Dear Nic,
Forgive my informality, but I have noticed that Australians like to shorten things — this even applies to Medicare.

As a former TeRD (temporary resident doctor), I dreamed of being able to access Medicare for my own chronic diseases. Now I am a proud Australian citizen and grateful for the care my general practitioner gives me courtesy of Medicare. He could view me as a cash cow because my ailments make me eligible for more care plans than I’d like. Instead, he sees me and addresses my concerns when needed, and I have never felt processed or tick-boxed.

Likewise, I want to give my patients quality, evidence-based and compassionate care. I love my job. I am at my best when trying to sort out what needs to be worried about and what does not. But although the Medicare system seems to be working for me as a patient, it does not work for me as a doctor.

Medicare does not reward doctors who remain working in the “swampy lowland [of] messy, confusing problems [that] defy technical solution”.1 Generalists like me can ensure appropriate investigation and referral, and thus reduce costs of health care.2 GPs provide accessible and comprehensive care for common problems and provide continuity and team coordination for complex care.3 But we seem to have created an inverse care law in Australia, where specialists and GP subspecialists gain more income, and managing undifferentiated illness — often the hardest to sort out — is not rewarded. We pay premiums to people who cut out the known, not to those who draw out the unknown.

To maximise this lower generalist income I am entitled to as a GP, I should conduct many consultations that last just over 5 minutes. However, taking a longer history and performing a focused physical examination (neither possible within 6 minutes) significantly increase my chances of weighing the multitude of factors that might contribute to a diagnosis or problem identification without recourse to expensive investigations (Box 1). Also, I am reminded that giving insufficient time or care to establishing a sound doctor–patient relationship and rushing consultations are two of the 10 “deadly sins” that will increase my risk of litigation.5 But this safer and, in the long term, cheaper care for my patients and my country generates less income for me in the short term.

General practice grew up when most illness was acute and there were limited therapeutic options; the funding arrangements reflected the style of practice. Now, these arrangements put us in a quandary — the way to make the most money is to see people for a short time and deal with only one problem at a time. Telling people to come back for another visit seems grossly inefficient to me but is, admittedly, one way of earning a crust.

Many patients want to save my and their time and bring in a list, little knowing that this will cost me income. I’ll use the example cited by the Professional Services Review (PSR), in which the clinical problems are more easily defined (a rare treat in my practice), to illustrate my less well defined billing problem. The PSR’s advice that

means that a level C consultation cannot be billed.6

However, the evidence shows that to do all three tasks well and safely is neither quick nor uncomplicated. Issuing a repeat script for a stable condition requires a check of the condition and its current impact on function, the medication, its known side effects, and potential interactions with other medications.7 The consultation should include questions about over-the-counter medications and complementary and alternative medicines (CAMs) taken, given that CAMs were reported to be used by 52.2% of 3015 people surveyed in South Australia, of whom 49.7% used conventional medicines on the same day and 57.2% did not report the use of CAMs to their doctor.8

According to medicolegal advice, before removing ear wax GPs should

• take a full history, asking specifically about ear discharge, previous perforation of the eardrum or ear infection

• carefully examine the external auditory canal

• recommend the use of wax softening agents

• explain the potential complications of the procedure

• ensure the person performing the ear syringing is fully trained

• ensure the equipment is correctly assembled. If the nozzle of the syringe is not properly secured, it may become detached and cause damage to the external auditory canal and/or tympanic membrane.9

The Heart Foundation’s Guide to management of hypertension 2008 recommends that doctors should “Manage identified lifestyle risk factors in all patients, whether or not BP [blood pressure] is elevated”.10 This cardiovascular risk assessment includes: personal and family history, smoking assessment, risk of diabetes, body mass index calculation, waist circumference measurement, exercise assessment, lipid assessment, and nutrition.10 Time and skills in motivational interviewing are needed to encourage change to reduce the risks identified.11

Once these simple, uncomplicated6 tasks are done, the GP should make clear, comprehensive and contemporaneous notes12 at a standard that enables another practitioner to take over care. Notes should include demographic and contact details, known allergies and a summary. Once the patient leaves, I begin my unpaid administrative work — reading letters from hospitals and emails from my Division of General Practice and practice manager; checking results; responding to patients’ queries; checking recall lists; and planning follow-up.

Do you see my dilemma? Each task can be done quickly, yes, but only with potential longer-term safety risks and costs. If I do one thing per consultation, it would take three visits to deal with the problems. This has a higher overall cost in terms of making appointments for both patients and staff, patient time out of work and in travel — and what of the environmental costs of all this travel (unless I have persuaded them to cycle to the practice, thanks to my motivational interview about cardiovascular risk)? I would argue it is reasonable and good practice to do all this in one half-hour appointment and claim a Medicare Benefits Schedule item 36 long consultation. Medicare policy does not! Tell me, why not?

Medicare and those practising medicine must learn the hard-hitting lesson from the current global financial crisis — that systems based on short-term gains have hidden long-term costs.13 You say you want GPs to provide quality care and include health promotion.14 Yet the announcement of increased audits of GPs’ billing practices coincides with a reduction in longer consultations of nearly a million from 5.53 million to 4.55 million between corresponding 6-month intervals in 2007–2008 and 2008–2009.15 I ask you, which do you want — short-term lower costs or longer-term better health for the people of Australia?

Please

• value the role of the generalist;

• reconsider advice that “implementation of a 7 tier item structure in place of the current 4 tier item structure would improve the quality of health care in Australia” (Box 2);16 and

• use holistic cost–benefit analysis to inform health policy.13

Thanks for listening. Oh, and can I ask one final question? When you next need milk, will you implement the same system we apply to Medicare and just get the milk, and nothing else, on that visit to the shops? Or will you be reckless and go in with a list — wanting multiple things? Doesn’t it make much more sense to buy everything you need at once?

Yours sincerely,

Susan

PS: please refrain from calling me Sue — I hate to be cut short.

2 The Attendance Item Restructure Working Group seven-tier rebate system*

The seven-tier rebate system creates a more consistent rebate per minute. At 2003 rates, this ranged from $2.00 to $2.50, whereas for the current structure, the rebate per minute ranges from $2.00 to $4.00 for consultations less than 10 minutes, but only $1.00 to $2.00 for consultations greater than 10 minutes. The proposed structure removes incentives towards consultations of just over 5 minutes.

* Figure adapted from the Final report of the Attendance Item Restructure Working Group.16