My vulnerable patients cannot pay large gap fees. Australia’s health system is failing them

·5 min read
<span>Photograph: RayArt Graphics/Alamy</span>
Photograph: RayArt Graphics/Alamy

Last week I took a call from a frail older patient. He was distraught, tired after sitting on a fractured femur in the emergency department waiting room for 12 hours. I had sent him to hospital the day before, X-ray report and handover letter in hand. And he had left in pain, 12 hours later, without being seen. It took me two hours, with an interpreter, and calls to three different hospitals, to finally convince this gentleman to return to a different hospital. That evening I picked up my children very late. For this work the Medicare rebate was $39.75.

It wasn’t until I’d hung up that it really hit me. We are in big trouble. Even someone with a diagnosed broken hip can’t access timely care. Our health system is overwhelmed and we are drowning.

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I should have known that this was coming. We are in the middle of a healthcare crisis, exacerbated by local Covid-19 epidemics. I knew that my local outpatient departments had long waiting lists and increasingly prohibitive referral criteria. I knew that my patients kept waiting for non-emergency operations. And I knew that my own GP clinic was getting more and more desperate calls from vulnerable community members, asking if we could please, please make an exception to our closed books.

General practice is the heart of primary care and it is the foundation for any strong health system. In its humble, quiet way, it can save money and save lives. But the truth is that many Australians now can’t afford quality GP care, due to decades of severe government underfunding. So they’re going to an ED, later and sicker than when they would have seen their GP. It’s cheaper for the patient but delayed care is much more costly for Australian taxpayers. It leads to overburdened EDs, expensive hospital stays, worse health outcomes and increased deaths. Our EDs are overflowing, and this is in part because general practice is overflowing.

We need to remodel the system so health workers aren’t financially punished if they work with those who need it most

They say every system is perfectly designed to get the results it gets. In Australia almost all GP clinics are private businesses, dependent on the Medicare rebate system to support patients to access these services. The Medicare benefit scheme system has been undervaluing the importance of primary care for years. The MBS for general practice encourages throughput and shorter consultations. It disincentivises longer consultations, complex care, conversations and communication.

Nine years ago a Labor government introduced the Medicare rebate freeze, a “temporary” measure, as part of a $664m budget savings plan. This has been continued by shortsighted successive Coalition governments and now we see GP practices scrambling to add gap fees to cover increasing costs, or reduce consultation times. Twenty years ago around 40% of medical graduates became GPs. Now, only 15% choose the specialty. GPs carry an immense burden of responsibility for the health outcomes of their patients. Why would a young doctor decide to become an undervalued, harried GP?

There’s a trope circulating about greedy GPs. But at Utopia Refugee Health, everyone has taken a pay cut to work here. Everyone is here because we care about the people we serve. And yet we are feeling the pinch more than anyone else. We have constant discussions among the staff: how do we recruit GPs to do this interesting, transformative community work? There are no GPs around. There is no extra funding from any government to support us. How long can we afford to stay open? Our patients, who are some of the poorest in Melbourne’s west, cannot afford large gap fees. They have complex bio-psycho-social needs and they need time and quality GP care more than most. But the system does not support this. There is no funding for our patients beyond Medicare, and it is failing them, and so many more.

Related: ‘Treated as a third-class citizen’: patients who need Medicare most struggle to find a GP who bulk bills

Altruism isn’t a sustainable way to run a health system. And relying on the free market doesn’t always work. Especially not for healthcare. Medicare should fund longer consults, not reduce your rebate if you need more time with your doctor. We should empower, not deter, doctors to spend time with people who need extra care: those with complex health needs, mental illness, with low literacy or language barriers, with social stressors and chronic illness. Medical schools must prioritise diversity and support those from poorer backgrounds. Training and recruitment schemes should attract the brightest GPs and health workers to build skills and work in poorer and disadvantaged communities. Clinicians in community health should have the option of equivalent salaries to their colleagues in hospital systems. We need better services for those who are struggling, left with low-quality care in our “universal” health insurance model. We need to remodel the system so health workers aren’t financially punished if they work with those who need it most. Patients deserve better rebates and quality care. We need to unfreeze primary care so it is not stuck in a bygone era.

To alleviate stress on the whole system, we must redesign and boost investment in general practice. Primary, preventive care should be valued by policymakers as the foundational skeleton of the health system, giving patients continuity of care and saving the healthcare dollar long term. A system that cares well for a vulnerable person with a broken hip is a system that will look after you and your family when you need it most.

• Dr Mariam Tokhi is a GP, writer and educator in Naarm. She works at Utopia Refugee Health in Hoppers Crossing