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Does Medicare discriminate against women?


Filip Vukasin


2/09/2022 5:08:45 PM

Five GPs reflect on being a woman in medicine and the ‘sad reality’ of a system that rewards speed over holistic, comprehensive care.

Collage image of interviewees.
(From L–R) Dr Anita Muñoz, Dr Alla Smoliar, Adjunct Professor Karen Price, Dr Sian Goodson, Dr Silvan Lee.

Earlier this year, a World Health Organization (WHO) report showed that women across the globe earn on average 24% less than men when working in healthcare.
 
While the research encapsulated the experience of women all over the world, Australia is no exception when it comes to differences in remuneration and working conditions.
 
Ahead of Women’s Health Week, which this year takes place from 5–11 September, newsGP has spoken to five female GPs to canvass their views on Medicare, discrimination and being a woman in general practice:

  • Adjunct Professor Karen Price – GP and RACGP President
  • Dr Silvan Lee – GP and cosmetic physician
  • Dr Alla Smoliar – GP and skin cancer doctor
  • Dr Sian Goodson – GP, Director and Deputy Chair of RACGP SA&NT
  • Dr Anita Muñoz – GP and Chair of RACGP Victoria
Financial disincentives
Numerous reports over the years have exposed the gender differences when it comes to earning potential in healthcare and general practice, even prior to the aforementioned WHO findings.
 
And with a tendency for patients to seek out women for longer, complex issues in a system that financially rewards speedier medicine, Dr Anita Muñoz is not surprised that the gap persists.
 
‘It’s a sad reality that reflects the way our system is set up, and the way the community and other professionals view GPs and the work female GPs do,’ she told newsGP.
 
‘We spend longer with our patients and manage multiple issues per consultations – often chronic disease management and mental health.’
 
A General Practice Mental Health Standards Collaboration (GPMHSC) survey showed that for female GPs, 47% of their consultations include a mental health component, compared to just 32% for male GPs.
 
The findings also suggest ‘it is not the female GPs themselves that are seeking out this work, but perhaps patient choice or practice related factors that channel this work in their direction’.
 
While the statistics appear to be an endorsement of the care provided by these GPs, the outcome is that they are financially punished due to a system that provides the same Medicare rebate whether a patient is seen for six minutes or 20.
 
All the GPs spoken to by newsGP point to this as a problem.
 
‘Because of the way Medicare contributions are structured, the longer you spend with a patient, the less the rebate is,’ Dr Muñoz said.
 
‘There are perverse incentives that reward fast medicine, that aren’t necessarily associated with good outcomes.’
 
According to Dr Sian Goodson, the gender pay gap leaves some women in general practice feeling undervalued.
 
‘Medicare favours those who provide higher volume medicine,’ she told newsGP.
 
‘Some women find it harder to charge gaps to their vulnerable, complex patients when they attend for longer consultations, partly as patients need to pay the full cost up front.
 
‘It’s easier to charge gaps for level B consults as the total cost is easier for the patient to manage, even if the out-of-pocket cost is the same or similar.’
 
For Dr Silvan Lee, this experience is familiar.
 
‘It is well known that female GPs are much more poorly remunerated compared to their male colleagues,’ she told newsGP.
 
‘Our patients tend to take longer to assess, [and have] more mental health and family dynamics.
 
‘Billing four or I dare say five level B consults is better financially than two Level Cs, or one level D and a level B. The only doctors who I have ever worked with who see five or more patients in an hour are all male GPs.
 
‘I [also] have witnessed male GPs purposely referring anxious, tired female patients to their female colleagues “as they are more experienced with women’s problems”, or who refer adolescent patients to see their female colleagues as they are more understanding and will take the time to listen.’
 
In Adjunct Professor Karen Price’s opinion, there is real discrimination from Medicare, not perceived or alleged.
 
‘The BEACH study shows us that women see more issues per consultation, and they spend more time with patients [who] seek them out more,’ she told newsGP.
 
‘But there’s also an empathy issue. Women enquire more than men, particularly in psychological issues.’
 
The GPMHSC finding that female GPs are not necessarily seeking out this work echoes her own experience.
 
