3:50
I would like to acknowledge the traditional owners of the lands of which we each are meeting across the country and for joining this webinar today. I wish to pay my respects to Elders past, present and emerging. For the webinar, on your control panel it will appear as a black bar at the bottom of the presentation with the audio settings that you require. You can flag the questions and answer through there for us to receive. The black control panel… if you can’t see the image like that, hover your cursor over the bottom section of the shared presentation screen and the panel will appear. This panel allows you to set audio settings like speakers you are using and interact with the presenters through the Q&A. We are in a listen-only mode for those who are attending, so you have been placed in a mute button to optimise the opportunity for the learning experience. Use the question box circled below to present a question-and-answer for us to collate and work with later in the session for the question-and-answer phase. So, move to welcome and introductions, this is flagged. I am Dr Emil Djakic, Chair of the RACGP Business Sustainability Working Group and a GP based in Ulverstone in Tasmania, a regional rural area. We also have Dr Lisa Fraser, RACGP member of the Queensland Council. Emma Keeler, member of the RACGP Business Sustainability Working Group. Dr Bernard Shiu, who is also a member of the Business Sustainability Working Group, and Mukesh Haikerwal, who is a GP from Altona North Medical Group. Tonight we will hear from these four RACGP members about their billing model that they have in their practice. The aim is to encourage GPs to reflect and review on their own billing practices, to hear lessons learned from peers who have implemented mixed billing models, which reflects a combination of bulk billing and private billing. Our presenters will take questions at the end. A quick recap as to why we are here, the statistic of just 16% of our final year medical students in 2020 listed general practice as their first preference specialty. That particular percentage number does really raise concerns for us and the ability of general practice as we have in Australia continuing in the form that we have got. We also recognise that the insurance system of Medicare has a rebate for a level B consultation that increased by 65 cents in July 22 to AUD39.75, and that rebate has gone up by just AUD3.45 in the past decade, and clearly reflected as a problem in terms of the rise in the cost of living over what has been a decade. This graph has probably been viewed before, but it has the additional numbers now for 21 and 22, showing the increase that we have seen associated with inflation and where the rebate for Medicare should be if it had followed that journey, and the actual increase that we have experienced over this period of the past 10 years. Of course today we are greeted with the figures of inflation in Australia being at 6.1%, our adjustment for the year in Medicare clearly has not entertained even reflecting that in terms of parity. So, the divergence of these figures clearly represent a major falling behind of the insurance system for primary care and the future ahead, at least in the near future, does not bode well at all. So, these statistics tell us that bulk billing rates we are told remain high despite chronic underinvestment in general practice by successive governments. According to the productivity’s commission report on government services, 67% of patients are bulk billed sometimes for their care, so, there’s a rather big difference between the government's stated figures, which reflect 88.8% of GP services were bulk billed compared to 35% of non-GP services. The truth of what’s actually happening in our community and billing practices with regards to general practices billing does not seem to be completely reflected in the quoted quarterly Medicare billing statistics and how that particular 88.8% is derived continues to remain a reasonable mystery, much to our distress, not that we haven’t tried to look for it. It is important to remember that we feel that this high figure is misleading and not representing the truth, and we as a college would like to start moving towards looking at data that can help us support our members by a more accurate reflection of what is actually happening in the community. The RACGP view is clearly billing is an individual choice because there are many factors and how you might choose to pass on your costs for your service on any one day to any one patient. The RACGP isn’t in the position to be dictating what someone can charge, and hence the RACGP does not have a list of recommended fees. We have a very diverse community, we have a very diverse population of general practitioners in the way they deliver their services and who and how they do that. So, set fees which we are approached about quite frequently are not part of the college’s platform. Patient education on billing is a necessary part of the relationship between the GP and their patient, including the need to really focus on making sure the patient is aware that Medicare acts as an insurance to help subsidise the patient's cost of care in general practice and other health services. It is not the fee for general practice and this particular representation of it being the published fee is of course a myth, and a myth that I think our Medicare system is quite happy to see perpetuated. So, referring to it actively as an insurance for patients is important and in no way is the expectation of the full cost of the service apart from the one anomaly so far, which has occurred in the COVID vaccination arrangement. So, the college really is asking members to carefully reflect on their current billing models and really looking at them from that point of view of, is it sustainable. It is important to consider that, there are patients in our practice who do live under abject poverty and who have difficulty in maintaining and meeting the cost of living and healthcare is only one of the costs in their daily lives that they have trouble meeting. So, we aren’t ignorant of the need of that part of the community, but at the same time there are an awful lot of people in our community with the capacity to afford the services that we as an industry continue to bulk bill and hence accept the substantial discount for what the service is perhaps worth. There isn’t a one size that fits all, and clearly change and implementing change creates some difficulty for the community and patients, particularly when it comes to finding that they are out-of-pocket or more out-of-pocket than they were expecting to be. That is an inevitable difficulty and hence the change process has to be engaged in an informed way, both with your practice team of doctors, nurses, receptionists and managers as much as with the patients in the community. Applying a combination of bulk billing and private billing, the college’s position isn’t one of stock bulk billing, it is one of consider changing your billing practices in some of your patients and moving to some full-cost payments to patients will improve practice viability and allow us to compensate for what clearly isn’t happening in the bulk billing subsidy that is coming the patients’ way. Increasing the amount of out-of-pocket costs is a sensitive pressure point from the government's agenda. Increasing questions are coming from patients and the community to their local member, local senator and politician in general, is a sensitive area that we think isn’t something that we are exploiting, but it is something that’s going to promote some response within the funding of Medicare. Reduction in bulk billing rates may lead to government finally choosing to invest in general practice services in a more substantial manner supporting our GP colleagues who are working in other areas clearly where their choice is mostly to bulk bill because of the nature of the communities they serve. So, we are not here to tell you what to charge, that’s not the role of the GP, other organisations do have recommended fees lists that people can look at and again, they are only recommended fees lists and hence people belonging to the AMA will be familiar with that. The RACGP is here to support the diversity of general practice and the setting of fees and it should be considered appropriate. Don’t be afraid of change. These conversations are a big shift for both patients and GPs, again communication about why, about your costs. Of course, having flagged that the set rate of inflation of 6.1% at the moment applies to us as much as everybody in terms of our costs of employing staff, our costs of disposables, our costs of power rental, we appreciate those costs aren’t there for the community as well, but your business, my business, if we don’t make some allowances for that inflation rate then, yes, you will find yourself falling below the viable line and wondering why your business isn’t going to be sustained. Billing rules as part of Medicare is an inevitable thing that we all need to digest and understand very clearly, and repetitively stated bulk billing is when you accept the Medicare rebate for the full payment of a service. So, them assigning the benefit automatically is an indication that there were no other costs passed on, meaning if you bulk bill you can’t raise any additional charges for that service. If you privately bill a service you charge a patient first and then they receive the rebate amount back from Medicare. In the majority of cases now working through the telecommunications and point of payment services, that process happens almost immediately. It does pose a problem for some patients who rightly can say that the bill you just gave them for an AUD80 for your level B, that they don’t actually have AUD80 in their bank account to pay you and hence can’t trigger the component of the automatic payment system. They are valid arguments that patients can raise, but they are not things that are insurmountable. If you provide multiple services during the same attendance, you can bulk bill some or charge the rebate level for some and privately bill others. The only exception we flagged, I think the first statement is important and we did find this from our first seminar or webinar we ran a few months ago, that some of our questions came with some surprise that they thought they had to bulk bill. Now, there may be some practices across the country where that is the expectation and that is a discussion between you and the person or business you are contracting with or you are employed by, but for the great number of people who are in a contractor situation the choice to either accept bulk billing or raise a fee is the choice that sits at your desktop between your patient and you. The only exception were services involved with COVID-19 vaccine in this past year or two, and that wasn’t something that we seem to have been able to make any great difference with. So, the thought that the choice to be involved with private billing is outside your remit is an unfortunate one. I will move on now and introduce Lisa Fraser, who is going to take us through her case and experience and the changed management side. Now, I will hand over to you Lisa. Oops, no, we haven’t got Lisa there, have we?
