- by Anna Pha
- The Guardian
- Issue #2041
Photo: Anna Pha
For anyone looking for solutions to the Medicare crisis, the Albanese government’s Strengthening Medicare Taskforce Report raises more questions than it answers. It is full of fine-sounding, generalised proposals that fail to address key causes of the present crisis including the privatisation of health care.
“Strengthen funding to support more affordable care, ensuring Australians on low incomes can access primary care at no or low cost,” the report says. Strengthening funding is not the same as increasing funding. Why restrict “no or low cost” access to people on low incomes?
Quality health care should be universally accessible with no fee – this was the central principle of Medicare and why it was so popular when it was introduced by the Hawke Labor government in 1984.
“Since the pandemic began, more people are presenting at emergency departments or delaying care, practices are finding it harder to recruit GPs and other health workers, and bulkbilling rates are falling,” the report says. Tellingly, this is the only mention of bulkbilling!
The report proposes that “coordinated multidisciplinary teams of health care professionals work to their full scope of practice to provide quality person-centred continuity of care, including prevention and early intervention; and primary care is incentivised to improve population health, work with other parts of the health and care systems, under appropriate clinical governance, to reduce fragmentation and duplication and deliver better health outcomes.”
A fine sounding objective but the detail is lacking.
“Fast-track work to improve the supply and distribution of GPs, rural generalists, nurses, nurse practitioners and midwives, pharmacists, allied health, Aboriginal and Torres Strait Islander health workers and other primary care professionals.”
Does this mean the training of more GPs and an increase in the income of GPs? A multidisciplinary team could be of great benefit, as long as health professionals play a role within the scope of their training.
“Develop new funding models that are locally relevant for sustainable rural and remote practice in collaboration with people, providers and communities. Ensure new funding models do not disadvantage people who live in communities with little or no access to regular GP care, and whose care is led by other healthcare providers.” What are these funding models?
“Support general practice in management of complex chronic disease through blended funding models integrated with fee-for-service, with funding for longer consultations and incentives that better promote quality bundles of care for people who need it most.”
There is no suggestion that GPs be salaried – “blended models of funding” presumably refers to other members of the multidisciplinary team such as nurses being salaried, but this is not spelt out.
Doctors have been calling for more than a decade for an increase to the Medicare rebate while the costs of running a general practice rise and bulkbilling rates fall, forcing more people to pay out-of-pocket for primary care.
That doctors’ pay is unaddressed in the report is a reflection of the fact that GPs are a main target of the government in its Medicare plans. It intends to excise GP practices from the Medicare system, so that provision of primary care is found in “blended models” only. “Integrated with fee for service” is code for user pays.
Adequate funding for longer consultations is urgently needed, but why just for people “who need it most”? Why not for anyone who needs it? What are these incentives and bundles of care?
Here the door opens for private health insurers to move in.
The review repeatedly refers to people managing their own health and recommends a greater role for use of centralised digital data. In parts it could be interpreted as a revamp of My Health Record. Adoption of technology, including e-prescribing and telehealth is recommended. Telehealth has its uses but should supplement, not replace face-to-face consultations where a doctor can see the patient and check such things as blood pressure.
“Fast-track work to improve the supply and distribution of GPs, rural generalists, nurses, nurse practitioners and midwives, pharmacists, allied health, Aboriginal and Torres Strait Islander health workers and other primary care professionals.” Another fine sounding statement. But how?
Pharmacists, through their powerful lobby group the Pharmacy Guild, are pushing to be able to write prescriptions. Would this create a second health care stream for people on low incomes or with no access to GPs in rural and regional Australia? Pharmacists would have a conflict of interest. They are for-profit businesses, and every additional script adds to the bottom line.
The GP is at the heart of primary health care, referring patients and prescribing medications. They know their patients’ medical history and in cases where patients have a number of chronic conditions, which is increasingly the case, the role of the GP becomes even more important. Pharmacists do not have the necessary medical training.
FEE FOR SERVICE
Under Medicare GPs and specialists are paid a fee for each consultation or procedure, either through a government rebate (when bulkbilling) or by the patient who can then claim the Medicare rebate and be left out of pocket (the gap). This system is inefficient and costly. Decades of frozen or below CPI increases in the rebate have reached a point where many GPs have had to abandon bulkbilling.
This gap has been on the rise to the point where patients might be $50, $70, $90, or more out of pocket – unaffordable for many, especially families and those on low and middle incomes.
The failure of GP incomes to keep up with inflation over decades has deterred medical students from seeking a career as a GP, compounding the existing shortage of general practitioners.
The privatisation and commercialisation of medical centres has resulted in extremely short, inadequate bulk-billed consultations or longer consultations with fees that many patients are unable to afford. It is no coincidence that GPs are overwhelmingly located in wealthier suburbs.
Fee for service can also create an incentive for overservicing. Increasingly medical centres are for-profit businesses.
Medicare is underfunded and $750 million over three years in additional funding promised by the government will only scratch the surface, hardly making up for the billions of dollars in cuts by the Coalition. More importantly, the underlying problems of a broad system of care with a range of interconnected services are not addressed.
COMPREHENSIVE APPROACH REQUIRED
One of the weaknesses of the review is that its terms of reference were limited to primary health care and Medicare is much more than primary health care. It also applies to public hospitals, radiology, pathology, and specialists. Strengthening primary health care would of course have flow-on benefits in other areas.
It is difficult to find a specialist who bulk bills. Radiology, pathology, and other services are increasingly abandoning bulkbilling and becoming unaffordable, profit-churning machines.
Public hospitals are choked with thousands of patients who are ready for discharge but have nowhere to go. Some have been there for months or even years. This is because of the crises in aged care and the National Disability Insurance Scheme (NDIS). These systems are in crisis due to under-funding and being increasingly privatised.
Another aspect of the health care crisis is ambulance ramping at public hospitals as they wait for available beds to discharge their patients and get back on the road.
The shortage of bulkbilling doctors compounds the problem as people turn to public hospitals for conditions that are not emergencies.
The report fails to outline how shortages of health care workers including GPs would be addressed. Nurses have been leaving their profession in droves: they are overworked and underpaid. GPs who rely on bulkbilling find it difficult to sustain their businesses (and they are businesses) at the same time as providing quality care.
At present Medicare is being privatised by stealth with the undermining of bulkbilling and the health system Americanised with an increasing number of people denied access to the care they need. This report fails to address this situation.
Whether Medicare is really strengthened and its core principle of universal access to quality care is restored is a question of government priorities:
- $254 billion in tax cuts for the rich;
- $170 billion on nuclear-powered submarines;
- Billions more on other war preparations;
- $7 billion plus on private health insurance rebate;
- Further privatisation of Medicare.
- Wage rises for nurses, aged care and NDIS workers;
- Salaried GPs;
- Universal access to quality health care with no fee;
- Nationalisation of health care;
- Planned training and provision of health care workers.
See Page 3 for what the US health system looks like.