Three weeks ago a young man with a sore wrist walked into general practitioner John Houston's clinic in Ingleburn, on the south-west outskirts of Sydney.
Dr Houston, the chief clinical officer of $1 billion giant Primary Health Care, sent the patient for an X-ray by Primary radiologists in the same building. "[The X-ray] looked alright clinically but I think 'something is not right' so I send him back up for a CT scan and sure enough there is a fracture and I send him up to a physio to get a brace," he tells AFR Weekend.
To Dr Houston this is the epitome of quality care – the patient receives the right diagnosis and is treated quickly. But with Primary clocking up at least three payments from taxpayers in the process, it is also the kind of behaviour - as well as providers signing up patients "opportunistically" to chronic disease care plans - that the government's clinical advisers said last week needs greater scrutiny. The Health Minister Sussan Ley is also looking at it as part of separate reviews.
And Dr Houston finds that "offensive". "Why would I send somebody down the road when I've got a bloody good radiologist upstairs and when I can get the pathology on my desk?"
In the aftermath of December's budget update that revealed cuts to incentive fees paid to providers that bulk bill for blood tests and x-rays, Ms Ley has ramped up her criticism of corporate healthcare providers, especially those that co-locate GP clinics with other services like pathology and imaging.
As well as Primary its rivals, $7 billion Sonic Healthcare and $4 billion Healthscope operate similar structures.
"They [the government] seem to be using corporate [medicine] as a demonstration of what's wrong with general practice," Dr Houston says. "It should be celebrated, not criticised, but I think we are seen as a big easy target."
With these companies in her sights, Ms Ley rebutted messages from companies this week arguing the cost of pap smears could rise as a result of the cuts.
"Changes in MYEFO relate to an inefficient payment – worth between $1.40 and $3.40 – that is paid direct to pathology corporations separate to the Medicare rebate," Ms Ley said on Wednesday. "Medicare is not designed to be a guaranteed bankable revenue for corporations, nor is a taxpayer-funded payment like this provided to cross-subsidise other costs of doing business for pathology companies."
The incentives cost $500 million over five years and were enacted in 2009-10 by former Labor Minister Nicola Roxon to support levels of bulk billing. Ms Ley is right that removing them for any tests, including pap smears, will not change the base fee doctors are paid.
But doctors warn without the added extra sweetener to bulk bill, they will consider charging patients a further charge to cover their costs.
This could lead to fewer preventative tests being ordered, says Dr Sanjay Nijhawan, another Primary contractor who works in Sydney's Maroubra. "I see a number of aboriginal patients from the La Perouse area. We talk about closing the gap [in aboriginal health]. How are we going to close to the gap?"
Primary has been criticised in the past for schemes that pay doctors incentives to put sufferers of diabetes and other chronic diseases on care plans, which may lead to more visits and billings. But the company argues it operates within the limits of the government designed Medicare scheme.