19:53
I do.
1954
There we have, there we go.
19:55
Yep. Hello.
19:56
All good Lisa, welcome aboard.
19:58
Thank you very much. Alright, welcome everyone. I am a voted member on the Queensland Council of the college, and a GP and practice owner in far north Queensland, 30 minutes south of Cairns, and my billing and ownership journey has started three-and-a-half years ago and I bought a practice off two retiring male full-time GPs, and so we have had to have a lot of discussions about money and about billing, because things change between doctors and things change over time and these doctors have been in the practice for sort of 20 to 25 years plus, so there were some things that had evolved that were good and some things that didn’t. So, that naturally… so when you have change I guess there’s opportunities for conflict when there is change about spending if you don’t flag that properly, that is more of an opportunity for conflict. So, if you have a look at our fees there, we are in a low to medium socioeconomic area. A lot of our billing is historical, we bought a business and that was billing that they had come to over a long period of time. Interestingly, yeah, we look around as to try and establish our fees, we are the only practice in town and 30 minutes from Cairns, so, we factored that in, we think that we are saving people visiting Cairns and that sort of thing. Yes, we do the bulk billing of the children and the pension cardholders. We recently increased our fees from, I think we moved from 82 last year and then 80 the year before, that’s like pretty standard for the area. So, I guess probably the biggest issues for us were there were some people who … some of the doctors who had left who had sort of evolved into a very bulk billing… a lot of bulk billing practice and then when I came in and inherited those, even though the sign at the front said one thing, when they went to leave from their first visit with me, they would say Dr X always bulk bills me, why are you charging me? And that wasn’t sort of explicit and there were some difficult conversations. I guess we had to do a lot of communication, so we had to have reception. We did a bit of a drive, a communication drive with lots of posters and said, look just because you were bulk billed before doesn’t mean you will be bulk billed again, there’s been a change of ownership, these are the reasons, and we flagged them. That reduced the amount of conflict we had around at the billing counter when people had to pay for the first time after not having to pay for some time, so, that was a learning journey for us, and if I would ever change things I would do a really hard drive on communication, so website, posters on the front door, that kind of thing. I have to say despite doing all the communication in the world and we have got a HotDocs system where you actually click on the agreement button that says, yeah, I agree to pay a private fee. People can still appear surprised at the counter when there is an out-of-pocket cost. Alright. So, how much time have I got, because I am not very good with time, so I am going to rely on someone to give me a little bit of a nudge.
23:49
Well, a question from myself Lisa is, patients who are the frequent visitors to the practice, the complex condition ones, where does that fit in your model around social equity.
24:10
Yeah, I guess I have had to understand what my business needs to be viable. So, I have to balance how much is my business need to make to meet my expenses and also to meet the cost of the future, upgrading IT, upgrading instruments, growing services. It is very hard to get good staff, I want to be able to pay my staff as much money… a good amount of money so that I can be competitive with a hospital that pays nurses and other healthcare providers very well. So, I need to make enough money, so then I balance that with who can I bulk bill. So, naturally we have got some 65 to 85 100-year-old patients who at various times when they have an ulcer or a fall, might actually come, like, for dressing three times a week for a short period or come weekly to check their blood pressure. I guess the way that I do that is to make sure I use my nurses as much as possible. I minimise the impact of expensive dressings by involving BlueCare or getting them to bring in certain specific special products. I make sure they have had their health assessment and I use the reminder system to make sure that they are up-to-date with that and I make sure I do their care plans on time and that I use my nurse as much for that and less doctor time. So, that’s the angle that I come at it with. I also try and make sure I get their health summaries done so I get the payments… and yeah, that’s kind of how I do it, and I try not to, although they are complicated, I try and see them for a small amount often because often cognitively I find the load quite high rather than for big long chunks at a time.
25:54
Yeah. And in the more complicated consults which involve multiple things which might relate to procedures, the consultation and the like, the use of bulk billing and private charge, is that something you think about a lot or…?
26:16
I am not very good at that, which is why I am sort of involved in the webinar, I will be very frank and open and say there are some things I think I have learned well, but I am certainly not an expert in everything, but I am interested in those things, I don’t do them. I mean I might bulk bill an ECG, but privately bill a consult, is that what you mean?
26:35
Yeah.
26:36
Or privately bill a vaccine… like, prior to the Queensland Health’s sort of free vaccine rollout, I might have privately billed a flu vaccine and privately billed a consult or bulk billed a consult, yeah.
26:52
Yes. You would be in an area with some rural classifications, so you have got access to the 10991 numbers.
26:58
Yes, yes.
27:03
The additional incentive numbers for bulk billing?
