Feature
Does Medicare discriminate against women?
Five GPs reflect on being a woman in medicine and the ‘sad reality’ of a system that rewards speed over holistic, comprehensive care.
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.’
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.’
Medicare’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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