‘I was working in a high procedural practice in a low socioeconomic area seeing refugees, and people with poor literacy and health access, and I felt obligated by creed to do a good job,’ Professor Price said.
 
‘I got a reputation for thoroughness and so saw more and more long and complex cases and so I wasn’t able to see as many patients as other doctors. They would send me all their complex patients.
 
‘It was ridiculous. In a bulk-billing environment, I left the practice eventually.’

WHW-Medicare-article.jpg
Women tend to have more complex patients than men, which require longer consultations.
 
Another manifestation of Medicare’s discrimination occurred in early 2022, when anecdotal evidence suggests pathology nudge letters were predominately received by female doctors.
 
‘I haven’t received them myself but if I did, I know that my ordering for pathology would be justified from the types of patients I see – majority women, of backgrounds which have a high risk of vitamin D and iron deficiency, prenatal and antenatal women,’ Dr Lee said.
 
‘From the female GP support groups I’m in I saw that some [letter receivers] felt ostracised and self-doubted themselves as a doctor.’
 
In Dr Muñoz’s opinion, nudge programs do not consider individual doctor circumstances.
 
‘For example, if you work in sexual medicine, of course you will be an outlier on how many HIV tests you order,’ she said.
 
‘These blind nudge letters use a standard distributed curve and apply that on a profession that has skews in doctors’ varied interests. It punishes doctors who deal in highly specific situations.’
 
In relation to tending to women’s health, Dr Alla Smoliar sees discrepancies in delivering healthcare within the system.
 
‘I’ve always had a gripe [with] how underfunded women’s health is, compared to everything else in medicine,’ she told newsGP.
 
‘For example, when you start someone on the pill, only some are covered by PBS. With HRT [hormone replacement therapy], most are on private scripts.
 
‘The rebate for IUD [intrauterine device] insertion is still too low compared with excising a basal cell cancer [BCC], even though BCC excision is less risky, any GP can do it and it’s easier than IUD insertion, which requires training.
 
‘There’s clearly no incentive to do it.’
 
Medicare’s incentivising of procedures over more complex, time-consuming consultations is a common theme among all the doctors newsGP spoke to.
 
‘It is an old trope that women’s time isn’t as valuable, particularly in caring situations,’ Professor Price said.
 
‘But that time and care delivers better outcomes. Currently our system rewards procedures and quick consults, for example skin clinics, but they are not doing much general practice.
 
‘When we weight procedures more financially, that’s what you get. If we incentivised mental health, we would see a change in practice and better outcomes for people.’
 
The RACGP recently called for an item number for consultations lasting over 60 minutes as a means of addressing this discrepancy.
 
‘A longer consultation item number for consults over 60 minutes would be beneficial to all GPs, especially women,’ Dr Goodson said.
 
‘It would improve the compensation available for those complex patients who simply need more time to be able to provide holistic, comprehensive care.’
 
Regarding improving financial remuneration for women, Dr Goodson supports increasing the bulk-billing incentive.
 
‘[Also] reducing the “clunkiness” of the chronic disease management item numbers and reducing the fear of audit, would further enable us to provide high level care to our vulnerable, low-income patients,’ she said.
 
Meanwhile, Dr Lee believes the Medicare rebate alone is clearly not able to keep up with the increasing costs required to administer universal good primary medicine.
 
‘Medicare is not there to compensate doctors. Medicare is the [Federal] Government rebate for patients,’ she said.
 
‘It will be difficult for vulnerable patients who need more support due to their circumstances to be able to seek medical care as more and more GP practices [realise] they can no longer continue to survive solely on Medicare to provide good primary care.’
 
Women in medicine
According to the Department of Health and Aged Care, the proportion of GPs who are female increased from 43.5% in 2014 to 47.7% in 2020, with females representing 40% of full-time equivalent GPs.
 
The RACGP’s 2021 Health of a Nation report also showed that female GPs are more likely to work part time compared to their male counterparts. All the doctors newsGP spoke to concur this reflects women taking more time off to care for others.
 
Taking maternity leave made Dr Smoliar full realise the discrimination women in medicine face.
 
‘GPs don’t get paid for maternity leave and there’s a flow on financial effect,’ she said.
 
