On medicine and public money in Australia

Recently I was at a meeting organised by a community pharmacist to “remind” myself and other general practice doctors about a scheme available to patients that not only can help patients, but just also happens to be remunerated quite well by Australia’s federal health care system, Medicare. And I mean it pays general practitioners (GPs) well, and it pays pharmacists well. Suddenly another GP in the room asked just why are we being paid extra to do this when as GPs we have little to actually contribute to this patient’s particular health care encounter. The room fell silent. I couldn’t believe that finally someone had said what I had suspected for some time but didn’t have the courage to admit: that in some instances, the government does misspend money allocated for health care. I know, it seems so counterintuitive, so out of place, to suggest this at a time when the Australian government is saying that health care funding is becoming unsustainable, that the need for it has made it such a drain to government funds that it’s become unaffordable to fund alone on public money.

So where are the holes in the bucket with public health care funding? Well, in the interest of open disclosure I will admit that it’s been years since I worked in the public hospital system. I work in private practice, but as most doctors in private practice, still work under Medicare rules and (federal) funding. What I mean by this is, although we work in medical clinics that are privately owned, we receive Medicare money for part or all of the work we do. The choice to accept Medicare funding as the whole payment for services provided (i.e. “bulk-billing”) or only as part of the total fee is each practitioners choice. And the choice is not as simple as “some doctors are greedy and some aren't”.

I’m not a greedy person, but I refuse to accept the inadequately-low fees Medicare offers as payment for most general medical consultations. Let me explain this with a simple everyday example. Seeing a patient for a general medical complaint in a consulting room for 15 minutes costs the medical centre about $65-$71. That is what it’s going to cost to pay the doctor, administration staff, building running costs, etc. Now, Medicare Australia only pays $36.30 for this service. The federal government pays that not because they have calculated that that is what it actually costs for the medical centre to actually fund this consultation. No, this has been a federal budgeting decision that says that that is all the government is willing to pay for this service. It does not take into consideration the medical needs of the patient, the individual patient’s financial situation, and it certainly does not take into account the real costs of medical practice today. So, the government has essentially given the Australian public Medicare cards that you could roughly equate to “50% discount” cards (when used in private general medical practice), but they have unfortunately gone and told them that they are “100% discount” cards. And what’s more frustrating than patients not realising this, is that they expect this, politicians tell them they have a right to receive healthcare from private practitioners that are 100% subsidised (what is commonly called bulk-billing) using their 50% discount cards. What happens then is that medical centres have to charge individual patients the difference of what it actually costs to fund their healthcare and what the government is willing to pay on their behalf – or you go to a medical centre that has adjusted their practice not to suit the patient’s medical needs, but to try to make the smaller money from bulk-billing stretch (I won’t go into their practices, but there’s a reason I refuse to work in that system). But that’s not the story the governments tells the general public, honesty doesn't win votes, what they tell the public is that doctors are charging them more because they are greedy, not because governments are not funding their healthcare adequately.

Having said that, let me now discuss instances where I feel funds are not best justified. Some years ago, it was brought to the government’s attention that there is a high incidence of mental illness in the community. This affects a large proportion of people’s health, and ultimately it also becomes a drain on the social welfare system. It was identified that psychotherapy could help a lot of these patients with mental health problems. So it was then decided to allow Medicare to fund psychologist visits if it was deemed by a doctor that this was likely to benefit a person’s mental health. In order to encourage GPs to asses patient’s mental health and subsequently refer them to psychology services, Medicare offered substantial funding to GPs to provide this service. Considering the high incidence of mental illness, the cost of paying GPs and subsequently also funding psychology visits, this resulted in a massive new/extra expenditure for Medicare. So although the government wanted to encourage extra referrals to psychologists, they wanted to make sure that people weren't being unnecessarily referred who perhaps didn't require it. To ascertain this, Medicare introduced clauses that referring GPs had to obey, things like how long the consultation  must last, what must be covered in the consultation, what things had to be recorded in patient’s charts and in referring letters, etc. As time has passed, these things came to lose their function: most GPs could take less than 20 minutes (one of the initial clauses) to identify that a patient likely was suffering a mental illness that may benefit from psychotherapy and write a simple referral for this. In fact, I would argue that were it not for trying to meticulously (and unnecessarily?) follow all Medicare clauses, this could all be done in the course of a single standard medical consultation. Remove the clauses, respect doctor’s clinical judgement more, and get rid of special extra incentives to GPs. I know, I know, how dare I suggest a “pay-cut”? I’m not, really, all I’m suggesting is a redistribution of public funds within healthcare.

