This month, a short paper I wrote for the Australian Centre for Health Research think tank, exploring the reintroduction of the Hawke government's 1991 modest co-payment for GP services - updated to $6 from the $3.50 of two decades ago - has created something of a stir.
Apparently, I'm single-handedly destroying an Australian national institution, Medicare. Alternatively, I'm a stalking horse for the coyly silent Abbott government, proposing what the federal Labor opposition labelled ''a tax on taking sick children to the doctor''. Suggesting a matching co-payment could be charged by public hospital emergency departments for GP-type services, to deter avoidance, raised further ire. ''Save Medicare'' rallies are being organised against what's merely an industry think tank proposal, not federal government policy.
Most of the news reports and commentary about the proposal have been critical. Two excellent articles, however, by The Age's economics editor Peter Martin and health academic Jennifer Doggett particularly deserve a respectful response.
Martin went back to the intellectual source of the 1991 Hawke co-payment and its 2013 update, the US Rand Corporation's co-payment experiment in the United States in the 1970s and 1980s. The Rand work indicated that a co-payment of 25 per cent of the service price suppressed demand marginally without deterring patients from seeking healthcare they believed they definitely needed. Martin concluded my proposal was specifically dangerous because it focused on GPs as gatekeepers of the healthcare system. ''General practitioners are cheap compared to other forms of medicine,'' he said.
True, but Martin overlooked the point that this was precisely why a GP co-payment was adopted in 1991 and is being proposed now. It is, as Labor's health minister in 1991, Brian Howe, told Fairfax's Dan Harrison, designed to manage demand for services. Demand isn't just visits to the GP but what flows from them - pathology (with many pathology collectors conveniently located in GPs' surgeries), radiology, prescriptions, specialist referrals, and other health services. No one is suggesting people be denied access to these services, but ensuring the system's sustainability means price signals must start at the source, general practice, where 82 per cent of services are bulk-billed.
Doggett gave typically thoughtful consideration to the wider challenges facing our health system. She acknowledged, rightly, that ''our demand for care is growing in line with our ageing population and we need to ensure every dollar we spend on healthcare delivers maximum value''. She questioned my underlying assumption that there is excessive, sometimes unnecessary, use of GP services, that a co-payment would add complexity and expense and that a it is a simplistic measure that would most hurt the poor and chronically ill. Effectively, Doggett believes, GP co-payments would treat a symptom, rather than disease, of growing demand pressures on Medicare and healthcare.
To some extent, Doggett is right. GP co-payments would work only as part of wider systemic reform tackling financial, structural and demand pressures on general practice and primary care, disease prevention, and the efficient relationship between primary, hospital and aged care. It is a single policy measure within the healthcare system as a whole. I never suggested it is some magic bullet.
Doggett also is right in saying that we have too little hard understanding of why people visit GPs. Medicare data merely records services for which a benefit was paid.
My paper acknowledged we need more than anecdotal evidence to understand how the visits are used, and whether the time and money they represent was used most effectively. Let's have that research.
I make no apology for suggesting a modest price signal for bulk-billed GP and emergency department services, and encouraging people to question whether they really need a trip to the doctor. Surely $6 is far better spent on world-class healthcare than coffee, beer or junk food. Going further still, bulk-billing should be confined - ideally with co-payment - to those who can least afford that trip - pensioners, families with young children, people with chronic conditions and those in real financial difficulties. Anyone who reasonably can afford to pay a fair upfront price to see a GP, or visit an emergency department for GP-type services, should and must pay, and shouldn't expect free treatment.
Whatever the merits or fairness of reviving GP co-payments, my paper has achieved something. From nowhere, it has kick-started a lively but long overdue national conversation about the capacity of our healthcare system, the terms on which we should use it, and how we as a nation keep the ever-increasing costs of our high-quality health services affordable and sustainable.
While the healthcare establishment appears united against it, the intense interest this month indicates that wider public opinion appears to be far more open-minded, and wants this thrashed out.
This is no time for knee-jerk defending of the Medicare status quo: it's a time for being prepared to think the unthinkable to ensure Medicare survives looming financial and demographic time bombs. The genie unexpectedly is out of the bottle, and long may the debate continue.
Terry Barnes wrote the Australian Centre for Health Research proposal for a $6 GP co-payment for bulk-billed services. He was formerly a health policy adviser to Coalition ministers.