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Mixed feelings: Our clinic’s move away from bulk billing
When a move to private practice was the only option to keep the doors open, it prompted Dr Alisha Dorrigan to contemplate the current state of primary care.
Despite being almost inevitable, the changeover to private billing has been met with mixed feelings.
After 22 years of providing a mostly bulk billed service to the local community, our doctor-owned clinic in southeast Sydney transitioned this week to private practice.
Despite the move being an inevitability given the grim state of primary care funding, the changeover has been met with mixed feelings.
It’s a conundrum unique to the GP; asking oneself multiple times a day whether a person should be charged for the cost of a service provided to them, or alternatively offered a substantial discount that will leave the doctor grossly underpaid and their clinic carrying a financial loss.
Or in Medicare speak – deciding whether to bulk bill or not.
There is no other contractor or employee who has to grapple with this decision so frequently, and by extension who feels that they have to justify their income or the need to run a financially viable business.
At our practice, I encountered an intergenerational contrast in attitudes towards private fees and abandoning bulk billing, with some colleagues feeling deeply conflicted after decades of providing equitable access to healthcare.
Meanwhile, those of us in the earlier stages of our careers were generally more positive about the transition, in no small part due to an extension of those intergenerational differences, with younger doctors having to pay off sizeable student loans debts, struggling to afford their own housing, and – ironically – needing to pay out-of-pocket for their own healthcare.
Eventually, in one of many practice meetings where billings were discussed in the leadup to taking on a privatised fee structure, a colleague lamented plainly that it is ‘time we get paid like any other professional’.
It was one of many discussions that we had over the preceding months, which included exploring whether the increased bulk billing incentive that is yet to come into effect could make any meaningful difference. Ultimately, it was felt that the upcoming changes will add another layer of complexity to an already confusing system that could leave GPs vulnerable to audits with potentially devastating personal consequences.
I find it curious that other medical specialties have seemingly approached private practice with comparative ease. Those working outside of salaried hospital positions that come with the luxuries of leave entitlements, superannuation and indexed pay rates, charge a fee for their time and expertise that rarely aligns with the value assigned by the Medicare.
Over time, bulk billing non-GP specialists have become essentially non-existent, yet this is not seen as particularly controversial even though primary care GPs often find themselves criticised for doing the same.
I believe this reflects the deeply problematic attitudes GPs face, which stem from a lack of respect and value for our own time and expertise. These attitudes often become internalised and probably contributed to the apprehension and anxiety felt at our practice after the decision was made to stop bulk billing.
So, how did the first week go?
It is still early days; however, the first week of private billing went reasonably well. A few medical record transfer requests were received but the appointment book has otherwise remained active.
My predominant feeling has been a sense of relief that I no longer have to subsidise healthcare personally and the outlook on my career of choice is subsequently far more optimistic. I’ve had conversations with patients about what to expect moving forward and nervously talked money during consultations for the first time in my career, but the response has been largely gracious and understanding.
Taking a wider perspective, the view is not quite as positive.
The slow and steady collapse of adequately funded primary care as we currently know it is monumental, and the flow-on effects will be catastrophic as people delay presenting to their GP for medical care or avoid going altogether. Preventive health measures will be neglected and critical diagnoses will be delayed, all of which will have life-limiting consequences for those who cannot afford to access healthcare.
It will also be incredibly costly for Medicare, undercutting the economic rationale for stifling the funding of GPs who keep people healthy and out of hospitals.
When combined, it’s little wonder that there is declining interest in pursuing a primary care career, which is forecast to result in a shortage of over 10,000 GPs in the next decade. To compound matters, fewer than half of all GPs plan to still be practising in 10 years’ time.
Urgent care clinics may help carry some of the load, but they are no replacement for the whole person care across the lifespan that is provided by GPs who forge longstanding relationships with their patients. A relationship that fosters trust and engagement with our health system and ultimately saves lives.
Unless more is done, it’s only going to get harder and more expensive to access primary care – but no individual GP or clinic should have to bear responsibility for this system-wide failure.
In order for GPs to continue to do this work and for medical graduates to consider pursuing a career in the specialty, financial viability is essential.
Presently, charging a fee may be the only hope we have to keep clinics open, halt the exodus of working GPs, and attract young doctors who will hopefully regain interest in a job that is vital not only to the health system, but also for the 23 million people who each year need to see their GP.
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