!

 Stephanie Casey, Receptionist