27:05
Yes, yes.
27:07
How much thinking do you do there when there’s two billable item numbers, which then will flag two 10991s. Is that something you think about in terms of how…or does that just get like too hard (overlapping conversation)?
27:20
I am aware of it, but at the moment my head is sort of … is still cognitively sharing the clinical stuff. No, I don’t actually think about that. Tell me how you think.
27:37
Oh, I think it is an interesting one to realise that a cost passed on as a gap fee for say a consult service is very much out of the patient's pocket. But if they have an ECG or another service then we have already accumulated 22 to 23 dollars worth of other rebate from the 10991s that are there. So, quite rapidly, if we bill we lose that.
28:08
Lose it or is it we make it up?
28:10
Well, we might still end up with the same amount in our pocket, or close. The patient ends up with AUD21 or AUD22 less in their pocket and the bit that really hits me then is the government is actually the winner by AUD22. It is an interesting equation to think sometimes it is not worth your while to raise a private fee on a gap of AUD20, when you are already triggering an incentive. So, that’s just a complexity which makes some decision-making I think fantastically more difficult.
28:57
I think… my lessons there are around trying to be consistent, to be okay to talk about money, but in a limited way and to communicate broadly before the patient gets into the clinic about any changes in fees, so they are my biggest lessons. And also to make sure, I am an empath, I need to make money not necessarily for my pocket, but for the business and to pay particularly at the moment good nurses.
29:20
Yeah. Okay. So, I think the big message you had there again if you could do this again was some improvement in the communication area and that you underestimated the capacity for rigidity of thinking in the patient population and I guess that’s not their fault, we train them to be like that by how all your previous mentors did, and dislodging them from the existing behaviour was more challenging you thought than you expected.
29:56
Can I just say something else, someone has asked me a question about, do all my doctors follow the policy? In general, we all do some private billing, some do a little bit more than others and it depends, like I have got one doctor who has been there for 16 years and he might have some older more complex frequent flyers and do a little bit more bulk billing in that population, but all of the doctors in general more or less do it. Some are very rigid around it, absolutely rigid. In fact their patients like the consistency, but others aren’t. Oh I just want to say something, yeah, I think it is really important to talk about… to actually dive deep and this may not be the webinar, but into talking about money or the idea about money, because when people graduate one of the most common feedback is that people don’t want to talk about money and I think that’s natural and okay, but just remember as a doctor, we only remember the patients who complained. Reception always say, hey, you know you bulk billed that patient, but they actually had their card out and they usually pay and they were really happy to pay. So, we often remember that couple of sort of conversations that sting us, but not the 98% that are actually really grateful and happy to pay for our service. So just remember that emotional component as well.
31:20
Yes, yes, I think we undersell or undervalue quite frequently. Okay Lisa, we will move on to our next presenter and vignette and this is to Emma to unpack a bit of what made the choices around the billing model that you are using Emma and how you discriminate or decide which patients to bill and privately bill and how you went about letting patients know about fees or changes in fees. So, Dr Emma Keeler.
31:53
Thank you very much Emil. I suppose I would just give a little bit of my background. I am a GP practice owner in Esperance, which is about a seven-and-a-half to eight-hour drive from Perth. So, we are quite rural or remote, and I pretty much came here about 12 years ago as a GP registrar and at that point everybody worked in GP but also in the hospital and 50% of your income came from the hospital. I did pull out of the hospital for a few reasons and at that point I could barely afford to actually pay for my exams. I had a background in medical registrar, so I actually was going off and doing locums in medical reg to cover the bills at that point. So, I had basically made the decision I couldn’t sustain this and I was going to leave town. I had some colleagues who all decided that they were in a similar boat, so we decided to set up our new practice. We were the first practice in town to not see patients at the hospital and not be affiliated with the hospital. So, that was a brand new thing for the town and basically six years ago we set up from scratch. So, we had the benefit that we could basically set things up the way we wanted to. We also had the benefit that we had seen things that did work and potentially did not work and our reasons for leaving where we were. So, we decided that we were going to set up a mixed billing practice from the beginning and basically as per my slide, we offer bulk billing basically as a standard for under 16s, over 75s, even if they don’t have a healthcare card, people who are pensioners or have a healthcare card. Our standard B consult is AUD82 and we pretty much bulk bill our health assessments, our care plans, mental health care plans, but really at the end of the day the bulk billing is at the discretion of each individual doctor. We do have the benefit in rural that we do get an additional fee for bulk billing. The other additional thing for being a rural doctor is that we get an additional group payment from the Commonwealth Government, so, depending on how remote you are and how many years you have spent in a rural community, you will get a certain … every 12 months you will get a payment from the Commonwealth. So, I have got to say the difference between previously and opening our practice, my ability to cover the cost of living significantly improved. I have got to say I now very much look at how much I bulk bill versus how much I privately bill. I do have a lot of complicated, older medical-type patients, which is something that I quite enjoy, so, my bulk billing rate is probably higher than some of my colleagues and is something that we look at on a regular basis, and one of my ways of being able to do that is by cross-subsidising. So, I am very onto making sure that I get health assessments, care plans and things like that in place so that does in some respects provide a bit of a cross-subsidisation. When it comes to working out what our fees are, we sort of again looked at the AMA and then we looked at what other practices were doing in town and again what we sort of thought patients could afford, and initially we were finding it hard … you just set and forget and we weren’t increasing our fees or anything like that. So we have now got that basically… once a year we will look at our fees, work out if we are going to increase them. If we are increasing them we basically go… we are giving patients three months’ notice where we will advertise in the waiting room. We have a best thing ever, which is like a television screen which we use as our notice board so that we don’t have posters all over the place. So, we advertise it on that and we do have at reception stating what our new fees are going to be from what date. We do do procedures, so I do quite a bit of excisions, and basically our plan with that is that you do the excision, you wait for the pathology to come back and then the patient gets billed. If they have got a healthcare cover they get bulk billed, but if not then they will get billed whatever Medicare pay plus a AUD50 fee. So, we just basically increase their bill by AUD50 and then they get the rebate. When it is particular procedures then we have definitely got a set fee, venesections and things like that. A bit like Lisa, you have got to use your nurse, you have just got to use your nurse really efficiently and you have just got to be extremely efficient with how you use your time. We pretty much do flu clinics and we were doing the COVID clinic, so, pretty much we would have it running like clockwork, we would bulk bill everybody, but we would have it running like crazily efficient and that we found it was an equitable way to do it and we still actually covered our costs, but it does take up space. So, yeah… that is probably my bit….
