Is mixed billing the answer to business sustainability?

Anastasia Tsirtsakis

21/12/2021 4:27:09 PM

Government funding for general practice has failed to keep up with the real costs of running a small business. So what options do GPs have?

Doctor using a smart phone in his office.
The RACGP has compiled a range of resources to assist GPs around managing billing.

Practice viability has been a longstanding concern for general practice.
A rise in chronic disease has resulted in patients needing more one-on-one time with their healthcare provider, while salaries and the costs of health technology have simultaneously increased. The pandemic has also generated additional operating costs, such as personal protective equipment, rapid antigen tests and additional staffing.
All the while, government funding has failed to keep up.
But with a growing need for high-quality care in the community, how can practices remain viable?
Dr Emil Djakic, who is a member of the RACGP Expert Committee – Funding and Health System Reform (REC–FHSR), believes an important first step is for GPs to look at their billing and costs.
‘General practice has got a much-celebrated diversity in delivery,’ he told newsGP.
‘GPs need to be talking about whether they are achieving the outcomes that they want as a doctor. And if they’re not, how do they plan to address that?
‘From a fiscal outcome point of view, there's only two variables – work faster and longer, or charge more.’
To make this assessment, Dr Djakic advises that each GP consider what they think their working year is valued at, both from a fiscal and professional point of view, and how it fits with their social conscience.
‘They’re all part of this equation,’ he said.
Dr Djakic did exactly that almost 20 years ago. He analysed his average billing rates, how much time he sets aside for leave, how many patients he sees per week and the costs of the practice.
Where he initially thought he had to work harder and faster, he discovered that less was in fact more.
‘What I found was that I didn’t need to see 35 patients a day, I needed to see 28 to reach my target,’ Dr Djakic said.
‘It actually meant I could relax more. I could sit back and focus on my role professionally and found that it was more sustainable.
‘If you want to set yourself an unrealistic goal, go for it, [but] you’re going to have some problems.’
To assist GPs, the RACGP has compiled a range of resources around managing billing and maintaining wellbeing, including a billing calculator aimed at presenting GPs with a clearer picture of their current set up and the possible outcomes of tweaking their billing model.
Meanwhile, a number of case studies have been made available, outlining possible mixed billing options, including strategies to consider such as bulk billing certain patients and specific services.
While many factors influence a clinic’s billing practices, including patient demographics, practice location and desired income, Dr Djakic says it does not have to be all or nothing when it comes to passing on the cost of care to patients.
‘You don’t have to all of a sudden move to charging everybody,’ he said. ‘The big area to look at in general practice is not so much those who have concession card holder status, but those who don’t [to whom] general practice continues to provide a discount.
‘You can choose to select which part of your standard population you might choose to pass costs onto. It is a reality that the community lives with anyway, you only have to look at the price of petrol at the moment – this is the real world.’
Members also have access to a presentation on ‘Work-life balance and valuing your professional role’ recorded by members of the REC–FHSR for GP21. It encourages GPs to think about their personal expectations in terms of income, financial sustainability and work-life balance, covering:

  • issues affecting the sustainability of general practice
  • billing habits of GPs and other medical specialists
  • strategies to improve practice viability and achieve a better work-life balance
  • RACGP resources to help GPs manage their billing.
Dr Djakic said the benefits of practice sustainability are far-reaching, and have a flow on effect to patients and the quality of care they receive, but also the sector and its future.
‘We are wanting to see that profile raised because losing doctors to the system because of business or losing practices completely is a disaster for patients, and it takes a long time to restore or repair, particularly if it’s in a fringe regional or rural area,’ he said.
‘We’d also like to think that happier, healthier, more fulfilled GPs are going to find themselves choosing to stay in the system for longer and that will add to the net workforce base over time.
‘We will also, I think, find ourselves talking to our junior colleagues and our students with a little bit more positivity and enthusiasm to say there is a future here for you that’s professionally fulfilling, financially rewarding and vocationally delivers in serving your community.
‘Getting that balance right is important.’
The RACGP is set to undertake a number of activities in the new year to encourage members to think about their billing model, and whether it is sufficient to cover personal/practice costs and achieve an optimal work-life balance.
For Dr Djakic, it is about empowering all college members, from practice owners to contracted GPs, to take action.
‘There might be those GPs who are currently working in an employed setting thinking “surely there’s more”,’ he said.  
‘Or it might simply be existing GPs who just think “if I tweaked this a bit and achieve the same financial outcome but I’m working 5% less … that means I can go along and watch my youngster play football down at the local ground on Wednesday night”.
‘Those things matter – and that’s not indulging the profession, it’s just acknowledging that you’ve got to have that balance.’
The case studies and video are available on the RACGP resources to help you manage your billing webpage.
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Dr Oliver Frank   22/12/2021 7:39:45 AM

I am wondering whether the model available for non-GP medical specialists could be part of the answer. This model is that those who are able and willing to pay private fees are seen in private practices and those who are unable or unwilling to pay private fees are seen by salaried doctors in government-owned and operated facilities.

Alternatively government could provide differentially higher Medicare benefits for those who the government assesses as unable to pay private fees unaided, with the highest Medicare benefit for the poorest equalling the reasonable private fee. We have differential Medicare benefits now in a small way in the form of the bulk billing incentive payments.

Dr Mark Ian MacKenzie Peterson   22/12/2021 9:21:11 AM

This was plain to see about 30 years ago :)

Dr Suresh Gareth Khirwadkar   22/12/2021 12:04:47 PM

This is exactly what I did and I’ve never been happier.

@Dr Oliver Frank

The non GP sector is already a grossly inequitable 2 tier system, and basically pay to win, I’m not sure encouraging that in primary care is a good thing.

Dr Campbell Robert Crilly   22/12/2021 2:36:18 PM

Bulk billing rates have not kept pace with practice costs. I am pleased the college is promoting private billing. GP's have been treated poorly by governments and the public. Private practice is just that and deserves an appropriate fee for service. What fee is charged will differ between practices and hence competition will be evident. This is a very positive change and needs to be supported and promoted. General practice is a specialist field and should be respected and rewarded for this.

Dr Peter James Strickland   24/12/2021 12:08:00 PM

The answer to the GP problems with their fees and bulk billing is there in the action of the GPs themselves to solve the problem. ALL concession card holders pay an extra $5 (min)per standard visit, and also for dressings and such things as sutures etc (up to maximum of about $50). ALL the other patients pay for a fee in the range of $60 for a standard consultation, plus dressings, theatre fee etc.. The bulk billing fee is an "insurance" payment made by the Federal govt, and should NOT be the fee charged. The RACGP should institute a date (say March 1 2022) to tell every member of the RACGP to start that fee structure. Concession card holders can almost all pay something to their GP for their medical care. It is done by them for specialists, lawyers, car mechanics etc etc, and so should also it be done for their GPs. Toughen up, and look after yourself, your staff ---and your families!