Radio interview with Minister Butler and David Bevan, ABC Radio Adelaide - 9 February 2023

Read the transcript of the radio interview with Minister Butler and David Bevan on Medicare; bulk billing; Medicare compliance; medical graduates; medical workforce.

The Hon Mark Butler MP
Minister for Health and Aged Care

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DAVID BEVAN, HOST: Federal Health Minister and South Australian MP Mark Butler joins us now. Good morning, Minister Butler.


BEVAN: The Royal Australian College of General Practitioners has warned that even if the Medicare rebate is adjusted by - I think it's 1.6 per cent - that's not going to be enough to save bulk billing. You know, the headlines in papers around the country is the end is nigh for bulk billing. To satisfy them, you've got to do better?

BUTLER: The College has played a really constructive role, along with a whole range of other groups working with me over the last six months to present and produce some ideas for reform in the next Budget, the Strengthening Medicare Taskforce report. I've been calling out the decline in bulk billing now for a couple of years, frankly, at a time when the former government used to say bulk billing rates were at record highs. I've tried to be really honest about the fact that I think general practice is in its worst shape it has been in in the 40-year history of Medicare, which is why strengthening Medicare was the centerpiece of our health policy at the last election. I've also tried to be honest, we're not going to turn this around overnight. The Medicare rebate was frozen for six long years, initiated by Peter Dutton back in his first Budget and it's put enormous financial pressure on general practice and driven up gaps.

BEVAN: I think most people listening right now would agree that there's a big challenge for any government and it's your task now to turn this around. And people would agree that there would be many, many things in this rich tapestry that need to be addressed. But are you also going to have to raise the Medicare rebate? The College is saying it has to be raised by 20 per cent?

BUTLER: They were clear about that. They've also said they want an increase in the bulk billing incentive, which is a payment made to GPs, if they bulk bill a patient that is that they don't charge them an out-of-pocket gap fee. There are different ideas around that. I've seen some correspondence from the Doctors Reform Society about other ways you could increase bulk billing. 

Obviously as a Labor Government we're very focused on making sure, particularly pensioners, concession card holders, children, are able to get healthcare at in a really accessible way. I've said all  of those ideas that were presented by doctors' groups and others is on the table. But I've also tried to be honest in saying we're not going to simply add more money to the existing system because the existing system is not working for patients in the 2020s - 

LEE: And Mark Butler, when will we find out -

BUTLER: I'm not finished. It’s not working for an older population. It's not working for the sort of chronic disease that turns up at general practice every single day, that's not what Medicare was built to deal with.

LEE: No, and I think everyone has seen that. When will we find out from you what the plan is? You keep saying everything's on the table. When are you going to clear the table and give everyone the plan?

BUTLER: In the Budget. I've been very clear about that. The money is in the Budget. We've said that we wanted advice from -

LEE: So you know what the plan is now - just waiting for the Budget to announce it?

BUTLER: No, we’ve just released the Report and there's a Budget process underway right now. We’re meeting very regularly as the Expenditure Review Committee across portfolios considering a whole range of things the Government needs to need to work through, and right near the top of the list is strengthening Medicare. So this will all become clear in May. I've been honest about that since the election campaign where we said we'd allocate additional money – we were the only party to promise additional investment in Medicare – but we were going to work with doctors and nurses and patient groups and others to make sure we got the investment of that money right.

BEVAN: After 9:00, we're going to talk to Dr Tim Woodruff. He's with a group called Doctors Reform Society, and he has a letter which is published, I think, around the country today, it’s certainly in the local paper. He says Health Minister Mark Butler could increase the payment - it's a special payment - immediately to help those patients and reduce the likelihood of GPs giving up bulk billing, he could set in place an adjustment to a small special payment GPs get, and it's called the Practice Incentive Payment. Its value depends upon age and gender. He – that’s you Mark Butler - could add socioeconomic status to that adjustment. Again, is this an example of another thing you can do? You could tweak this thing called the Practice Incentive Payment to help GPs in their current crisis.

BUTLER: That's right.  I just mentioned that the Doctors Reform Society have slightly different ideas about how you can stop the slide in bulk billing that we're seeing right now and turn things around. It's not just by increasing a single payment, which is the position of the College of GPs. You could do the sort of Practice Incentive Payment that the Doctors Reform Society has proposed, and all of those options were discussed through the Strengthening Medicare Taskforce and remain on the table. But I've just tried to be clear that there's a whole range of pressures on the system, the financial pressure from the cuts and neglect over the last decade, but a much broader systems pressure that results from the fact that Medicare was designed for a different era when people went to their doctor for a short episode of illness, got fixed and then didn't return to their doctor until they had another illness. That's not what happens today. You’ve got much more chronic disease that requires wrap around care, not just from a doctor, but from nurses and allied health professionals, all working together as a team. And the system doesn't support that well enough.

BEVAN: I think we've got an example of that. Dr Danny Byrne joins us now. He would be very well known to many of our listeners. He's immediate Past President of the Royal College of GPs. He works in the southern suburbs as a GP. Danny Byrne, you received a please explain letter from the Federal Government?

DR DANNY BYRNE: I got my robodebt letter on Monday from Mark Butler.

LEE: Robodebt?

BYRNE: Well, I'm overusing the nurse Medicare items. I'm under threat of an audit. I've been asked to repay the money. So my nurses, the immunisations, injections, B12, ring dressings, lifestyle counseling, sleep apnea management, ACAT referrals. I may spend 45 minutes with a patient for a $12 Medicare rebate. And I've been told that I'm overusing that.

LEE: How much money do you owe?