37:10
Yeah. In the scenario with patients who are experiencing reluctance to pay or are concerned about fees and don’t want to pay, do you have strategies there that you look at, or how you engage on that as a challenge?
37:26
We do. I normally sometimes find that the people most vocal about not paying are the ones who probably can most afford it. Whereas you get people who really can’t, who are like, I really really want to pay. I suppose because we are in a small community and you know your patients pretty well, you have a pretty good idea of where people are at. So, I do make a judgement call on whether or not I bill. I have to say with COVID I got into the habit of just bulk billing everything, and it is very easy to just go back into that mode. So, I think one of the most important things is to actually have in your head what it is beforehand, don’t be thinking about it at the end of each consult, you just need to go, I have spent this amount of time and for this particular person, that’s how I bill, because you can’t be taking a lot of time to be thinking about it. But basically the other thing is that reception know patients pretty well as well and if there is a particular complaint or whatever, the practice manager will generally manage it. There will be times where a patient has left because they are used to being bulk billed by a particular doctor, but another doctor doesn’t bulk bill them, in which case they will get called and asked to come back and actually pay. The majority of the time people are actually okay about that. And we just try to … for them to know what the cost is going to be going in so that you don’t have arguments at the end.
38:58
Good. Alright. Thanks Emma. So, we will move on to Bernard Shiu now.
39:15
Hi everyone.
39:22
Alright Bernard. Again, the same discussion we are having, which is about the sorts of why you are in the billing, why did you choose the billing model you are in and how you decide to sort of split that discrimination and how you let patients know about fees and what’s happening.
39:40
Yeah. I am a clinic owner in Geelong, so I run the Banksia Medical Centre. So, the centre has been there for … this year would be 39 years, so when I talk all that _____ so around seven years ago. It was mainly a bulk billing clinic and then when I took over, on the first day we started to move over to the mixed billing model from the first day. And we slowly moved over all the existing patients to the paying sort of model, and it is a journey, it takes a while. So, we started with explaining to them about the importance of sharing the cost of the healthcare and explaining to them the government is not supporting enough for their healthcare and then slowly move over. So, we made a standard increase on every 1st of July, so patients know from the 1st of July that there will be a new fee structure, except during the pandemic, we didn’t do that last year and then we didn’t do that the year before as well. So, currently we are charging AUD90 for each item 23, a 15 minutes’ consultation, and it is probably one of the middle to high sort of range in Geelong at the moment, and considering our local area it is actually lower socioeconomical class. We have bulk billing clinics that are around… surrounding our areas, so, we consider ourself to be quite lucky that we still have a lot of patients that are supporting us and willing to pay the amount. So, overall our bulk billing rate from very early on, which is over 90% now, we are slowly bringing it down. So, seven years later we are at around 50 to about 58% and we are aiming at around 40% bulk billing rates. So, it is not a 100% non-bulk-billing, but we are moving towards a more comfortable model. Like you spoke about, every clinic is slightly different, every community is slightly different. So, we feel comfortable with roughly about 40% overall bulk billing rate. And all the concession holders, be that they are pension cardholders or healthcare card holders, we reduce the fee to 74 dollars and all the care plans and health assessments and immunisations are bulk billed. And also all the DVA gold cardholders, we also will bulk bill them. Kids, it is an interesting one because some of our clinicians actually deal with very particular type of kids, they have special issues, so, we allowed all clinicians to set their own fee structures, some decided not to bulk bill at all, some would like to charge on a lower fee and some will charge a higher fee and some of our clinicians decided for kids we will also not bulk bill, but some decided to charge a little bit, so, instead of charging 74 they charge 60 or 65 dollars for those patients. On Saturdays we are open only for three hours and everyone pays including kids, and so kids will be 74 dollars and adults are 90 dollars. So, that’s our fee structure.
43:21
Yeah, Bernard, in the area… which has already been mentioned by Emma, the change with COVID and telehealth consult, which initially started out with the mandated bulk bill, which fortunately changed to normal measures. How are you managing that and what have you seen with regards to telehealth consults?
43:44
It’s quite interesting. We were one of the first clinics that offered telehealth before the pandemic. So, some of our patients are quite used to using the telehealth service without even any rebate. So, that’s a bit of an anomaly because I know not every clinic that offer that before pandemic. And of course when the pandemic broke down, we continued to offer telehealth and it became the main mode of delivery of care because of the lockdown and things, and some of the patients continued to ask for… hey, how do I pay for my consult. We actually had to surprise them by saying it’s actually bulk-billed, so that was kind of interesting. And then moving on now, we have started to charge them exactly the same thing. If they book a 15-minutes consult, but the delivery mode of how they want to receive care is up to them. So, if they choose to have a telehealth appointment with me, the fee is exactly the same because it is their choice because they choose to see me on video, they choose to talk to me on the phone or they choose to come in to see me. The care that I give to them is no less, so I am not charging them any less, it is exactly the same as 90$ per 15 minutes.
45:01
Yes. We are seeing data that shows significant higher levels of bulk billing in the telehealth space because of a perceived reduction in value or some explanation of that sort, but yes you said the time is still used and the value is still there, and …
45:24
Patients actually really appreciate not needing to bring their kids into the car and come in just for a script and things like that. They really appreciate having this sort of communions for them this and they don’t mind to pay that. And obviously there will be some other consultations that are much shorter, say for example they are just needing their result… so, those consultations, some clinicians would choose to charge them less or bulk-bill them, and I can certainly see that happening and it is not something that we recommend because it is still time that we are spending with the patients.
46:07
In your website, you have got it listed as recommended fees, which of course general practice currently under the competition regulations is entitled to do as a special dispensation, which is reviewed on a five-yearly basis, which currently allows us to notionally set fees as a group of doctors in a practice, but each clinician ultimately makes that decision about how they bill. Do you see it at times where there are some pressure within the practice of others to change their behaviour or not bill or the like?
46:50
So far we are very fortunate, everyone works very well together. So, for example the patient that I have been seeing for a while, whatever the fee structures that I have been using, when I am on holiday one of the clinicians will see my patients and they will honour the same agreement with the patient, so, that’s the sort of culture that we have, it is a team approach. At the same time, we encourage each of the GPs to set their own fee and we only recommend whatever that is, and so far all of us are going by the standard what we set according to the administration that we have. So, so far we are okay.
