And in Melbourne, Brisbane, Canberra, Adelaide, Perth and Hobart
A lot of Australians are still unaware of this, but some of Australia's best doctors (especially bulk billing doctors) are struggling with financial hardship — and/or having to leave medicine — because of a bureaucratic bungle by our Federal Government.
Australians: Please consider this important issue when you vote in September.
At some point in our lives we will all need to rely on our medical system for our own survival, and/or the survival of our loved ones. While the current Australian federal government talks up its promises to remedy the shortage of doctors, behind the scenes it is illegally targeting about 4,150 fully qualified and experienced bulk billing GPs so that many are having to leave the field of medicine for other careers.
What's Going On? And Why Does it Affect Bulk Billing Doctors in Sydney?
Unknown to most Australians, there are two classes of GP (General Practitioner) in Australia.
In the 1989 a list called the "Vocational Register" was created. The Vocational Register (VR) effectively created two classes of GPs: those who were vocationally registered (the VR GPs), who had access to higher Medicare rebates, and those who were not (the non-VR GPs), who only had access to lower value Medicare rebates.
The Vocational Register was part of the new system where GPs were trained as another specialty of medicine. Most existing GPs were automatically transferred to the VR (i.e. they became VR GPs) by a process known as "grandfathering". However some GPs were not grandfathered. This includes anyone who was not working as a GP at a particular period of time (when the grandfathering was done). Any GP (no matter how qualified and/or experienced) who was not working at that time, for any reason (such as staying at home for a period when they were needed to look after a sick wife, husband, child, or other relative), was not allowed to join the VR.
Those who were overseas furthering their education, or doing humanitarian work, or off work while they cared for sick family members or having their children, were caught out by the legislative changes - potentially excluded forever from the Vocational Register.
"Doctors in No-Man's Land", Australian Medical Association Website
The non-VR levels of Medicare rebate were originally set to 93% of the VR levels. This is a bit lower (and unfair) but not a huge difference. However, the VR levels of Medicare rebates are indexed to inflation, while the non-VR rebates are not. Instead they are fixed to remain forever at their 1992 levels of remuneration. And the Australian Consumer Price Index (CPI) has almost doubled since 1992 when the non-VR Medicare payments were frozen.
This means that non-VR GPs are now getting half the medicare rebates of VR GPs.
Since this inequity only affects payments from Medicare to the doctor themselves, the more a doctor's income comes from Medicare (such as from bulk billing), the more they are discriminated against. Doctors who bulk bill most or all of their patients are affected the most. Doctors who work with disadvantaged groups of patients, such as in nursing homes, or disabled patients, are very severely affected, since many of Australia's most disadvantaged medical patients qualify for bulk billing.
And since their rebates are fixed at a dollar value (of 93% of the 1992 level of pay), the longer this unfair system lasts for, the less pay (in real terms) these non-VR doctors will be working for. I wonder how many businesses (in other industries) would still be in business if they had to operate now on 93% of their 1992 level of income, but still having to pay the full current 2013 amounts for their operating expenses (such as staff and rent and insurance)?
There are currently about 4,150 non-VR GPs in Australia.
Why are Sydney, Melbourne, Brisbane, Perth, Newcastle, and other Metropolitan Areas Affected?
There is a provision for non-VR doctors to receive full Medicare rebates (including from bulk billing), but only if they are practicing in a designated rural area. This means effectively that there are 4,150 less doctors in Australia who are able to bulk bill their patients while practicing in any of the Metropolitan areas. The Blue Mountains used to count as a rural-enough area for this until 2012. Since then, any non-VR doctors in the Blue Mountains have to either treat only (or almost only) private patients and/or patients who can pay upfront (i.e. not bulk bill). Any doctors who were working a lot with nursing home patients (or any disadvantaged groups that cannot afford to pay upfront, who would usually be bulk billed) are the most affected.
Most capital cities, Sydney (including Sydney CBD), Melbourne (including Melbourne CBD), Brisbane, Adelaide, Hobart, Perth, and their suburbs such as Manly, Parramatta, Penrith, Chatswood, Mt Druitt, Campbelltown, Sutherland, Bondi, Alexandria, Ashfield, Dee Why, Hornsby, North Sydney, Rockdale, St Leonards, Turramurra, etc., are of course all affected, as are the large country centres such as Newcastle and Wollongong, Coffs Harbour, the Gold Coast, and even smaller ones such as Armidale, Tamworth, etc.
Where Can non-VR Doctors Still Work?
To be eligible for full Medicare rebates, non-VR doctors can practice in areas with Rural, Remote and Metropolitan Area (RRMA) classification of 4 or higher.
Sometimes (if there is a specific provision for that area due to a shortage of doctors) RA3 areas are also allowed. Also certain "defined areas of consideration" may be allowed, though I haven't been able to find any information on what/where these are.
