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Thursday, 11 March 2004
Page: 21352


Senator ALLISON (11:27 AM) —We have now had not quite 24 hours to reflect on this arrangement—this deal—and the more we know about it the more we realise what a mess we are getting into. Already it has been demonstrated comprehensively how unfair this package is on some regions and on some individuals. It does not, to say the least, hang together as a comprehensive approach to solving some of the pressing problems that we have in Medicare in this country.

Senator Harradine and Senator Lees have argued that something is better than nothing. We do not agree. There was another proposal on the table—our proposal. It did not cost any more but it had much more integrity to it because a lot of the things that are now being raised as problems had been thought through at that time. I am disappointed. I am not disappointed that it is someone else's deal and not ours. That does not matter. At the end of the day it is the outcome that is important. I think what we have here is a poorer outcome than we might have had otherwise. Our proposal, I would argue, would have strengthened Medicare. Whilst $300 for a safety net is certainly going to make the relief of out-of-pocket costs more available to people on low incomes, it sets up so many problems that it is not worth doing. In our view there should have been a uniform safety net and it should have been about $500.

These amendments will make primary health care more affordable, but that goes nowhere toward solving the biggest problem which we came to understand through the important Senate processes—and I am referring to the two inquiries that were conducted into this bill—namely, the importance of specialist fees in all of this. Big out-of-pocket expenses come principally from specialists, not from GPs. Most of the people who will reach that safety net will be there because of the very high costs of specialists. The increase in bulk-billing of $7.50 for some people in some areas will not assist in this respect. As I understand it—perhaps the minister can clarify this—that $7.50 will not go to specialists; it is just for GPs. In any case, $7.50 would probably be laughed at by most specialists, who now exceed the schedule fee and the rebate for their services in many cases by hundreds of dollars. So it is problematic from that point of view. It has not addressed the most pressing problem here, which is that of specialists.

The government admitted yesterday that, as a result of the safety net changes to the $300 and the $700, one in five patients will face a doubling of the fees that they have to pay for specialists by 2007. That is a very large increase. There is nothing by way of either a message through these amendments to the bill or anything the government has said that would discourage that doubling. I think we can expect to see that doubling. It sounds like the government expects it to happen, and most thinking people would reckon it likely in any case. There is nothing in here to discourage that inflationary impact. We are not just talking about inflation in the normal sense of health costs; we are talking about the encouragement for specialists to increase their fees.

That will make it worse for GPs. We are in this position of GPs opting out of bulk-billing because of how they see themselves in relation to specialists. The relative values study that was quoted endlessly in this chamber throughout the process was about GPs comparing themselves with specialists and saying, `Our income is so much lower than theirs, and yet we do extra training—we do the same kind of training, in effect, as specialists. How is it that we are missing out so much?' There is nothing in this package that, as I said, discourages that doubling of fees for 20 per cent of those people who will be caught up by the safety net, so a fifth of those are going to see a doubling. There is absolutely no question that that is going to be inflationary, and we may see that spreading over to GPs, who will continue to be grumpy about the fact that they have missed out.

Our amendments will go to a review of the government's strategies—if you can call them that. I do not think it is a strategy; we just have a mess. We have an ad hoc bundle of approaches to these problems. I think that down the track, in three years time, we will see that costs have blown out significantly for not just specialists—we already know that they will go up—but for GPs as well. So, as I said earlier, we felt that a $500 across-the-board safety net would have been preferable to this two-tier arrangement. Obviously, people who have costs of $300 and $400 would miss out—there is no question about that—but at least it would maintain the universality of Medicare and would not differentiate between income groups or any other approach.

What we have here is a welfare approach, as many people have said in this chamber already. We do not want to go down that welfare path. We value the universality of Medicare. That is an overused word, but it does mean that, regardless of your income, the amount of dollars that flow through to you from Medicare will be related to your need—that is, not need in terms of your income but need in terms of your health. So the sicker you are the more you need the services of GPs and specialists and the more Medicare dollars flow to you. That is right and proper, and it is what Australians value.

I think that the eligibility criteria that have also been canvassed throughout our inquiries have been very poorly thought out. There have been a lot of criticisms of the tax A category. We are going to get an enormous amount of division in the community and very justified claims of unfairness. We are going to get the anomalies that could have been avoided—very simply avoided, and at the same cost. We have here a two-tiered approach. This is not just rhetoric. We are not just saying that two-tiered is bad because it is bad; it is bad because it is often targeting the wrong people.