47:34
And within your practice as a group, how much comparison or sharing of data about billing outcomes, bulk billing rates and diversity of item numbers and a whole range of things that are there within the data systems now of our electronic systems, how much sharing of knowledge or comparison do you say goes on?
48:00
Individually of course one GP cannot see another GP’s billing and how they bill, but I allow them to see mine, so, we use a software called Cubicle to analyse our data in the background and each individual GP has access to their own data so that they can see how they are billing and I allow them to see mine, so I just want to be transparent, if I can do that, if I can follow the rules of Medicare and not overbilling or underbuilding as the boss of the clinic, so they can use that as a benchmark if they like, but they are not allowed to see other GPs billing.
48:44
Yeah. In a setting, do you see a role for obviously opting in voluntary sort of comparison where practice as a group can sit down and understand the variations and nuances of why someone might bill more or less and the like, do you see that happening at all?
49:00
Every month we have an hour-and-a-half clinical meeting, that’s the time that we talk about issues like this, and I would look at the summary every month and identify some of the issues that I may see during billings. For example, some of the underusage of some very good items, for example, recently we have been talking about the telehealth items for smoking cessation advice. So, that has been very much underutilised, so that was highlighted during our meeting and encouraged all other GPs to start using that if they have discussed their smoking cessation campaign with them.
49:42
Yeah, so, peer-to-peer learning in that space you clearly see as a value.
49:47
Yep, absolutely.
49:48
Yeah, very good. Alright, thank you Bernard.
49:54
No worries.
49:55
So, I will move on now to Dr Mukesh Haikerwal, who has been a well-known GP in the Altona region and is going to shed his light on… and very generously of course a published a very good article outlining the step-by-step process of engaging on change from a practice which was predominantly bulk billing and I think Mukesh, I will let you do the talking.
50:26
Thanks Emil. Good evening everyone. I am Mukesh Haikerwal, GP in the Western suburbs of Melbourne. I have been in the practice for just over 30 years now. This is our fifth _______ and we have moved from two rooms to five rooms to 12 rooms and now we have got 18 GP consulting rooms. And that’s something that’s scaled and helped sometimes and allowed us to move that ______. Just for your information, I do currently still support the funding of health systems group via REC at the RACGP. I am actually a life member of the RACGP and ____ to the Australian Medical Association, so, I have been involved in this stuff for quite a while. And this whole billing issue has been one that we have been toying with for quite some time through various other organisations. We have come to the point which is displayed before you for our current billing status. When I started the practice I was a refugee from the National Health Service in Britain, but was not, contray to normal experience, averse to charging, because we thought that was one of the things that… the cost, the volume control was something that was a big problem in the NHS and made the system there quite unsustainable as people can see if they look across the NHS system now. When we moved to our new building, I think no point in going through the history, the history was when we started in the 90s, there was something called vocational registration and we had to continue charging to generate income. What happened over time working with Bernard_____ in a region of Victoria which is the second most ethnically diverse municipality in Victoria _____ country and also have a significant lower socio-economic group, and it became very difficult to start that process of charging an out-of-pocket, especially with competition, Bernard mentioned the same thing, there’s many clinics that pop up around you. It is very hard to have a sustainable business if people pick out the eyes of your business and leave you with the hard stuff, which is kind of where things are with general practice. Just to say the biggest change we have seen in billing was in 2004 with Tony Abbott as health minister and John Howard as Prime Minister, when we went from 85% of MBS as a rebate patients would get, to 100% MBS, and then the bulk billing incentive was provided and at that stage we had just gone through a process of putting private billing into place and we just put in billing for children actually, and the amount that they brought up the Medicare rebate to 100% MBS and the bulk billing incentive for kids, it was just 2 dollars or so less than what we were charging as a private fee, but we actually stood by our guns and carried on charging children. Interestingly, when we moved to our new practice, we sort of rolled back the clock a bit and said we will bulk bill people who are in aged care and pensioners, healthcare cardholders and all children, gold cardholders obviously, and beyond that everyone will be paying a private fee. In our context, that become quite significant, a number of people were bulk billed. What we were finding was that we were actually starting to lose money when we opened extended hours because we opened from 8 till 8 and also we were losing money in having people on Saturday and Sunday at those rates. So, bit by bit we changed our model of consulting and the Sunday was the first day to go, and nobody on Sunday or a public holiday was bulk billed, and we thought oh god, is this going to be very tough, but actually it works extraordinarily well, we have really good consults for people who need to be there, want to be there, and are prepared to pay for it, understanding the cost on the way in through the door. And that also extended if it is a longer consultation. We don’t do care plans and stuff on a Sunday by the way because it becomes a bit difficult with the other stuff we have got to do. We then increased that to Saturdays, Saturdays nobody was bulk billed on Saturday, but the rate was the normal rate. Obviously public holidays were a higher rate and then we then extended it to 6 pm and over. All hours out of hours started being not bulk billed because you have an opportunity to be seen and we bulk billed in the normal working hours, so, we thought that was relatively fair. At the moment we are not taking new patients, but we had set a fee whilst we were taking new patients because additional consultation regardless of their card status generally tend to be quite onerous. The children issue is the most recent change we made where with a whitsle and a prayer we said we really don’t want to go down the road of charging for children because we want to make sure they have good access, but the same way as everyone else was seen to have capacity to pay a smaller out-of-pocket fee for their child. If they were from a family that didn’t have a healthcare card, we made that quite difficult decision, there is quite a lot of discussion about whether we actually did that or not. With that, we are quite agreed across the practice, everyone bills in the same sort of way, we do charge privately for our care plans, we do charge privately for the ____ checks or heart, health checks and so on, and generally people are quite comfortable with that because they get a service that they value and they feel they are getting value for money from that. So, it is a big journey, there has been some changes that nearly stopped us from doing this. The way we did this was with good communication. Obviously things have changed now, when we first did it there were no websites, we actually used to give out fridge magnets and do mailouts, so…. those days are gone a bit, but sometimes a piece of paper to take away or some sort of token is still useful as people remember that the service that they are getting and the benefit they are getting from that.
57:00
Yeah, and the telephone system for you in terms of this past two years or how do you currently see billing around phone consults?
