THE MEDICARE GENDER GAP: Female GPs penalised by our flawed system

The Australian Government has just proposed an overhaul of the Medicare rebate system to address the “troublesome issue of six-minute medicine”. This will create contentious debate, which can only be a good thing as the Medicare system has serious flaws. Did you know female GPs in Australia earn on average 25% less than male GPs, even after adjusting for hours worked? I believe the solution lies in the problem – we need to pay GPs in 6 minute blocksLet’s examine the current system, and explore why female GPs lose out.

The Medicare gender income gap certainly doesn’t surprise me, or any other GP I know.  According to Professor Tony Scott, the Principal Investigator of the national MABEL survey:

“This is something of a mystery… While such differences persist in other occupations, this is particularly difficult to understand in an occupation where men and women have the same high level of education. Our results have adjusted for differences in hours worked, years of experience, and a host of other factors. It could be that female doctors see a different mix of patients than male doctors. We are puzzled and are continuing to look into this.”

Anecdotally, these are the reasons female GPs see less patients in a day:

  • Female patients often self-select female doctors when they wish to discuss complex problems.
  • Many patients report using a male doctor for ‘quick problems’ and a female doctor for ‘slow problems’
  • Female GPs see more;
    • Mental health presentations, disclosure of domestic violence and sexual abuse/assault
    • Family dynamic problems and child behavioural issues
    • Patients presenting with long lists of multiple problems they wish to discuss
    • Patients with vague non-specific symptoms and the worried well
  • Some GPs laterally refer patients to their female colleagues when the problems are complex. “You should see Dr X, she’s great with hormonal problems and bloating”.

Rather than simply label Medicare as inherently sexist, I thought it was worth examining WHY the system fails female GPs. The issue at the heart of this is not gender based – it’s a symptom that female GPs are paid 25% less, but the diagnosis is a flawed payment system that favours rapid turnover ‘6 Minute Medicine’, instead of good quality thorough care.

The Medicare fee system means a GP is paid the same standard “Level B” consultation fee for a 6 minute consultation, as a 19 minute consultation. This means a GP who sees ‘quick problems’ every 6 minutes can churn through 10 patients per hour, earning $370.50 in Medicare fees. A GP who sees ‘slow problems’ every 19 minutes might see 3 patients per hour, earning $111.15.  Of course, these earning figures are significantly reduced by income tax and clinic overheads. But you can see the incentive for practicing 6 minute medicine, and who will be taking home more at the end of the day! This is why female GPs overall earn less – they simply see more ‘slow problems’ than male GPs – because of the type of patients who choose to see them, and some differences in how they practice a consultation.

Of course, there are many times when 6 minutes is all that is needed – for an ankle injury, treating school sores,  or tonsillitis. But at the end of the day, the Medicare system is failing patients and favouring poor quality care when it disproportionately rewards ‘6 Minute Medicine’. Counselling, education and preventative health discussions cannot be achieved in 6 minutes. Complex medical problems and care coordination suffer. The quality GP practice as the ‘central medical home’ that keeps patients healthy and out of hospital ceases to exist, and it becomes a service centre for acute drop-in presentations, saving the national health budget nothing in the long run.

Female GPs aren’t the only losers in this system – any GP, male or female, who practices ‘Slow Medicine’, is penalised.  GPs who take thorough histories, who are willing to dissect complex problems, who perform full examinations, who spend time listening and counselling and educating their patients about their conditions, will end up taking a pay cut at the end of the day.

What’s my proposed solution? 6 Minute Medicine. Let’s call it for what it is, and pay accordingly for time spent. Most other professions, like lawyers and accountants, break their day into 6 minute allocations.  If you spend more time with a patient, you are paid more for that time.  There is no incentive to seeing either ‘quick medicine’ consults or ‘slow medicine’ consults – rather, the GP is paid appropriately for the length of time they spend with their patient. Compare our current system to my proposed ‘6 Minute Medicine’ breakdown:

CURRENT MEDICARE REBATES:

Level A 0-5 mins = $16.95 / Level B 5-20 mins = $37.05 / Level C 20-40 mins = $71.70 etc

MY PROPOSED REBATES:

Each 6 minute block is paid at the flat rate of $ 16.95

Level A – 0 to 6 minutes.  $16.95 / Level B – 6 to 12 minutes. $33.90 / Level C – 12 to 18 minutes. $50.85 / Level D – 18 to 24 minutes. $67.80 / Level E – 24 to 32 minutes. $84.75

I’d love this system – I’d take home similar pay to my male colleagues. I also feel in the long run it would also raise standards in GP care by removing the financial incentive that favours ‘quick medicine’. Hopefully, it would encourage everyone to take just as much time as the patient and doctor needs, knowing they will be fairly recompensed. (Of course, the payments MUST fairly recompense the GPs for their time, expertise and overheads, which is an argument for another article!)

You may be reading this thinking, “But this would make my General Practice financially unsustainable!” Spare a thought, then, for female GPs who’ve been 25% less sustainable than you for years. Let’s keep the Medicare discussion open until we find a financially equitable and patient-centric system – after all, good primary health care must put quality of care first.

 

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6 thoughts on “THE MEDICARE GENDER GAP: Female GPs penalised by our flawed system

  1. Agree 100% – however have to be clear about who is paying you – Medicare….or the patient.

    Remember that Medicare was a rebate system designed to offset the cost to patients of seeing doctors – doctors charged, patients paid and the Medicare system provided a rebate. Wedding doctors income to the rebate is problematic – not least because either rebates may be frozen due to political expediency, or because spending 60 minutes at 2am with a patient (GPO after hours) will only bring in 10x$16.95 = $169.50, less than a plumber.