‘Now I can’t get a home loan because I had two kids in two years and banks don’t take in earning potential, just that I’m a contractor and have taken time off.
 
‘There was a scholarship I applied for, extra training, that I was rejected from because I wasn’t working enough hours. When I explained this was because I was just coming back from maternity leave, I was told “reply later when you’re working more”.’
 
Dr Smoliar escalated her concern with the provider and they reversed their decision, with the CEO telling her they were grateful for her feedback – but the episode still left her frustrated.
 
‘I don’t know that people are actively discriminating, but there are systems in place accidentally discriminating, particularly after maternity leave or against mothers,’ she said.
 
‘Mums are more likely to take time off work when kids are sick. Mums also breastfeed and we have to express at work, and all of this means taking more time off.’
 
Dr Muñoz points to the fact that general practice is the only speciality where doctors work with zero entitlements.
 
‘No annual leave, no sick leave, no generous educational grants. That approach to GPs puts us at a significant disadvantage to non-GP specialists,’ she said.
 
‘We take a pay cut leaving hospital to work in the community and forfeit all entitlements that other specialties can enjoy.
 
‘It affects women more because they take time off to care for kids and other family members, and so they do even worse than their male GP counterparts who are already behind their hospital specialist counterparts.’

WHW-Medicare-article2.jpgMedicare’s incentivising of procedures over more complex, time-consuming consultations tends to disadvantage women.

Dr Lee says being a female GP has clear hurdles.
 
‘I feel quite demoralised as a female GP, especially in the current climate,’ she said.
 
Apart from the Medicare discrimination, being devalued by non-GP specialists and government departments ‘throwing GPs under the bus time and time again, especially during the pandemic’ has taken a toll.
 
‘We get blamed for the state of the public health system, for not seeing [enough] patients and shifting them to the overwhelmed public system,’ she said
 
Professor Price believes you only need to look overseas to identify where change could be made.
 
‘Australia is 50 years behind somewhere like Denmark, with nationalised childcare and parental leave,’ she said.
 
‘Childcare is an investment in culture and society, and would increase workforce participation more than the mining boom.
 
‘Being a woman, I feel fierce about it. There are knowing looks exchanged between women in my era, still fighting similar battles.
 
‘If you speak out too much, sometimes you get a backlash, but we need a more progressive society and it’s worth it.’
 
Meanwhile, Dr Goodson is encouraging all practices to use Women’s Health Week to celebrate female GPs and ‘acknowledge the amazing work they do’.
 
‘We desperately need to encourage medical students to choose general practice for their career,’ she said.
 
‘And we need strong female role models who feel valued and respected by Medicare, non-GP specialists and our peers to mentor the next generation of female GPs.’
 
Outlook
Despite the current obstacles and inequities, Dr Smoliar, who works in rural NSW, says there is hope for the future.
 
‘I enjoy being a woman in medicine,’ she said. ‘I can get a job anywhere, am in high demand as a female GP and I noticed not many women were doing skin checks, so I did get the scholarship and there was a need for that extra skill. Patients also appreciate me doing it.
 
‘Becoming a mother made me a better doctor because I got more patience, more empathy, and learnt [about] more kids’ behaviours and caring for newborns.
 
‘People are ready to support me when I do call [sexism] out, but it’s tiring to do it all the time because there are so many other things to do.’
 
Professor Price said working as a GP provides flexibility, but ‘we’re stuck regarding progress for women in medicine’.
 
‘No one seems to want to address complex care issues,’ she said. ‘I’d like us to see a frank discussion about the complexities in the system, of the old-fashioned way of looking at the workplace.’
 
In a similar vein, Dr Muñoz hopes Australia is entering a phase where the health system stops mimicking the NHS, which she believes is being undone.
 
‘We need to reward people who do hard and complex jobs, not come up with schemes that remove funding and leave businesses to skate close to the breadline,’ she said.
 
‘True generalism is fabulous.
 
‘I would like for our funders and regulators to recognise this but there is this dogged determination to refuse to recognise it, which will be the undoing of our own health system.’
 
And regardless of its faults, Dr Goodson describes general practice as ‘amazing’.
 