57:08
Yeah, look, we have made the effort to move away… actually it was after the RACGP practice owners conference in Hobart, where the figures were _______ people saying, you do realise that so much of this is telehealth. It is actually worth the same time, so I am now in the same boat as Bernard, we try and charge. There is a problem because people tend to put the phone down and then they don’t pick up the phone, you call them back to take a bill payment, and that is the issue of chasing bad debts which is starting to pile up a little bit at the moment and I think that is obviously the downside of all this. One quick comment if I could, Emily, you said how do they set the fees in the federal government, it is something called WCI5. Which is based against civil servants pay rates, which is a complete and utter piece of rubbish. They should have used something called the _____ but nobody would ever dare do that.
58:01
No, it is still in a drawer somewhere isn’t it?
58:06
It is in the drawer gathering dust (laughter).
58:08
Thank Mukesh. I will draw a note there too at the last one in your line there because we get this question a lot about the concept of a fee for new patients or an annual fee. I mean, all of our patients meet an annual fee every year irrespective of their card status and that is from 1st of July forward for the first consult they had with us, which might have previously been bulk billed, we now have a AUD35 fee added to it as part of the fee, so, not bulk billed, and that was introduced by us at a time when the freeze in Medicare had started and it was a response to known deficits that the freeze and the lack of indexation was going to cause, which of course sustained for four or five years and hasn’t directly been unfrozen at all. It has been frozen in place completely and is now a permanent recurrent deficit and everybody's bottom line. So, these measures are about trying to adjust for that.
59:17
Yeah, I mean we know with inflation is 6 now, previously inflation over the years of the freeze has been 5% and things like ____ inflation. Health inflation is much greater, public health, private hospital insurance is increased and increasing general practice… patient’s rebate for general practice services was 0.5%. And you asked a question and in terms of how do you get people to say to the patients or express this issue, is it the value of that rebate. It was not too different from what was the AMA set rate way back when in 1983 or before, it has really been hacked away and the value of that rebate is such that your access to healthcare is diminished and our citizens’ rights and healthcare has been slashed by this process. And that is something worth advocating against and the health department used to look at spending money to sustain health, not simply save money.
60:17
Yeah. And advice to GPs who are hesitant about moving away from bulk billing?
60:21
I think it is not only for _____ there’s good science behind this and it works. The difference between a happy and unhappy practice is a matter of 20 or so patients anyway, and sometimes we are taking a hit of 20, 30, 40 whatever it is, you initially think of it, but people stay, people come back, people understand what they are missing because they have had a good service and they actually respect and value the service that you provide.
60:51
Thanks Mukesh. Thanks to all of our presenters. I think lived experiences by our own colleagues and members across the country are the best stories to share and learn from, and realise that even the most experienced people in our areas have had to face these challenges and have had to come up with their solutions to retain the value in what they have done. The RACGP over time has continued to work on building resources which focus on how to achieve, managing and sustaining a successful general practice in business, maintaining work-life balance and continuing to be able to provide high-quality care to the community, something which Australian general practice is well known for internationally, and we should be proud of, but yes it has a cost to it. So, the website of the RACGP is a good link to the running of practice and practice management tools for you to help you run your billing. These tools are there to help you with implementation around mixed billing policies, a suite of resources that can help you look at things inside the billing toolkit, the billing calculator, the MBS online tool, which I can thoroughly commend to people if they have not seen the MBS Online Tool, I downloaded and use it on my desktop, it gives you access to the majority of the GP item numbers very quickly, but also gives you direct link of that into the MBS Online if you wanted further clarification about the descriptor. So putting those two side-by-side I think is brilliant and well worth looking at. So, resources that can help you advocate what is happening with sustainability and billing in terms of posters and things that can help you with the education process for your patients and allow your journey to be explained to them, and I think this will surprise you to find that a large majority of them will choose to come with you on that. You can also contact us at the funding and health system reform team through healthreform@racgp.org.au for your enquiries. We have a recently updated billing calculator on that site now as well, which is really a simulator for your experiences on how you can manipulate your hours, your working the days, your working the billing rates you are using and pricing to look at your outcome for the year, and it is a very interesting tool to have a little play around with to see what differences you can make if you choose to change, particularly some of your rates of bulk billing. Looking at annual income and monthly billings. So, there are things that are there well worth exploring if you have got the interest in this particular patch. In the near future we have an upcoming series of webinars which will focus in more detail on improving sustainability in practice and this webinar series later this year will be in partnership with CommBank Health as a partner, and these will be spread fortnightly from September 1 through to October 27, and topics will cover strategies for sustainable practice, improving and understanding of MBS, managing change within your practice and then a final one trying to look at the current topical issue around what GPs need to know about payroll tax in the system. So, I thank everybody for their presentations and contributions and the attendance. So, what we hope to do now is move to the poll question that is there and focusing on the impact of COVID-19 and the business of general practice. So, I think we would like you to look at that and post your response. (Pause). I am going to just allow some time for that to progress. And there is a resounding yes in the interest for webinar based around the COVID-19, I know that I have looked at data within my practice and the GPs within my practice and can clearly identify substantial changes in the downward direction on a per-hourly billing rate, which I think is something that really deserves some focus and requires some attention to be addressed by us, or we accept the consequences and the consequence of going below the black line and account sheet isn’t very appealing. Now, we will move to the question end of the session, and those questions that have been arriving are things that we can take to all of our panellist members. So, I will look through … now the questions that we have got, have been organised generally if they are repeated or they are similar they tend to get promoted to the top of the list. So, I will look at the first one here, which is listed from anonymous, and that is fine. As a practice manager I would really encourage GPs to have a hard discussion with patients about their own billing policy and the expectation that payment is required at the time of the consult. Leaving it up to the reception staff to deal with it isn’t fair and creates additional stress. So, I think I can see lots of nods going on from our team and I would clearly agree that we need to remember that the front end of our businesses, being our reception staff and management, are frequently the people who are taking the heat for change, particularly if it has come in an unexpected way. Bernard, you would like to make a comment on that?
67:44
I think that I completely agree with that, but at the same time I want to flip it around, it would be such ____ so, sometimes when a patient walk out there and then they start questioning it, so, the receptionist will call us and say, oh, can you bulk bill this patient. And that also is not being professional. So, when the doctors are paying us 30%, 35%, 40% to do the job of administration, we need to follow that. If the doctor made that decision, this patient is going to be charged for that amount and it is our job to make sure that ____. So, I think it is probably, as a team have a good discussion, what do we do if the patient ______ pay, would you like us to be consistent to say that, yes, now doctor so and so says that today this is the fee. Maybe next time, then you can discuss with him about your situation, but today this is the fee, and then the receptionists need to put that and help us bill them appropriately.
