The news in Canberra over the past few days about the closure of the Wanniassa Medical Centre and the relocation of the doctors to the Phillip Medical Centre has sparked a strong community reaction. Understandably, many patients are very concerned about their continued access to good primary health care and in particular, their ability to continue to see the GPs they have been seeing for many years.
For those without access to private transport, there is also the concern about their ability to travel to Phillip to see their doctor. These concerns are compounded by the shortage of GPs in Canberra and the difficulty of finding another GP in their area.
In many ways, the move was a predictable commercial one. Large commercial organisations, known among doctors as corporates, have moved into primary care in a big way over the last 10 years. The corporates hoped that by setting up medical centres with GPs, pathology and radiology facilities and sometimes allied health-care workers, these would make money from a process of internal cross-referrals. GPs would refer their patients for pathology tests and X-rays to the in-house facilities, and some referrals could also flow the other way.
For the medical centres to work, corporates had to get GPs into them and money was paid, sometimes quite big sums, to lure the GPs in. For a lot of older doctors and some young ones too, this was a chance, sometimes seen as a final chance, for them to pay off their mortgage and have something to put into superannuation. When figures for doctors' incomes are bandied about, allowance has to be made for the fact that these income figures also have to include their holidays and superannuation and so start to look a lot less generous.
Symbion Ltd was the corporate which initially bought the Wanniassa Medical Centre. Primary Health Care, which ran the Phillip Medical Centre, has now bought Symbion and so now owns the Wanniassa Medical Centre as well. The GP who started Primary Health Care, Dr Edmund Bateman, is rumoured to be the richest doctor in Australia. Primary Health Care is probably the most successful medical corporate in Australia now.
In addition to their medical centres, they also own Medical Director, the most widely used software program amongst Australian GPs.
Corporate medical centres vary a lot in their mode of operation. Some are run exactly like traditional general practices with only the difference of ownership. Others are radically different to the average general practice. The new model medical centres are often open six or seven days a week and are usually open for extended hours every day. They all bulk-bill. A lot of them don't take appointments for their doctors.
Patients therefore have to queue up and wait, and if a patient chooses to see a particular doctor rather than the first doctor available, that obviously means an even longer wait. Patients of mine who have been to one of these new model medical centres tell me that the use of the waiting time and other subtle pressures work towards encouraging loyalty to the medical centre rather than loyalty to the one doctor.
A lot of them do not take medical students or medical registrars for training, arguing that they take valuable time from their doctors, time which could be spent seeing patients and earning more money. They therefore take advantage of the work of other doctors who have spent valuable time and effort on training the next generation of doctors.
The reason why these medical centres are so commercially successful relates to the Medicare Benefits Schedule, that is, the fee structure by which Medicare reimburses doctors. Currently, a doctor is reimbursed $32.80 by Medicare for a Level B consultation. This is basically a consultation with a GP lasting from five to 20 minutes and is by far the most common Medicare item claimed by GPs.
The GP can claim another $8.20 from Medicare if the patient is bulk-billed and has a Health Care Card. So, if a patient sees a doctor for a cough and cold and is found to have a simple respiratory viral infection for which the prescription is rest and a medical certificate for a few days off work, and the consultation lasts six minutes, the doctor gets $32.80 from Medicare. If a patient comes in for a check-up for her diabetes or to discuss the complications of her latest antidepressant medication and the consultation takes 20 minutes, the GP still gets $32.80 from Medicare. So, for a corporate to maximise income for itself and the GPs working there, they need to encourage patients with chronic and complex problems to seek health care for their conditions elsewhere and to encourage as many six-minute consultations as possible. This is precisely what the structure of the corporate medical centres does.
In Canberra, we have a GP shortage. So for any corporate to operate its medical centre, it has had to persuade local GPs to move in, some of whom have been GPs here for 20-30 years and who have built up a loyal following. One of the heartbreaking things about the advent of these medical centres has been the stories of patients who have had to reluctantly leave their GP of many years because they can't sit in the waiting room for several hours waiting to be seen when they have a chronic back pain or a mental illness. What makes it even more cruel is the difficulty some patients encounter trying to get their medical records transferred to their new GPs.
The previous federal government had little love for corporates, and tried to encourage traditional general practice by bringing in targeted payments like the Practice Incentive Payments and Extended Primary Care Item numbers. Many corporates simply did their sums and decided their model offered a better income than the model that Practice Incentive Payments would enforce.
As for the Extended Primary Care Item numbers which were meant for GPs managing chronic complex problems, the corporates with their better infrastructure and emphasis on maximising income were simply better at doing the paperwork necessary for these payments than the traditional GP.
Of course, as more GPs are seduced into working for corporates, the non-corporatised GPs are left with an increasing caseload of patients with chronic and complex problems with the ''easy'' coughs and colds that used to leaven their day taken away. At some point, the burden of work and responsibility gets too much to bear and many non-corporatised GPs just give in and leave medicine or join the corporates.
Who, then, will care for the chronic and complex ill patient? So much of the public discourse about primary care in the last few years has been about bulk-billing rates and admittedly, it is a major issue for the disadvantaged. What about the quality of primary care?
What will happen to the patients of Wanniassa? I hear from other sources that the doctors in Wanniassa, when they move to Phillip, will be given rooms in the upstairs part of the medical centre and they will have their own secretary and appointments. Perhaps things will go on as before for the doctors and their patients. Only time will tell.
Ultimately, the corporates are just applying the inexorable commercial logic of our current Medicare Benefits Schedule. The players at the big end of town can recognise a winner when they see one, and some have substantial shareholdings of medical corporates in their share portfolios. If patients and voters don't like the consequences of this commercial logic, then they have to let our politicians know. Maybe they should even ask our politicians to look at other ways of funding general practice.
Dr Tuck Meng Soo is a Canberra GP who practises at the Interchange General Practice in Civic.