‘I absolutely recommend general practice as [a] fulfilling career for men and women,’ she said
 
‘I hope that I will still feel comfortable recommending it to women in a few years’ time as a female-friendly option … [especially if it] enables women to be just as well compensated as their male colleagues.
 
‘[It] has career pathways that offer flexibility to make time for life outside of work, such as family or other interests [and] maintaining a work-life balance that enables GPs to thrive.’
 
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Dr Louise Marie Edwards   3/09/2022 7:20:44 AM

This article is sadly representative of my 26 years of life as a 'female' General Practitioner. Notably,I have not called myself by the term "Lady Doctor" . I wonder how many others have been referred to as a "Lady Doctor" and I wonder whether they resent the term and recoil when it is still spoken aloud as I do.


"Lady" made a distinction not on basis of gender alone, but extended to a set of assumptions about behaviours that would be expected of the "Lady Doctor".

The term "Lady Doctor" is still spoken out aloud but less so. However, the expectations and assumptions of how women will behave has stayed the same. This is discrimination. It is deeply rooted in the culture of General Practice.

As the General Practice workforce has become feminised, so too has the funding from Medicare diminished to the extent that those who provide diligent and compassionate care are doing unpaid work. Women have been bearing the brunt of unpaid work since we walked the earth.


Dr Daniel Thomas Byrne   3/09/2022 8:05:29 AM

Great article. Time for real action on this issue.
My wife earnt 30% less than me per hour as a GP for over 20 years. Now she is in a salaried hospital job and the reverse is true. Just sayin’.


Dr Thomas Anthony Shashian   3/09/2022 10:47:04 AM

This not a gender issue but an issue for the whole of general practice. Complex issues need more time and need to be remunerated accordingly for both genders. General practice is a specialist vocational career now and should be remunerated accordingly.


Dr Peter James Strickland   3/09/2022 12:10:23 PM

This gender pay gap statements are wrong ---- as a GP for 50 odd years I found no difference in pay of residents, registrars, GPs or specialists. What I did find is that women GPs were in general less experienced due to less patient contact. Many times during my residency I had to assist my female colleagues with difficult patients they could not handle, could not do procedures on, and less able to handle the long hours of work up to 120 hrs/week without more rests than their male colleagues. Working longer and efficiently is the way for all GPs. Male GPs deal with as much mental health as female GPs, but less gynaecology, but more minor surgery. Male doctors work longer hours overall. As an examiner (RACGP) males are more efficient with such procedures as Pap smears. Females are less likely to to do (eg. surgery) specialties with smaller hands, and due to their decision to not do the study and work of achievement, NOT availability. Everyone is equal in medicine practice.


M   3/09/2022 1:26:29 PM

What an evocative title!

Medicare is a confusing and poorly conceived system with dubious valuation, no doubt. However, it does not stipulate about gender in the explanatory notes.

I would also say that procedural work in or outside general practice is a very different life. It takes more years to train and hone with a large opportunity cost.

The job requires making yourself available more often, working more hours, accepting more liability and on time on call, and being less free to do other things.

You could earn more money and enjoy some gratification but it comes at personal sacrifice: time with family, friends, and for yourself.

Such a career path is available to any gender with sufficient interest in the job and a willingness to put aside other pursuits.

Paid leave in private practice would be nice, but I’m also grateful in GP to be able to hop off the treadmill the moment it suits our family.

Respectfully,
Your procedure bro pulling out deep implanons.


Dr Ingrid Katya Speight   3/09/2022 5:19:38 PM

About time this was addressed. Despite loving being a GP and feeling like I do a good job I feel completely undervalued by our government and society. I would no longer recommend it as a career path. My daughter has an interest in medicine and frankly I'm not encouraging it. It's just not really worth all the hard work, responsibility and stress.


Dr Anthony Cletus McCarthy   3/09/2022 5:31:35 PM

“Men and women working in healthcare” sounds a very vague descriptor for a study to conclude there is a definitive percentage difference in earnings between genders for similar work.

I have seen women increase from a very small percentage to around 50% of the GP workforce during my working life, and it saddens me so many of them are unhappy. We are all faced with the reality that if you want to earn a lot of money, general medical practice may not be where you should be.