    I think the idea of charging in six minute blocks is very sensible. But I would encourage GPs to set their fees and then let the issue of rebate amount remain between patient and Govt. It’s tough love, but it’s clear Govt ain’t going to listen to GPs. They MAY listen to patients who vote. I am not sure how much longer primary care can continue to subsidise patients – our practice costs continue to rise, rebates do not.

    Many remain worried about the competition of the UBB clinics down the road. Patients will have to make choices; either pay for quality (longer) care or accept a churn in a UBB clinic.

    In an ideal world, rebates would match the doctors fee. But whilst GPs remain wedded to the rebate as their fee, this will not happen. Given the impotence of individuals and organisations such as RACGP/AMA, I think the time has come (sadly) to move the fight to the voters – they are the only people that the pollies will listen to.

    So – a resounding YES to setting fees in six minute blocks. But the world will freeze over before the Govt establishes a fair rebate. Like it or not, if you offer a uality service, you are going to have to charge what you are worth – which will invariably be above the MC rebate unless for a simple item such as script or ultra-quick ear review etc.

    It’s very sad.

  2. Great article, and great comments below.
    I had just accepted that I would earn less by practicing the kind of medicine I felt was right – but you’re right – we shouldn’t be penalised for spending time with our patients. Its what our patients want and need, and we should be providing that service without penalty. Lawyers charge in 6 minute increments – why not GPs?
    I do note however that with your proposed items (A – E) that even a level D consult would have a lower rebate than the currently available rebate (C). Your proposed scheme has more graduations so would be more accurate, and may actually lead to cost savings based on the amount of item 36’s I (and probably others) charge! Dya hear that, Abbott? savings!

  3. Pingback: DID THE CORPORATISATION OF AUSTRALIAN GENERAL PRACTICE CREATE ‘SAUSAGE FACTORY MEDICINE’? | Pinson Opinion Piece

  4. I’m not sure I quite follow the maths- a ‘fast Dr’ seeing patients in 7 minutes will still earn more than a slow Dr seeing patients in 11 minutes. I think the range for a level B and indeed level C is very large and should be reduced to 5-15 minutes (neatly fits with appointment systems too) and then then next one should be 15-30 (= 2 x15 min appointments). Can you imagine people being on time for a 9:24 appointment?

  5. The other thing to add is that a lot of GPs don’t charge a gap fee for children, contraception or pap smears. Guess who sees the bulk of these patients?

    I find it interesting that paps are the one procedure that does not attract any type of additional payment. Inserting an implanon is quicker, but it attracts a significant extra fee.

  6. I don’t believe there is gender discrimination in terms of doctor’s pay. Female GPs who choose to spend more time with a patient may also choose to charge more. If they accept less for their time, that’s their problem – grow a spine, because we’re not going to break ours for you.
    Also, you should not feel guilty to charge a patient your fees. If hairdressers can charge $70-$300 for 30-60min, a chiropractor $100 for 10min, dentist $250 for 15min, Lawyers $450/hr, Accountants $200-400/hr, specialist physicians/surgeons $150-250 for 15min, and real estate agents a 1-3% commission on a sale, why do GPs feel the need to sell themselves short?? Why???
    All the aforementioned professionals provide a valuable service to the public. Lawyers are just as important to people’s legal disputes as GPs are to health. Hairdressers are just as important to client’s self esteem/image as are dentists to their teeth. So Why do GPs consider themselves to be any more responsible in financing a person’s expense by absorbing the cost? This doormat mentality is what has earnt GPs such a low reputation in society – as if GPs are slaves of the public health system (that’s what hospital doctors are for!) and are responsible for being compassionate to patient’s financial woes – that onus is not on the GPS, it’s on the government. If the government supports welfare dependency or feel that certain patients with “disabilities” need more support, then that is their responsibility to provide it.
    So in short, it’s not really an issue of a gender gap or discrimination against female GPs, but rather, an issue of GPs feeling conscious and guilty to charge patients what they are really worth – it just happens that female GPs have less of a spine in being upfront that it would cost more for a longer consult. It really is a vicious downward spiral if you meet someone else’s expectations at your own expense – that applies to anything else in life – imagine a couple where one partner is in an abusive relationship to the point that they are completely subservient out of guilt and fear of being criticised – that’s exactly what the GP profession has become, and the situation is only becoming worse with more corporates taking over practices. Corporates aim to compete via scale of economy – increasing the number of practices and lowering the costs (i.e. mostly bulk billing) in order to meet the same income targets and compete against private billing GPs. This is a disgrace. Any GP who accepts bulk billing and 5-minute medicine is a joke. You should know that a standard consultation in medical school was defined as 20 minutes – incorporating history, examination and a management plan. What’s this 5-minute medicine nonsense and absorbing the cost of your service??? GPs have to pay anywhere between 30-50% of their consult fees to the practice, and have income tax etc on top of that. In reality, you’re only taking home something like 30% of the fee you charge.
    GPs – I urge you all to stand up and respect yourself. Because if you don’t, clearly society won’t either. If you advertise yourself as a free service provider, that’s all they’ll see you as – just another freebie like the dust around you. Don’t compromise your professional ability and patient’s health with 5-minute medicine. You studied a lot to get where you are, and should know better than that.

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