The Government has ditched its controversial plan to charge patients a $5 co-payment when visiting a doctor but it looks like the Medicare rebate freeze for both specialists and GPs is here to stay.

But just how this freeze will affect patients with chronic diseases like arthritis — and the doctors who treat them — seems to have been swept under the carpet.

We speak to President of the Australian Rheumatology Association Mona Marabani about how the rebate freeze is leaving rheumatology patients out in the cold.

The five-year freeze

The rebate freeze is certainly not a new phenomenon. It was first introduced by the labor government in November 2013 and extended by the current government in July 2014 for the next two years. The latest reports suggest it will continue until at least 2018.

Most doctor groups believe the freeze will mean the gap between what the government is willing to pay and the actual cost of the service will be passed onto patients. This is a big issue for patients with chronic diseases like arthritis who already have high out-of-pocket costs.

Specialist bulk-billing rates have gone down

There are signs that costs are already being passed onto patients, at least in the area of specialist medicine. 

In a recent feature on how likely doctors were to charge more due to the rebate freeze Anthony Scott from the Melbourne Institute of Applied Economic and Social Research illustrated how bulk-billing rates for GPs had continued to rise since the beginning of the freeze but Medicare bulk-billing rates as a whole had levelled off.

This suggests the effect of the rebate freeze is having most impact in specialist and diagnostic services, he said.

 Bulk-billing rates in Australia

ARA President Mona Marabani agrees that the freeze has resulted in a decline in bulk-billing rheumatology patients, and higher out-of-pocket costs to patients as a result.

The rebate simply represents what the government is prepared to pay. It doesn’t reflect the cost of providing a quality service, she says.

In Marabani’s practice, which is in a low-income area, she has found it increasingly difficult to bulk-bill patients and provide quality care to her patients while at the same time trying to run a viable business.

She recently made the difficult decision to restrict bulk-billing because she feels she really has no choice. She currently has a sign up in her practice explaining to patients the reasons why.

“It’s a difficult decision to make, some people find it easier, perhaps those working in more middle class areas might say we just have to forget about what the government will pay and we have to value our services,” she says.

And while it’s a good principle that she fundamentally agrees with, she says there’s no getting around the fact that some patients have social and financial hardships.

“It’s more difficult for those people to access good care and this ongoing [rebate freeze] is going to make it harder for them,” she says.

No incentive to bulk-bill

Unlike GPs specialists don’t have an incentive to bulk-bill because they don’t receive 100 per cent of the scheduled fee.

“Many would argue the scheduled fee is woefully inadequate but specialists do not receive 100% of the scheduled fee they receive 85% of it,” Marabani explains.

“That’s a significant hit that most people just can’t afford to take,” she says.

“We can’t afford to just take the government rebate because we can’t afford to run a practice safely and with quality medicine on that sort of remuneration”.

Out-of-pocket costs for patients would vary widely between rheumatology practices, and a lot of rheumatologists do recognise that people are under financial pressure and may choose to offer a reduced fee or even bulk-bill, she says.

“Everybody has a different way of looking at this so sometimes patients will ring around and come and see you because hopefully their doctor recommended you, or sometimes because you are the cheapest.”

Where will patients go if they can’t pay?

Some patients who need to see a rheumatologist just won’t come, or they’ll go to the nearest public hospital or to an emergency department if they are having a crisis, Marabani says.

But that hospital clinic may have a waiting list of up to 12 months and there’s no indication that this situation will improve because the hospitals don’t see outpatient care as part of their core business, she says.

Marabani fears that escalating costs may mean patients will take short cuts such as not visit their rheumatologist as frequently as they should or not get all their medications.

“It is going to potentially cause problems in unexpected ways,” she says.

Communicating the value of rheumatology

According to Marabani one of the issues is that the rheumatology profession is not very good at communicating its value to the wider public.

People who are not very well off will save up for a private operation, say an arthroscopy for an osteoarthritic knee, despite no evidence that it’s helpful for their condition, says Marabani.

They view it as a more tangible thing than coming to see a cognitive specialist, she explains.

“We have a lot to do in terms of getting out there what our value is and how we can make people’s lives better, improve their mobility… that’s something we haven’t done well and need to do better.”

The forgotten specialists

Health Minister Sussan Ley has been consulting with medical groups about changes to medicare but the Australian Rheumatology Association has not been consulted.

Rheumatologists and other cognitive specialists tend to get forgotten in these discussions, which tend to focus on GPs and hospitals, says Marabani.

While these are the lynchpin of healthcare people with chronic disease do need and should expect to be able to access proper specialist care.

“There’s the potential for that to stop happening because everybody is focused on one part of the health system,” she says.

“We need to advocate more strongly for the conditions and the patients we look after and we need to forge better relations with the department of heath and be more visible advocating for the patients,” she says.

Because really in the end it’s not about specialists income.

“We can choose whether to bulk bill or not and there’s a relative shortage of rheumatologists and we’re all busy. That’s not the issue, it’s really about providing good safe quality care for people with chronic diseases,” she says.