Dr Elizabeth Jenkins   3/09/2022 8:32:29 PM

Amen. Thank you for this powerful, well articulated article that touches on the many areas that general practice can aim to improve on. With women in leadership roles I am hopeful that we will be the change.


Dr Conor Calder-Potts   4/09/2022 9:14:26 AM

Gender stereotyping …


Dr Veronika Marie Kirchner   4/09/2022 9:53:17 AM

THIS IS NOT NEWS. Sorry for the shouty capitals. I’ve been a GP for 40 years and the gender pay gap in our profession was recognized decades ago. Why has nothing changed? What’s the answer? Special item numbers to be used by female practitioners only? Any suggestions?


Dr Bethany Reynolds   5/09/2022 10:55:59 PM

I feel this. I routinely run over and probably average 18 minutes for an average 23 consult. I see so many patients that have felt dismissed at the bulk billing clinic and come to see me, happy to pay a gap to be heard. Their symptoms may not be serious, but the time spent reassuring, explaining why I’m not worried and when to be worried adds up!
I particularly am impacted with this with the restrictions of only having a 23 equivalent for phone appointments. I’m constantly caught out going over 20 minutes discussing complex results with patients that I have seen face to face recently. there is no added benefit for another face to face or video call, but I am effectively punished for taking the time to explain, answer questions and write useful referrals to specialists.
it must be nice to be the the kind of GP that the government wants us to be; who appears cold enough people don’t open up about complex struggles, can usher them out in 6 minutes and be oblivious to their discontent…


Dr Bethany Reynolds   5/09/2022 11:03:24 PM

@dr Peter James Strickland

Is this satire? Or does someone in 2022 honestly believe that women don’t do procedures because of “ smaller hands, and due to their decision to not do the study and work of achievement”.

You claim men are more efficient with Pap smears - perhaps according to a clock. But what you don’t hear is how many women have told me that after a Pap smear that that first time it wasn’t a painful experience for them. I don’t think I do anything special, but if you believe other archaic ideas about women you probably also believe the cervix doesn’t have nerve fibres and that women with pelvic pain are just hysterical…


Dr Philip Charleson Manfield   6/09/2022 7:07:41 AM

As a GP with 40 years of experience, I resent the implication that male GPs do not practice holistic comprehensive care. Medicare rebates under-remunerate ALL GPs, not just women. For those of us (males & females) who do a lot of longer consultations, the only way to break this so-called gender gap is to value ourselves and the services we provide by ceasing to bulk bill. Charge a realistic fee for the length of the consultation, and if enough of us do this, we will force Government to do something about this discrimination against not just women, but all GPs. I did this about twelve years ago, and experienced true GP liberation, not just women's liberation. Please do not bleat on about people who can't afford to pay, as that is not OUR problem, it is a problem for an under-remunerated MBS i.e. Government.


M   6/09/2022 1:12:06 PM

You know what I don't get here? This article is predicated on the assumption that men don't listen to patients and that women alone are punished for "thorough care."

It is natural that if you don't do procedures or engage in some niche in general practice, then you will default to having more mental health consults. However, even proceduralists do mental health consults, and most of those are poorly remunerated for the emotional and temporal efforts.

What we have here is a terrible system that doesn't value time spent, but this article is an inflammatory, smutty prose that frames it as systemic sexism. Huge logical leap there.

There is no pay gap, the wage is exactly the same. How you work within that lousy system is a choice. If you see a lot of 18 minute consults, consider talking for another 2 minutes or remind your patients to respect your time and book for longer.

But please, don't wrinkle your nose at the poor returns and start blaming men.


Dr David Leon   10/09/2022 3:14:18 PM

to all the males commenting "what about me, I'm special" or "this is an issue for all GPs, not just female GPs"
you're making the same argument as "all lives matter" vs. black lives matter (and it's not a good argument).

yes there are issues in general practice effecting all GPs, but there are also further issues on top of these effecting predominantly females.

Additionally females saying that they have particular/additional issues or that on average they have a different demographic is not the same as saying no male GPs have these issues too.