68:52
Another question from another anonymous attendee, looking just at tips and tricks. What I can speak to that, and a meeting we had earlier today with our business sustainability working group, was a document we are preparing at the moment, which is basically going to be tips and tricks and stories related to moving to mixed billing that have come and have been generated from questions that have come from two previous webinars. So, that is a resource we are hoping to put in place in the next month or two once it is collated and reviewed, so that we can spread tips and tricks to help give people some hands-on pathways of going forward. I move to a question that is clearly present for a lot of people and that is that the population of people under the age of 16 can be quite a substantial part of the population in some practices, and how we might move our way through dealing with bulk billing for that group if it is a large slice of the population. We have someone who wants to contribute to that as an answer?
70:11
Look, I think it was something that always played hard in our conscience, we know that people will come with one or two kids or more and their expenses mount up for the parents who bring their kids in, and you make a decision not to charge every single the full thing every single time, you don’t have to charge for every single time, and it is a large proportion in our practice. We have doctors who have got ____ looking after children and they do a job with that, and the complexity of children's presentations now, you would be well aware of, is becoming more and more problematic trying to get services for them. Certainly in Victoria and Melbourne, getting paediatricians is really hard and getting _____ services for people with disabilities or ADD, ADHD, is getting very difficult. Let’s not forget it is not acute stuff only we are dealing with in kids, it is not just ears, eyes and throat, there’s a lot of more complexity to them as well, and we are, in many ways, physicians actually, we are the general physicians in our general practice who have to do lots of complex stuff and that includes kids. Thanks.
71:34
Thoughts on the practical visiting of the annual fee increase, so, firstly I think we heard Emma flag that obviously having a fee review and at least a discussion about increases at some frequency is important, but how frequent, annual? Quarterly? Inflation at the moment, weekly? No? What’s people's thoughts?
71:58
I think if you make it too frequent people get very confused and I think that then makes it difficult for reception. So, I think personally from a transparency perspective what we go through to make our price increased, to be doing that too frequently I think would be problematic for the entire surgery let alone our patients, so, that’s why we choose an annual, but I don’t know about others.
72:27
I can say Emma this year for myself or our practice was the first year we revisited in six months and that was purely because we had a reasonably strong and valid argument from our nursing team about some salary increases and the only way we could see that we were then going to be able to address that was to say, well, there has to be a way of managing that and that led to a six-month adjustment to allow us to adequately cover that and retain the staff we needed to continue delivering the services we needed, which were going to naturally come at a higher value. Bernard, I saw a hand up from you.
73:09
I guess it really doesn’t matter about the frequency ____ just make it consistent, so patients won’t be surprised, and we chose to do it on 1st of July every year and they know, everyone knows it is 1st of July and that’s it, there’s no argument, and we don’t make a big deal out of it. So, 1st of June we make the announcement on our Facebook and in our receptions so everyone knows that’s the fee, in a month’s time it is going to happen, on 1st July it happens, we never never really have any patients that are annoyed because of the slight increase every year.
73:43
Now, a question from Marianne Lau, the concept, the mechanics of private billing telehealth consults with prepayment, so, have we got any of our colleagues on the panel who are currently doing that? Can you explain the mechanics or the technology?
74:04
If they are bulk billed in the online booking system there is an option that they can choose to put down their credit card and then, I don’t know if there’s a prepay, I don’t think we are allowed to charge a patient for a consultation that we have not done, but they take a certain amount and I think that is allowed, and we are not doing that at the moment, but I think there’s that option, are you aware of that option.
74:28
I am looking with HotDoc and Health Engine to see if they would allow in the same way as you get prepayment for a prescription and then you collect it once you have done it. I don’t see why it can’t happen, but we haven’t got there yet.
74:48
Yeah, I was aware that HotDocs were working with some systems and that will take a bit of patient education and training and there’s an awful lot of our population who are very literate in their usage of electronic transactions with regards to payments and I think it will be part of our landscape. A question, Adelle Azees, good evening Adelle. For a practice thinking of transitioning to a mixed billing from a fully bulk billing practice, what are the first three steps to take. So, nice simple message of what would you do first A, B and C. Lisa, are you up for it?
75:34
Yeah, I just replied to that, I was thinking about that. So, I think, research, understand and feel good about the change that you are making and what your gap fee will be, particularly so that you don’t have to increase it any time soon, we understand what your numbers are and what your projected numbers might be in the next sort of year or something. Talk to your doctors and talk to your staff, understand all of their concerns and issues and then I would do it as project management, when is it going to happen, what do we need to do, and consider a transition period, and include the project management, include what’s your communications plan. Talking of billing before, when someone comes to a clinic, they are informed about billing from your website from their HotDocs booking. If they phone, my receptionist will say, just confirming this appointment and the fee today will be X. There are multiple moments at which a communications plan can roll out and reinforce any messages that you are delivering to a patient, and that’s even before they have got to you. So, that’s my three things, and then probably at the end of it is a bit of a reflection, so, have a transition period and then have a reflection about how it went and if you want to actually change anything. But I guess, do it on paper, document it, do it like a PDSA cycle type thing if you want.
77:07
A question ….
77:10
Can you please add to that…I think ___ do and understand why and have that patter to get back to patients to it and let them understand why this is happening.
77:22
I would call that scripting, I think that’s a great thing, I would script my staff, because often they are like, oh… all flustered, I don’t know what to say, I literally write down ____ we talk about short phrases that they can just spin off and it just reduces the anxiety, what comes out sounds a lot more polished and it is all about fairness, it’s about transparency, it’s about offering a service, it’s about maintaining the doors open of a business that they really value, so have that ready to go.
77:50
Like having a practice that still exists verses one that doesn’t.
77:51
And you need to have that in your head as well so that you don’t feel guilty. You need to know the alternative is, we are not here, what do I need to do to still be here, and that is a good thing for the patient.
78:09
A very broad question there, and I think a good question for some discussion is, do you bulk bill Aboriginal and Torres Strait Islander identified patients? How does that sit in people’s practices?
