Don’t protest too loudly, doctors - we do have a Medicare crisis

“The lady doth protest too much, methinks” is a line from the play Hamlet, spoken by Queen Gertrude in response to the insincerity of a character trying too hard to convince an audience, and therefore losing credibility in the process.

There are echoes of Hamlet in the Australian Medical Association’s response to this week’s allegations of widespread Medicare misuse. Its protests have centred around questioning the extent of fraud allegations made through The Sydney Morning Herald, The Age and the ABC’s 7.30 program.

That’s a fair question to put to the journalists raising the allegations, but not really the point. The point is that leakage of public funds to the tune of billions of dollars is occurring due to a combination of waste, over-servicing and in some cases fraud.

Billing for low-value care is a business model threatening our venerable health system. Credit: iStock

One of the surprises is the extent to which our profession has been united in its rejection of the allegations. From the “medical left” of #medtwitter to the doctor’s union itself, the AMA, and the Royal Australian College of General Practitioners, the response has been a united “it’s not the doctor’s fault”.

With doctors exhausted after three pandemic years, this response is understandable. But it shouldn’t prevent much-needed debate on the role of the medical profession (or at least, parts of the profession) in the decline of Medicare as a venerable Australian institution.

So what is the truth? Overt fraudulent claims such as recurrent billing of dead patients, billing for services not provided or gross over-servicing are relatively well managed through our current compliance systems administered by the Health Department.

As with any regulatory system, it could be improved. The ability for doctors to “repay” ill-gotten gains, sometimes measuring in the hundreds of thousands of dollars, without public reprimand, would be a good place to start. Doctors over-servicing should have a notification placed publicly on their practitioner record. Shame is a powerful self-regulator.

But the real threat to Medicare, and our world-leading universal healthcare system, is not fraud. It is the insidious billing of perfectly legal but low-value care. Low-value care is care that provides little or no benefit, may cause patient harm, or yields marginal benefits at a disproportionately high cost. It is the reason the United States has the highest per capita healthcare costs with some of the poorest health outcomes in the Organisation for Economic Co-operation and Development.

A key structural reform challenge for Medicare is how to stop funding low-value care when the business model of large diagnostic companies in pathology and radiology, private hospitals and corporate general practice conglomerates depends on that low-value care continuing. But to execute that reform, we must acknowledge our role as doctors in prescribing low-value care and commit ourselves to reducing health costs.

In my professional career, I have not yet seen a doctor’s representative body seriously commit to reducing healthcare costs. When former Labor health minister Nicola Roxon attempted to reduce the Medicare Benefits Schedule rebate for cataract surgery, which has markedly decreased in time and complexity over the years, the AMA and College of Ophthalmologists executed a lobbying campaign that would make the Minerals Council of Australia blush. The rebate was not lowered.

The political response to this week’s allegations has been underwhelming, perhaps because the memory of past reform failures is still fresh. Both the government and the coalition have taken the AMA line that the $8 billion estimate is “exaggerated”. The announced “review” by Health Minister Mark Butler is an easy way out that will do little to save Medicare.

Indeed, reviews have already highlighted the need to reform the fee-for-service model. The most recent, the Medicare Benefits Schedule Review Taskforce, led by Professor Bruce Robinson, delivered 1400 recommendations on modernising the MBS. Delivered in December 2020, the Coalition was slow to respond, and the new Labor government seems to have shelved the recommendations in favour of appointing its own taskforce.

The government needs to commit to the Robinson reforms and go further to reduce the MBS rebates across a range of diagnostic tests and procedures. It needs to show we value the time we spend with a patient, not what we do to them. Freezing or removing entirely the rebates on low-value care can then be funnelled into where it is needed – meaningful increases to general practice funding. This will ensure GPs can spend the time they need with their patients and is a critical step to making general practice attractive to our medical students.

Accompanying this should be a focused review of corporate general practices and “super clinics” with stronger regulatory penalties for corporates that abuse Medicare. Any increase in GP rebates must go to the doctor, not to large corporates or private equity firms. Finally, the alternative of removing fee-for-service primary care entirely and putting our GPs on salaries, as we do our public hospital doctors, needs deep consideration.

Unfortunately, no government, Coalition or Labor, has been able to stand up to the vested financial interests of select and powerful parts of the medical profession, interests that now include large corporate practices.

The task therefore stands at the feet of the profession, to look honestly at itself and recognise that the Hippocratic Oath does not mitigate against the financial incentive to provide low-value care and that leakage of public funds, to the tune of billions of dollars, is occurring. Until we recognise it, and own it, and fix it as a profession, the greatest publicly funded health system in the world will remain at risk.

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