Australian Standard Geographical Classification: - Remoteness Areas (ASGC-RA) systems is a geographical classification system that is used to classify areas of Australia into geographical categories called Remoteness Areas (RA). RA categories are defined in terms of ‘remoteness’ - the physical distance of a location from the nearest urban centre (access to goods and services) based on population size.
The RA categories are as follows:
RA1 - Major Cities of Australia
RA2 - Inner Regional Australia
RA3 - Outer Regional Australia
RA4 - Remote Australia
RA5 - Very Remote Australia
In Tasmania the RA categories are:
RA1 – no areas classified
RA2 – Hobart and Launceston
RA3 – areas not mentioned in RA2, RA4 and RA5
RA4 – areas on the east and west coast and parts of north-east Tasmania
RA5 – Flinders Island and King Island
Prior to 1996, the criteria for being able to work as a General Practitioner in Australia were to graduate in Medicine from university and subsequently work two years in the public hospital system.
The "Vocational Register" was set up in 1989 by the Federal Government of the time. It is a list of names held by the Health Insurance Commission. General Practitioners were encouraged to sign onto the "register" before the cut-off date; those who signed were automatically "grandfathered" onto the "register" and given VR status.
The criteria for signing on to the VR at the time were 5 years experience in general practice. The majority of GPs in Australia today were "grandfathered" in this way. Most GPs who graduated between 1989 and 1996 therefore missed out.
So called "non-VR" GPs thus represent a group of GPs who graduated between about 1989 and 1996, plus a smaller group of doctors who graduated before that date. In total there are approximately 4,150 "non-VR" GPs, nationwide.
Within a few short years of the government’s new system, non-VR GPs were getting paid significantly less than VR GPs, for identical work. Since 1992, non-VR Medicare rebates have been frozen; VR GPs are effectively now paid double the Medicare rates that "non-VR" GPs are, despite both "categories" of GPs having the exact same responsibilityand care requirements for their patients, identical practice costs and medical liability insurance.
non-VR Australian born, Australian trained GPs represent a cohort of GPs who graduated between about 1989 and 1996, plus a smaller group of doctors who graduated before that date. Some of these latter GPs nobly refused VR status in protest against the blatant discrimination against non-VR GPs. Given it's been about 20 years, they've lost well over a million dollars (and counting) for their noble stance...
Many non-VR GPs are female, having taken time out of the paid workforce to have children and thus missed out by a few short years on automatically being offered "grandfathering" into the government’s "VR" register.
Other non-VR GPs had to take time out of medical practice - even for a relatively short period of time - to care for sick relatives, which put them in this non-VR category, and thus subject to pay discrimination.
Some non-VR GPs have over 30 years of practical GP experience. Others were kept out of the VR system precisely because they were upgrading their skills during the government’s cut-off date. (e.g.: working in public hospital emergency departments for a number of years).
Australian born and trained non-VR GPs have the same patient responsibilities, and University medical qualifications, as the Australian GPs who were all "grandfathered" into the VR system. Yet they receive FAR LESS Medicare rebates (especially when they do a lot of bulk billing), despite providing the exact same level of care.
The Australian public has been in the dark for years about this secret government pay scandal.
This discrimination is due to a complicated bureaucratic policy at the Department of Health but can be explained in very simple terms. In 1989, the Australian federal government created a bureaucratic "register" called the VR. If a GP’s name is on that "register" they get paid normal GP Medicare rebates. The majority of GPs in Australia today were "grandfathered" onto this register. (That is, their names were just entered onto the list!)
After a certain date, if a GP’s name wasn’t on the list they were called a non-VR GP and paid less money for identical work and responsibility.
Thousands of Aussie GPs fell into this so-called non-VR GP category. Many of these doctors joined a series of class actions against the government. All the class actions were, of course, successful: thus those GP's names were also put on the VR list.
Dr Walker, the Aussie doctor who started the association "Fair Go for Doctors", was unaware of those class actions as, at the time, he was caring for his wife, who had been injured, and their 3 infant children. The family went on the carer/disability pension for a couple of years while Dr Walker also worked part-time as a GP at night. No doubt all the remaining so-called non-VR GPs were unaware for other various reasons. e.g.: some were overseas working in disadvantaged countries (for instance, médecins sans frontiers), others took some time away from fulltime work to have kids (there are many women in this discriminated category), some of the doctors were working in emergency departments, others caring for sick/elderly relatives, etc etc. So they all fell into this nonsensical bureaucratic bucket.
Ever since 1992, all these doctors, plus any remaining non-VR GPs, have had their Medicare rebates frozen! Their pay from Medicare (e.g. from bulk billing) is now half, for identical work.
This is obviously completely unfair.
In fact it is brazenly unjust.
And it is actually AGAINST THE LAW.
Examples of the Medicare Rebate Discrimination Against Bulk Billing Doctors
Here is an example of the current pay discrimination between so-called "VR" and"non-VR" General Practitioners:
DVA Std Nursing Home consult:"VR" 7 patients:
DVA Std Nursing Home consult:"non-VR"(LMO) 7 patients:
DVA Std Nursing Home consult: "non-VR" 7 patients:
(Average 20 min consult).
