What would Repin do? The daily grind was not restricted to coffee

The Secretary-General who guided the medical profession through the early turmoils of Medibank and Medicare

George Repin was the son of Ivan Repin, a Russian émigré whose contribution to Sydney culture is described above. Ivan died suddenly and, although George was a new medical graduate, he took over management of the business with the same meticulous approach with which he was later to guide medical opinion. It is reported, for instance, that George contributed a six-page article on coffee in the first edition of Australian Gourmet in 1966.2

When George Repin entered the Australian Medical Association (AMA) as Deputy Secretary-General, he was in his early 40s and it was a critical time after the 1969 Nimmo inquiry. It has been said about him:

While such statements often overstate his role, Repin had the ability to ensure that the medical profession provided coherent information in closely reasoned submissions to the government. Repin always bristled at the concept that the AMA was negotiating fees — he believed that doctors should charge what they deemed fair and reasonable, and that it was not for the AMA to tell them what to charge. The successive inquiries into what were termed “fees for medical benefit” involved the government, Repin and the AMA. Essentially, the fee for medical benefit was a government floor price.

Repin was conscious of service relativities — the relative value of different medical services, which became accepted by government and the medical profession. Hence it was an article of faith at the outset that specialist services attracted a higher price than those provided by general practitioners. In only one area during Repin's time was there a major adjustment in relativities — that was in pathology, where advances in technology created a windfall, particularly automation in clinical chemistry. There is no better example of balancing throughput and price than the shift from manual to automated pathology tests. The ability to get that relationship right has dogged all considerations of the worth of individual medical services ever since, as instanced by the drawn-out Relative Value Study in the 1990s.

It is fascinating to read interpretations of what happened in the Australian health system during the period of Repin's stewardship as AMA Secretary-General (1973–1987). For instance, one latter-day guru has written that the Gorton scheme, which paved the way for Medibank in 1975:

Statements such as this ignore a simple fact of that period. There were regular formal reviews of the medical benefits scheme between the AMA and government, irrespective of which side of the political spectrum was in power. The price-setting mechanisms were not driven by the necessity for the doctors' fees to be totally reimbursed. Right across this period — up to and including the introduction of Medicare in 1984 — the AMA maintained a discipline over government negotiation through Repin's activities. The extent to which this discipline led to containment of health costs through the 1970s and 1980s cannot be underestimated. Repin was a resolute believer in free enterprise, but also believed that whoever paid should get an appropriate, good service. After all, Repin's always provided an excellent cup of coffee.

The problem has been that, since the cessation of the inquiries in 1984, myriad forces have all been negotiating for their own particular patch. Once the formal inquiry link with government was broken, there was no ability to maintain any of the discipline that Repin had been able to exert when the model anticipated a price for a professional service — a direct result of negotiation between the medical profession and government.

The model did not cater for a corporate sector which quickly exploited the price government was prepared to pay for services by increasing throughput. The rise of technology accelerated this disconnect. Pathology was an early example, but diagnostic imaging also produced windfalls for those who could do their sums — bulk-billing clinics, endoscopy day centres, and any setting in which price advantages occur because of this throughput variation and technology advances. Appropriate business models proliferated, and “gaming” the medical benefits scheme has made many a fortune. This has been reflected in the emergence of powerful vested interests which are able to lobby political decisionmakers and do not have to rely on the objectivity of regular formal inquiries. The problem is and always will be the hesitation to rein in the price that government is prepared to pay for technology. At the same time, states and territories have joined the market with a variety of cost-shifting exercises. A copayment for general practice services is a popgun against the leviathan.

So what would George Repin do now if he were thrust back into the world of medical politics, and at the same age as he was when he first confronted the need to negotiate with government? Perhaps he would have a strong cup of coffee for starters.