Medicare erosion

The erosion of Medicare was an incendiary issue in Australia’s recent election. Among other controversies, a freeze on rebates to doctors threatens bulk-billing, and hence access to general practitioners for those on low incomes.

I was therefore surprised to see, just a few days after the election, an article urging people to make more use of general practitioners “for minor problems such as gastro” to relieve the pressure on hospital emergency rooms.

Is that actually a realistic choice for people who are unemployed, underemployed or living at or near the poverty line?

The last time I saw my “regular general practitioner”, the gap payment was $40 for a standard visit. It would be more for an extended visit, or after hours and at weekends; if my doctor worked after hours or at weekends – which she doesn’t. She can also sometimes be booked a couple of weeks in advance, which is not much use for emergencies, or even for “minor problems such as gastro” that may need prompt attention.

There are therefore crucial barriers standing between patients and access to general practitioners that might stymie the otherwise sensible aim of reducing emergency room traffic.

GPs do not parallel emergency rooms

I posted the article to Facebook to get other opinions.

Several people supported the idea of thoughtful and frugal use of emergency rooms, and I have no argument with that. Emergency rooms are what their name implies, not de facto general practices. General practices can, however, only absorb more of the pressure if they’re available on equivalent terms.

The general practice system works well within its limits. People commented on their wonderful practitioners, the value of having medical histories on site, and the specialist referral systems that occur via GPs.

My questions are not about the value of general practitioners but about their accessibility and affordability. My thoughts were echoed in several comments:

• The clinic I go to is often booked out.
• It can be a long wait.
• It’s often hard to get an appointment with my own doctor, and the whole practice is closed at weekends. So, you have a choice of going to a medical centre or a public hospital, and many people trust the latter more.
• Our local GP is our medical centre, and it’s only open Monday to Friday 9-5.
• I pay a gap of $50.
• I have to pay the full $70 up-front and claim the benefit ($37.05 for a standard 5-10 minute appointment) separately from Medicare. The process is cumbersome.
• I recently paid 30% of half a couple’s weekly pension as co-payment for one X-ray.
• I live in a town where there’s high unemployment, low incomes, and bulk-billing is almost non-existent.

Issues of access and affordability are real and get more real in areas less well populated by general practitioners, particularly regional and country areas.

A subsequent article, written by a woman whose son needed medical attention because of a holiday accident, picks up some of the themes of geographical and financial accessibility.

The small town in which the family were staying provided only one option – a general practitioner, who charged $80 for a consultation and did not bulk bill. The injured limb cost $90 to X-ray and showed a fracture that meant going to the private hospital and paying $195 for admission.

“My eight-hour to and fro between GP, X-ray centre, back to the GP and then to hospital has left me more than $300 out of pocket…This might be the cost of the winter electricity bill for some.”

Jane Gilmore also recently shared her cautionary story about the cost barrier to general practitioners. She got a cold, which she self-treated, but then got sicker and didn’t go to her doctor because of the up-front charge and co-payment gap. She ended up with a staph infection and some weeks down the track “the overall cost to the health system is exponentially more than one free appointment two weeks ago.”

Maintaining and improving access to GPs makes good sense.

Salvage and extend Medicare services

If people are to cooperate in relieving the pressure on hospital emergency rooms, alternatives need to be available. If the alternative is to be general practitioners, they need to be accessible, provide the services required (X-rays, for example) and bulk-bill.

All of this might be more feasible if we can salvage Medicare, and possibly extend it. One suggestion, for example, was to have bulk-billing general practices located onsite with hospitals.

Relieving the pressure on hospital emergency rooms is a perfectly reasonable aim. It is not reasonable, however, to simply advise people to go to general practitioners as an alternative. These do not currently provide a parallel service at parallel times and parallel costs.

The suggestion by the head of the AMA (Australian Medical Association) to “give GPs the opportunity to make a judgment about which patients could afford a co-payment” does not hit the spot. On what basis would they make such a judgement? Why would they take on this non-medical role? Why should patients trust doctors to make such financial decisions on their behalf?

To relieve hospital emergency rooms we need to salvage Medicare bulk-billing and extend out-of-hours access to non-emergency room services in accessible geographical locations.

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