The biggest flaw in what has been negotiated is that it will not encourage bulk-billing of patients. The government may say, `Medicare is not just about bulk-billing.' I agree; it is not just about bulk-billing. But bulk-billing has become a signal. It is a measure of the success of our system in delivering affordable primary health care. The other signal is the schedule fee. That used to be everything in Medicare. The schedule fee was the compact between government and doctors, so it had integrity as a reasonable fee. What has happened in recent years is that that compact—that regard for the schedule fee—has broken down. I would agree: I think that we could have quite low bulk-billing rates if doctors kept to the schedule fee, because then patients would be out of pocket by only 15 per cent—the difference between the rebate and the schedule fee. I think our system would be much better off if we focused on this question of the schedule fee and how to bring it back in terms of compliance with the figure.

But, as we heard through the inquiry process, pretty much everyone has given up on the schedule fee. We just shrug and say, `Expectations, costs and so forth have now exceeded the schedule fee, so we'll dismiss that. It is no longer part of our system. We don't need to worry about it.' Putting in a safety net at all reinforces that notion. So, whilst I join with others in saying that bulk-billing is not everything, the schedule fee is everything. You do not have affordability if you do not have adherence to the schedule fee. We have seen specialists in particular ignore the schedule fee—and we have seen no attempt on the government's part to retrieve it.

The $7.50 measure will not work without a target. The importance in all of this is seeing a movement to stem the decline in bulk-billing and hopefully lift it. The $7.50 rebate in country areas is not enough. I agree with the principle, the concept at least, of taking money out into areas where it is in short supply. We argued very strongly to fix the black holes in Medicare. On average, somebody in a remote area might receive $80 a year from Medicare, whereas someone in a well-off metropolitan area can receive $200 a year. Fixing those anomalies—those black holes—is important, but I am not sure that the $7.50 will do it, Senator Harradine.

GPs in country areas, the more remote areas in particular, have high salaries—much higher than those doctors who work in the cities. Are they seriously going to say that for $7.50 they will increase their bulk-billing rates? We know attitudes are different in the bush. There is a much different approach to bulk-billing there than in the city. My colleague Senator Cherry has drawn upon the very serious anomaly of using RRMA as a measure for deciding who gets the $7.50 and who does not. We do not even have targets in this for bulk-billing all concession card holders and all children. You get your $7.50 for those who qualify. It seems to me that this is not going to deliver any change in the way that doctors do their business.

One of the most serious and disappointing problems with this package is what might have been a very important step in the right direction for allied health. The Democrats succeeded, I think it is fair to say, in persuading the government not to go down the path of giving doctors a bucket of money under the extended care program and asking them to contract out allied health, as they saw fit, through case management and so on. That was unlikely to deliver much in the way of improved access to allied health. Out of 97 million GP consultations only 150,000 have been involved in case management and, by and large, these have not involved allied health services. There is no obligation to make sure the money goes to clinical, professional allied health services. It could well be siphoned off to other doctors or the nurses in the practice. It is the most disappointing aspect because we could have had a system where there would be GP referrals. We could have contained it. We could have still had the GP as the gatekeeper, as it were, but it would have been an opportunity to refer off to the allied health professionals so that in their own professional capacity they would be in charge of those services being delivered.

I have a lot of questions to ask about this aspect of the package, which I will come to as we proceed. Case conferences have not been picked up by GPs so far. They complain about the red tape, which is going to be greater. The AMA have come out and said that they do not like this. If they do not like it and the previous package was not being picked up, then this was not going to be picked up. There are questions about how this interacts with the safety net. We have a mishmash here. It could have been simple. It could have been straightforward. It could have been contained. It could have been cost effective, but instead of that we have got a very complicated arrangement which is clumsy, to say the least, and not likely to deliver. If people think they are going to get physiotherapy, access to a dietician or a podiatrist or whatever else as soon as this bill is passed, then they are mistaken. I think we are going to see a very small number of GP consultations that will take advantage of it. Again, it is a lost opportunity, because we could have relieved doctors of some of the work that they do not need to do—and are not very good at, I might add. That is one of the most significant disappointments.

We all know that at some stage we are going to look at a more comprehensive approach to this. I do not even like using the word `fix'. It is a short-term approach. It is ad hoc. It is not going to solve our overall problems in the long term. I think we will be back here debating this in the not too distant future when those costs start to blow out. We need to improve access and affordability. We also need to find alternatives to GPs and other ways of relieving them of the tasks they have.