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The AMA and Medicare: a love-hate relationship

The AMA described the proposed reimbursement changes for level B consultations as “an assault on general practice”. AAP Image/Lukas Coch

The Australian Medical Association (AMA) has emerged from the recent brouhaha over the Abbott government’s proposed Medicare reforms as both a winner in the protection of doctors’ incomes and an apparent champion of the affordability of health care for patients.

Medicare changes that were due to come into effect this week would have imposed a ten-minute minimum for regular (Level B) GP consultations, which currently attract a A$37.05 rebate. Consultations under ten minutes would have attracted a smaller rebate of A$16.95. GPs were faced with a choice: absorb the cuts or pass them on to patients.

The AMA framed the change as a A$20 cut to patient rebates for short visits and used data to dismiss government claims of “six-minute medicine”.

The proposals drew widespread public condemnation. When the opposition vowed to disallow the regulations implementing the cut when the Senate resumed in February, the government was left with little choice but to abandon the plan days before it was due to take effect.

It was an effective demonstration of the power and profile of the AMA, using a potent combination of evidence and scare tactics.

Now the real work begins for the new health minister, Sussan Ley, the cabinet and all the stakeholders in Medicare. The AMA is (rightly) guaranteed a place at the consultation table, but others are equally entitled to be there – including other professional medical groups, a wide range of primary care workers, pharmacists, aged care and mental health representatives and consumer and patient organisations.

Students of the history of Medicare are entitled to expect that in the upcoming negotiations the AMA will revert to standard practice, crowding out others and zealously safeguarding turf, fee-for-service and doctors’ incomes.

But the definition of a successful resolution to the current impasse does not lie solely with an agreement between the health minister and the AMA; the problems to be addressed are much broader than an adequate reimbursement for Medicare services provided through general practice.

The AMA has a tradition of opposing key health reforms, good and bad, dating back to the 1940s when the Pharmaceutical Benefits Scheme (PBS) was introduced. The AMA (then an offshoot of the British Medical Association) opposed the PBS with unrelenting vigour.

The then-BMA opposed socialised medicine and tried to block the PBS. Everett Historical/Shutterstock

Robert Menzies, then leader of the opposition, agreed to support the government’s case. But the price for this, extracted by the BMA, was a referendum question to change the constitution to prohibit any form of civil conscription, thus effectively making socialised medicine forever impossible.

Similarly, the AMA met the introduction of Medibank and later Medicare with ferocious opposition, although it was not alone – many in the medical professions, the General Practitioners’ Society and the private health funds were also against these reforms. Opponents argued that the system constituted a socialist takeover of medicine that would limit their incomes and the freedom of Australian citizens.

Fortunately, the AMA eventually agreed that perhaps there were some benefits to publicly subsidised health care. No AMA spokesperson today would advocate the abolition of these programs. And in fairness, on the other side, cabinet documents released some years ago revealed that the Whitlam government had its own – largely irrational – fears that doctors would treat Medibank as a licence to print money, by over-servicing patients, knowing the government would foot the bill.

These confrontations occurred decades ago, but they highlight deep-rooted suspicions on the part of both the AMA and government about each other’s value systems that still linger, mostly hidden, but emerging regularly. Last week, the AMA described the proposed reimbursement changes for level B consultations as “an assault on general practice”, while Liberal Party backbencher Andrew Laming called for a crackdown on “cowboy doctors”.

It is increasingly clear that Tony Abbott and his government are not the “best friend that Medicare has ever had” and the Coalition’s preferred position would be a Fraser-government-style retreat on publicly funded health care, leaving Medicare as an increasingly ragged safety net for the poor. So there are no great expectations for real reforms to emerge from the promised consultations, despite the strong case for change.

New health minister Sussan Ley will consult with various health and medical groups in the coming weeks. AAP Image/Alan Porritt

In recently published articles with colleagues Jennifer Doggett and Stephen Leeder, I have outlined the need to focus on delivering increased value and quality in health care, how growing out-of-pocket costs are arguably leading to increased hospital costs, and the need for more teamwork and connected and coordinated care.

Reforms are needed to address these and other problems, including:

  • years lost needlessly to disability
  • growing health disparities in some population groups
  • a health workforce that does not reflect current and future needs in its make-up and distribution
  • outdated reimbursement methods
  • a failure to direct spending to ensure improved long-term health outcomes and economic sustainability.

Will the AMA be an effective protagonist for these issues in the upcoming discussions and negotiations?

On the one hand the AMA has an outstanding record as an advocate for issues as important and varied as the social determinants of health, climate change, asylum seekers’ health, problem gambling, violence against women and rural health. Most years over the past decade have seen the production of an Indigenous health report card and the AMA has used its resources to highlight the need to close the gap on Indigenous disadvantage and to encourage Indigenous doctors.

On the other hand, the AMA has generally opposed Medicare reforms at their introduction, regardless of political parenthood. AMA panned Fairer Medicare, Medicare Plus, GP Super Clinics, Medicare Locals and coordinated care for diabetes. Its support for bulk billing has been lacklustre at best, although the AMA has spoken out about the impact of out-of-pocket costs.

The AMA has campaigned aggressively around medical indemnity costs, managed care programs, Scrap the Cap on work-related self-education expenses for professionals, reduced reimbursements for cataract surgery, the provision of immunisation and other services in pharmacies, and the ability of optometrists to manage glaucoma patients.

An astute minister will consult widely to ensure all doctors’ voices are heard. Alex Proimos/Flickr, CC BY-NC

Basically the AMA is very good at doing what most unions do: protecting members’ income and interests. In health policy terms this boils down to two basics: fee-for-service as the gold standard for reimbursement and aggressive turf protection as non-medical health professional boards look to expand their scope of practice.

Given the growing recognition that fee-for-service encourages volume over value and that primary health care is about more than general practice, there will eventually be showdowns on these issues, even if they are not on the table this time around.

It is important to realise that there are many Australian doctors who do not see their interests as well represented by the AMA (only about 40% of Australian doctors are AMA members), so an astute health minister will consult more widely to ensure that all doctors’ voices are heard, along with those of other health professionals and – most importantly – the patients.

The AMA is just one of the keys to unlocking an effective resolution to the current health and budget impasse.

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