I could raise a similar argument about other general practice activities that are all clunked up with a lot of Medicare clauses, that pay a lot money (and I say this only comparatively to other general practice activities like consultations [which are underfunded]), and that could be just as well performed by doctors without either the extra clauses or the extra money. I mean things like home medication reviews where it is acceptable that pharmacist are paid for, but it is hard to justify why doctors should also receive an extra reimbursement when we are already expected to review patient’s medications as part of a normal consultation. A lot of people also seek ‘care plans’ to be eligible for some Medicare-funded allied health services. Why not just trust that GPs can make an assessment in a general consultation that a patient has a chronic illness and would benefit from allied health assistance? And while we’re on Medicare-subsidised allied health referrals, why is Medicare funding referral for therapies whose benefit’s on people’s health is not widely accepted and tested as beneficial? Medicare offers subsidised consults with osteopaths and chiropractors for patients with chronic illnesses (on a care plan) who have been referred by a GP. Why? Even some private health funds refuse to subsidise this (due to their unproved benefits) and the Australian government thinks it is worthwhile throwing precious health care dollars at it?!

To maintain my focus on what I have more personal experience with, I haven’t commented on how public health care money can be misdirected in public hospitals. However, you can speak to many public health employees in Queensland and they’ll all be able to tell you that a lot of public health care money is directed to bureaucrats and purely bureaucratic processes. Now, I will give you a simple example of how I have noted this happening more and more – even from my end as a private practitioner in the community.

Remember how one of the “perks” of private health insurance in Australia is said to be that the patient can nominate which specialist they are to see? Well, the opposite of this is that if you attend a public hospital, there is no choice given and people are triaged on clinical need, etc. as to which practitioner they see and in what relative time frame. Well, a few years ago I could refer a patient to a public hospital outpatient clinic for review with doctors of a particular specialty and exactly that happened: the patient received a letter to attend an appointment to the outpatient clinic of a particular specialty. Do you know what happens now? That when I send a referral for a patient to see a general surgeon, for example, in a few days’ time myself and the patient receive the first of a series of letters. This first one says this clinic is heavily booked, reconsider the referral, and go back to your GP to discuss this further (I tell patients to expect this letter and to ignore it). The second letter is just for me, and  it says that the patient has been given an appointment with a specialist (but they don’t state who) but because of Medicare rules, could I please tick the name of the specialist on the form, rewrite my referral, sign this new referral form, and then fax it back to them. But the patient already has an appointment booked with a particular specialist so that’s the specialist’s name I need to tick (I have to call them to ask them who this is before I can fax it back to them), and they obviously already know the clinical details I had on the original referral or the appointment would not have been booked. After I return the form to this hospital booking department, the third letter (and the only one that needed to be sent, really) arrives giving details of when the appointment is booked for. I ask myself why all this bureaucracy? And more importantly, which of my hospital colleagues in clinical roles lost their income so that this crazy bureaucracy  could be funded?

On happiness (again)

I just found this quote again from The Zahir, one of my favourite books by Paulo Coelho: "No one should ever ask themselves that: why am I unhappy? The question carries within it the virus that will destroy everything. If we ask that question, it means we want to find out what makes us happy. If what makes us happy is different from what we have now, then we must either change once and for all or stay as we are, feeling even more unhappy."

