Should patients determine their own gap fee?

Four in 10 Australians believe patients should be able to determine how much they pay for a GP visit, and would be willing to make a voluntary gap payment of $25.36 on average in return for shorter waiting times, longer consults and choice of doctor.
 
These are among the findings of a new study by the Monash Business School and Monash School of Primary Health and Allied Health Care.
 
Researchers proposed the idea of a ‘patient-chosen gap payment’ (PCGP) model, under which patients could choose their own out-of-pocket payment, rather than solely be bulk billed or charged the compulsory gap, to 1457 Australians.
 
But research co-author Dr Daniel Epstein, a GP and PhD student at Monash University’s Department of General Practice, is quick to clarify it does not mean GPs would see patients for free.
 
‘What we’re suggesting is a non-compulsory gap payment on top of the Medicare rate that would normally comes to a GP if they were, for example, bulk billed,’ he told newsGP.
 
‘The worst case scenario is that absolutely everybody pays nothing, which is what currently happens in bulk-billing clinics. So even if you have 10% of people paying 10 or 15 bucks, that’s extra revenue for the clinic that they wouldn’t otherwise normally get.
 
‘There are definitely patients out there who would be willing to pay but simply aren’t asked for it.’
 
The concept, if realised, could see practices choose to either run entirely under the PCGP model, or adopt it as a ‘middle ground’ third-option payment method.
 
Dr Epstein says the model would offer greater flexibility for GPs who feel ‘gridlocked by Medicare’.
 
‘A lot of the decision-making about how you structure your appointments, how you structure your day, how you process patients, how you do the paperwork, is based off the remuneration scheme of Medicare,’ he said.
 
‘You have to either bulk bill or you have to charge a gap to the person. If you could split those up and charge a patient chosen gap and also charge Medicare, it would enable a lot more flexibility for GPs to structure the way that they practice and be reimbursed for it.’

Policy simulations suggest the PCGP model could obtain up to 39% of the market share, with the potential to generate an extra $1.48bn in revenue for general practice.
 
But lead author Dr Duncan Mortimer, Associate Professor at the Centre for Health Economics, says that figure is dependent on the quality of service being delivered.
 
‘It’s a well-known finding that patients prefer quality. That means shorter waiting times, longer consults, choice of doctor, higher patient satisfaction ratings,’ he told newsGP.
 
‘If those things aren’t present, then there is additional revenue – the patient contributions weren’t zero – but [it] is a smaller magnitude.
 
‘We see this as empowering patients to really express their preferences, and to provide an incentive for GPs to respond to those preferences. The idea here is that not only would this increase revenue, but it would also provide a stronger incentive for patient centred care.’
 
As a result, Dr Epstein believes the model has the potential to provide greater access to quality care for vulnerable patients who, under the current models of funding, cannot afford it.


Research co-author Dr Daniel Epstein was keen to clarify the model does not mean GPs would see patients for free.

Dr Michael Wright, Chair of RACGP Expert Committee – Funding and Health System Reform, told newsGP the research provides interesting insight, but that the average voluntary gap payment of $25.36 per service falls short.  
 
The average gap payment for consultations that were not bulk billed in 2018–19 was $38.46.
 
‘This is less than what the average out-of-pocket cost currently stands for a privately billed consult, which suggests that patients may not be willing to contribute to the full cost of private care,’ Dr Wright said.
 
Yet-to-be-published GP-focused research by Dr Epstein shows many GPs are ‘very sceptical’ about the model.
 
‘A lot of them were under the impression that patients aren’t going to pay anything if they don’t have to, and that you’ll just get people who are bad GPs who’ll flog antibiotics and opioids in exchange for money,’ he said.
 
‘GPs are very good at picking it apart. But, at the same time, GPs are the first people to say we’re underpaid, Medicare hasn’t indexed in 10 years and we can’t get any more funding from the government.
 
‘But it’s getting to the point where chronic diseases is so that we can’t actually fund good quality care of it completely from the government.’
 
Dr Wright says the research is sure to spark discussion around the delivery and funding of primary care, but highlighted that it remains an experimental model that could pose real world challenges.
 
‘The current restrictions in Medicare, which don’t let you charge a gap payment, mean the patient would have to pay for the gap plus the Medicare rebate in order to get it back,’ he said.
 
‘The other challenge is, if patients had concession cards, then practices would lose the bulk-billing incentive and not be certain what the voluntary payment might be.
 
‘[The research] does give you more information, but we’d just have to be cautious to make sure that the results are fully applicable for real general practice.’
 
Associate Professor Mortimer and Dr Epstein plan to find out.
 
They are currently building the evidence, including further research with GPs, for a real world trial.
 
‘Obviously one of the major limitations of this study is the participants didn’t face an actual loss of money. So you don’t know if what they’re actually suggesting they will contribute is the amount they will contribute,’ Dr Epstein said.
 
‘Likewise, you don’t know if those behaviours will become extinct over time and they might contribute less over time. But you don’t know unless you actually trial it.
 
‘I just think it’s time for GPs to at least rally around alternate ways of creating funding and revenue for primary care.’
 
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