78:30
I will check that from my side out, I have done a lot of work with the AMA, with the aboriginal communities around the country. But the folks that come to us have the same parameters, often it is not just the Aboriginal and Torres Strait Islander community, but others who are potentially doing it tough and can’t get services and can’t get services through the state-funded services. To use Medicare is possible if you use the Safety Net and they will often talk to you about the Safety Net and the extended medical Safety Net and saying you might spend some money upfront now, but once you hit that cap…it’s actually capped to 80% of real gap to you. So, it’s true to Aboriginal and Torres Strait Islander community people who will often have more healthcare needs and often are lacking access to services, especially state run services and it might be an alternate way for them, and others who are having difficulty with financing to think about that. And once you explain it at first if they are a a healthcare cardholder that to reach the threshold isn’t as significant a steep climb as it is for those who are non-cardholders.
79:50
Yes, thanks, thanks Mukesh. Looking at some nitty-gritty around just the utilisation of Medicare, can you co-bill a 23 and the smoking cessation counselling item?
80:13
You can, absolutely can. But make sure that you document that it is done separately and the time that you just talk about smoking cessation. This is perfect for those asthma review or COPD review or cardiac failure review when they are still smoking. So, make sure that you document that from whatever time to whatever time. I spent 20 minutes with the patient talking about this, we looked at the patches, we looked at inhalers, referred them to the psychologist or whatever that is and you make sure that you document it properly, but it is a separate consultation.
80:43
Yeah, a question just again for information on a category of our patients, which is the veterans… gold card veterans are bulk billed. To my understanding they are linked in a contractual arrangement with us, which is effectively bulk billing and that we are not in a position to pass on costs to our gold card or for the conditions which are listed on the white card. White card represents, we will call it a partial incapacity or an isolated injury or impairment that has not led to reaching the threshold of full disability. However, the conditions that are not on the white card can be treated and billed as if they are a normal patient. Doesn’t that sound wonderfully confusing?
81:41
Just be reminded that DVA pays a little bit more than Medicare.
81:47
Yeah.
81:48
So, it’s probably fair to bulk bill them or not charge them and to me, I can’t speak for all, we are just paying a little bit of respect for those that have served the country put their life in danger, and just to ____.
82:03
And that’s out position as well, honestly, to get a gold card you have worked bloody hard to get it, so we take it as a bulk billing and you do definitely get a little bit more.
82:14
Yeah, and that one is variable in various patient population, mine runs about 3 to 4% at the moment with a large number of new veterans coming through, they all deserve their recognition for what they have done, whether they left the island or not. And I think the status of gold card and the white card conditions for them are very important things for us to support.
82:40
We have had in the past where DVA has not kept up, like everything else. The veterans themselves lobbied very hard to increase DVA payments, they didn’t want charity, they didn’t want us to ____ nothing, they thought that not only should they get the service but the people doing the service for them should get properly rewarded. So, that’s a very good ongoing collaboration.
83:11
Maybe time to mention about the CBC program as well, so, probably I want to enrol all your EBA assessments to the CBC program with the entitlement.
83:21
Yes, I think it would be important to look for the eligibility there and the additional support services that you can bring to them as care. A question about bulk billing the seniors card, do any of us take any particular interest in the seniors card?
83:41
I don’t have one yet, I am not eligible. I think it is more a shopping campaign.
83:54
Are they talking about a commonwealth seniors card?
83:57
____.
84:00
(Laughter) I didn’t want to say that.
84:02
I think you just have to be over 65, don’t you?
84:06
No, it’s lower.
84:07
Oh, it’s lower is it? You get money off the _____.
84:14
Yes, it comes with some other contracted subsidies for state services generally, but we are not involved with that directly, it doesn’t come in any sense of the way under a means test arrangement, it is a badge of having attained a state of seniority, that’s been very generous (laughter). Now, we have still got time for a few more questions, we do have the intention to wind up at 8:30.
84:44
Emil, I think it is probably important to address one other things… I think that leads to two questions talking about annual membership. So, now, I can’t find the official document and I believe it is not allowed. So, what that means is you are not allowed to charge an annual fee for a patient and then you bulk bill them for the rest of the year and so, that is not something that Medicare will allow us to do. Now, I have no doubt clinics are doing it and especially some of the _______ they would do that and there are a few clinics in Canberra who are actually doing that too, but if I remember correctly, it is not allowed, but I am sorry I can’t find that official document.
85:27
I think that’s the interpretation.
85:26
____ isn’t it, like a wellness clinic where….
85:30
I think you are talking about ____.
85:31
Yes, yes, yes.
85:34
You are not allowed.
85:34
____ yeah, okay.
85:39
Which is different to and this is the model that we use, which is in that first consult of the financial year that it is likely with a pattern of billing that patients normally would have been bulk billed, we pass on a cost, we don’t bulk bill them and we accept the rebates that comes back for that and the patient’s out-of-pocket for AUD35.
86:05
That is allowed. That is absolutely allowed.
86:06
And that’s our way of interfering with what we see as the deficit for the ____ still, but in no way it is a keep up with the absence of CPI adequately. I think this is a question I wouldn’t mind getting answered if we can, clarifying what we mean by bulk billing some items and privately billing others, as I think the language there might be wrong. Can someone answer that? Because I think what’s actually meant there is that there are some items where you might choose to accept rebate only and others you pass a full cost on. So, you are not actually bulk billing them, you are charging a rebate item, so for some circumstances I might choose to see a patient quickly for something I know it is for a certificate I might charge the rebate only and a AUD10 certificate fee or something…
87:04
A very classy example would be a pregnancy consultation, so someone thought they may be pregnant and they come in and we do a ____ consultation and you do a urine test and that test most of us would probably bulk bill that test and I cannot remember the number, but it is on my ….
87:21
_____
87:27
That’s right, yeah, yeah. And so that one would be _____ but bulk billed that item, but the 23 or 36 would be private billing items, so you can privately bill one item and then bulk bill another item provided that you put the time different. So, the receptionist would have to be trained to do that so they won’t reject the other item.
87:45
Okey-doke. I think in view of it at 8 o'clock, we probably need to move to the windup. I thank the questions that have come from those that have been viewing. I thank each of our panellists for their contribution and also the RACGP for their continued support in this space for us trying to move forwards with things. I think until the next webinar, which will be in the near future. We will come back to my slides, and we will move to the windup from there. So, thank you very much. Good night everybody.
88:53
Thank you. Good night.
88:54
Good night.