I haven't been happy lately. I mean, I don't even know if I'm unhappy, miserable, or just expectant. And I thought to try to solve my question of whether I am happy or depressed or what by asking myself this: what would it take for me to be happy? Well, I always thought that I'd like to have a family unit of my own, to provide a house for them, to provide for my family, to work a job I don't hate, and to raise a child and be a good mother. But lately it's becoming tiresome having to get up in the morning and go to work. I want my work day to go quickly. I want tomorrow to take it's time getting here. I want the weekends to last forever. I want to stay in bed longer, to eat more, and more time to sit and not interact with anyone.

I figure I'm not depressed as at least I still want something, even if they are avoidant things. I remember a time when I was depressed and I just wanted nothing at all, when nothing mattered at all. So at least I do want things now. But am I happy? Will I ever be happy? I think I want to be. Yet I remember another quote, another favourite of mine, and I remember why at the same time I want never to be fully happy. I've also quoted this, by Charles Becker, before: “I would urge that you be dissatisfied. Not dissatisfied in the sense of disgruntlement, but dissatisfied in the sense of that ‘divine discontent’ which throughout the history of the world has produced all real progress and reform. I hope you will never be satisfied. I hope you will constantly feel the urge to improve and perfect not only yourself, but also the world around you”.

Is that why I'm unhappy? Is it because I do always want to be progressive, someone who is always active and contributing? Or am I just depressed? Lately I've been thinking about the very real probability that I may actually have the chance to start my own family soon, and I am so wanting it, so contemplating it as a reality I want, that it's making the rest of my life seem tedious and just like a filler in time. And, oh God, the possibility of not having a family and a providing for them - that is pure misery! The thought of it can put me in tears and despair. Am I unhappy? Is this vision of "happiness" unattained slowly killing my spirit? Or is it something else? Sometimes I think the best way out of all the uncertainty that is weighing me down is to just ignore the questions and simply move forward.

And maybe it's not even forward that I need to go, but backward. That is to say that sometimes I think it's best I go back to simpler times; like the time I first learnt about positive and negative contingencies. Recently my pet rabbit became ill and I hadn't felt that miserable in such a long time. I was petrified she may die and was suffering. I wanted her so badly to be well again. She needed surgery and was at the vet hospital three nights. I worried endlessly about her. I thought that if she dies, my life will lose its centre of balance and I would be immensely sad. I cried at the thought of it. When I finally got to bring her home, she was still quite fragile and I was still worried, though not as much as previously. Then I remembered to set myself a positive contingency: as soon as she's eating, drinking, and pooing normally again, I will be happy as I will know she has recuperated. That happened a few days after she came home! And even though I was upset from other events in my life, I actually felt happiness again in my heart to see my little rabbit eating away at some food. Yes, such little things can make me happy if I allow them too. And it is also true, of course, that also little things can make me very unhappy if I allow them too. But for now, my rabbit is eating her hay, hopping around, and I am a happy woman again, moving forward :)

On insight

When I was younger a psychologist once asked me why I always ended up in relationships with people who were 'unavailable'. Of course, she asked me this rhetorically to prompt me to reflect on the pattern of my relationships. She asked if I could remember the first time someone had made me feel like I was vying for their attention and yet I wasn't getting my emotional needs met consistently. Yes, how cliché, it was with my mother as a child! Now, what most people instinctively do when we find a source to our problems is it either 1) brings us comfort by allowing us to say "hey, it's not my fault I'm like this", or 2)  we feel guilty that we are the way we are. The problem with blaming the past, though, is it's of no use to anyone if it doesn't force change.

If we feel guilt (which is an unpleasant emotion and thus makes for a great self-flagellation device), we come to believe that feeling guilty is exoneration enough for doing what we do. But if feeling guilty is ALL we do, we usually just continue to behave in the emotionally-immature coping patterns we're used to. It's not enough to feel guilty. It's not enough to wait passively for things to change. In real life, the poor little victim princess doesn't magically get rescued by a hero. In real life the princess needs to build up her strength, overcome her own past, and slay her own dragons in order for things to change for her. It's not a matter of 'good things happen to those that wait', but rather good things happen to those who make things change.