Please Note: all the above GPs
* Have to give the exact same level of patient care (unsupervised)
* Have identical rights to order whatever medical tests, or prescribe any
medical intervention they deem appropriate
* Have to take the exact same level of patient responsibility
* Have to pay the exact same level of professional indemnity insurance
The VR GP gets almost triple the remuneration from Medicare than the non-VR (Non-LMO) GP.
The VR GP gets virtually double the remuneration from Medicare than the non-VR (LMO) GP does, despite identical work, qualifications and responsibility.
This pay discrimination is actually illegal in Australia, and the Government keeps a close guard on its list of non-VR GPs, in order to make it hard for non-VR GPs to form a group large enough to form a class action lawsuit against them. This has happened before and the doctors won (which was inevitable since, as I understand it, the law is quite clear in this area). Iif you are a non-VR GP, you can join this new register of non-VR GPs to help the situation be resolved.
And if the Doctor Only Bulk Bills
If the doctor only bulk bills then the Medicare rebate from the government has to pay for all of the salaries and wages for the surgery staff (including super and payroll tax etc.), office rent, the doctor's liability insurance, workers compensation premiums, other insurances, utilities, all their other practice costs, before the doctor gets paid!! So the more bulk billing a non-VR doctor does, the more they are penalised under this unfair system.
A non-VR doctor whose bulk billing patients make up the "bulk" of their practice will end up with much less than half the before-tax (and after-tax) income of a VR doctor. In many cases it is a tiny fraction of the income, and this is what is forcing many non-VR GPs to close their practices, and even to quit medicine for other careers.
If a doctor's expenses (such as rent and staff and insurance etc) were as much as half of what their income would be if they were on the VR, a non VR doctor would be working for nothing at all. And if their running costs were more than 50% of their income on the VR, the non VR-doctor would be running at a loss, and having to pay thousands of dollars out of their savings each year (i.e. making negative income) just to keep their bulk billing practice running.
Remember that the VR levels of Medicare rebates are indexed to inflation, while the non-VR rebates are not. The non-VR levels of Medicare rebate were originally set to 93% of the VR levels. Not a huge difference. However, the Australian Consumer Price Index (CPI) has doubled since 1989 when the vocational register was introduced.
This means that non-VR GPs are now getting half the medicare rebates of VR GPs.
Non-VR GPs are also Ineligible for Government Bonuses
Various other payments and bonuses are made to "VR" GPs: for example "practice incentive payments", bonuses for visiting nursing home patients, etc etc. These can all add up to substantial amounts which help pay practice bills. Such bonuses mean that VR GPs - who themselves are constantly struggling to remain in medicine anyway on the Medicare Rebates they get, can at least keep their practices open.
Imagine how much harder it is for the (Australian born and Australian trained) so-called "non-VR" GP who doesn’t get these payments in any shape or form!
The Position of the AMA (Australian Medical Association)
The opinion of the Australian Medical Authority (AMA) is that non-VR GPs should be recognised by the Australian Government and given fair and equal treatment.
"The AMA has consistently argued that non-Vocationally Registered (VR) GPs should be recognised for their considerable experience in both general practice and other areas of medicine, and continues to opportunistically press the case for a final round of grandfathering, a lifting of the A2 rebate, and its ongoing indexation."
Read More on the AMA (Australian Medical Association) Website
Non-VR GPs should be recognised for their considerable experience in both general practice and other areas of medicine. Grandfathering these practitioners will help retain and increase their numbers in the general practice workforce and encourage them to increase their hours.
Specifically, the AMA calls for a final round of grandfathering for all of the non-VR GPs who had access to GP Medicare rebates prior to 1 November 1996 and have predominantly been in general practice for a minimum of five years since that date.
In addition, in order to further reduce the inequity in rebates for any remaining non-VR GPs, after this grandfathering opportunity, the A2 rebates should be increased to reflect the differential that existed when the vocational recognition structure was introduced. For those practitioners who are not eligible for grandfathering to the vocational register, A2 rebates should be increased to 93 per cent of the A1 rebates and indexed appropriately on an annual basis. This would address the inequity of these fully qualified medical practitioners receiving Medicare rebates similar to — and in the future potentially less than — that received by lesser-trained health providers such as nurse practitioners.
Join the email list at www.fairgofordoctors.org. (On the right-hand side of the home page, near the top, under the blue box that says "YES".
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Lobby your local Federal Member of Parliament about this issue. I'll add some more information on how to do this in the next week or two. If you contact your local MP, you could copy all of the text in the section "What Needs To Be Done About This?" (which is directly above this section of this page), and include that in what you write to them.
If you ask your local MP what's their position on this issue "because you would like to know before the election" (or anything like that) it will probably make them think a bit more about it.....