BYRNE: Twelve times 300. I don't really care about the money. I care about being threatened by the government and called a cheat, that I’m cheating the system. And all I'm trying to do is provide good care for my patients, get them to see the nurse instead of me for this care, it costs Medicare $40 to see me and $12 to see the nurse. I'm really upset as you can tell. Mark Butler’s carrying on about ‘we’ve got to get patients to see nurses instead of doctors.’ Well, that's what I've been doing and I get this.

BEVAN: Danny Byrne, you've sent us a copy of the letter, which we only got in the last half hour or so, and we've sent that on to Mark Butler's office as well. I don't know if he's had time to absorb it. We appreciate if he hasn't. But the letter says that in a 12-month period on 311 occasions, you claimed a nurse item and a chronic disease management item for the same patient on the same day. So that's almost every day for a year, now again, we don't want to invade the privacy of your patients, but it sounds like somebody's got a real issue and they're coming along to your clinic and you're using a nurse to manage this person under your supervision, which sounds like the sort of thing that Mark Butler wants to see more of?

BYRNE: Correct.

BEVAN: And you're being asked to explain the use of something that's already in place?

BYRNE: Yeah, it's mind boggling, really, because we know the future is to have more nurses helping us out and for nurses to do this work – their better trained at doing injections than I am. And they spend 45 minutes with a patient which I can only spend 15, and the patients love it. And what we're trying to do, I mean, really what we have to do with Medicare, Mark Butler is telling me, don't do that, make the patient come back another day. Now, a lot of these patients, their children take the day off work to bring them in for the care plan appointment, it's an hour and 45 minutes with a nurse, 15 minutes with me and we try and do everything on the one visit, which makes common sense. But now we're going to say: ‘oh no you have to come back next week for that immunisation, come back next week to discuss your aged care issues.’ It's just mind boggling.

LEE: Let's go back to the Health Minister, Mark Butler. Danny Byrne’s not alone here. We've got another text from someone saying that was another reason I left the general practice, too. You’re losing doctors over this, Mark Butler?

BUTLER: I am sorry for the experience Danny’s had. I can't comment on the case. I haven't had a look at the letter, I'm sorry. A whole range of these things happen on a regular basis with the Department, without me necessarily knowing the precise details. But the first thing I'll say is, Danny is absolutely right. This is what the Government wants more of - nurses to be able to work in a team with doctors. Currently there are very strict rules that doctors’ groups generally say they want to retain, which ensures pretty strict oversight by doctors about what the nurses are doing in their practice. There was a really deep conversation in the Taskforce about whether nurses could be working a little bit more independently, frankly, than they're able to do under those existing rules called collaborative arrangements. This is precisely the sort of thing we're trying to free up so that we're not hidebound by these regulations and frankly, turf wars between different health care groups.

LEE: So will you look into it?

BUTLER: I'll look into it, but I'll also say that there is a strong compliance regime in Medicare. It's only a few months ago that the ABC did a very strong investigation into whether our compliance system was robust enough, not too interventionist, but whether it was robust enough to ensure that taxpayer funds were being spent in accordance with the rules. So of course, we have that compliance program. I announced after that investigation by the ABC that alleged that there were billions of dollars being spent wrongly from Medicare. A review of that compliance program, which is underway right now, will be concluded over the coming weeks.

BEVAN: Danny Byrne, is that good enough for you?

BYRNE: Look, what I think is happening is that Mark Butler’s lost control of his Department because he is saying all the right things. He's got 100 per cent support from me as far as increasing nurses and allied health and helping me manage these patients. I do a lot of things for $40 that the nurse or podiatrist or physio could be doing for cheaper. That's the Medicare rebate - $40. I charge $85, of course, which is going to go up to $90 on the 1st of March. But Mr Mark Butler knows that. So that's great, but his Department is sending out these roboletters to over 600 GPs around Australia who are actually ahead of the game. We're leading the pack in this chronic disease management and use of nurses and we're being asked: please explain, and I will explain, but I just don't see why we should have been targeted like this in the first place.

BEVAN: Mark Butler just to cut to the chase, will you ask your Department, ‘are you sending out computer generated letters to GPs to police this kind of behaviour?’ Which is exactly what you want to encourage?

BUTLER: I'll have a look at the letter and ask for some advice from my Department about it. But there has been very broad coverage over the last few months over the compliance system in Medicare, as I said, substantially as a result of the investigation the ABC and Channel Nine papers did in in the later part of last year. But I think the point Danny is making is - the overall point of principle – is that he has clearly structured his general practice in precisely the way we want to see happen across the country. This way in which he is practicing is clearly the sort of thing we've talked about over the last several months and want to see more of. It's just that the systems, these regulations, these rules are restricting the ability for that to happen freely.

LEE: And if we can just move on to the training of doctors, Mark Butler, we heard earlier from our State Health Minister, Chris Picton, that there are caps imposed by the Federal Government on the number of local students that can study general practice or can study medicine. But there is no cap on the number of international students that can study it. Is that something you're also looking at?

BUTLER: That's right. There are caps in place for medical training, whether it's universities or the postgraduate training that medical graduates do. You know, when we were last in government, we doubled the number of GP training places from I think about 600 to 1200.

LEE: But is the cap on local students smaller or not a cap at all on international students? Is that the case?

BUTLER: The universities were able to offer international students training, and generally they'll return back to their home. And the question of them practicing is a matter for those countries. We've long had a system for many, many decades in Australia where there is a limited number of university places for medical schools and then a limited number of postgraduate training places for general practice, for psychiatrists, for cardiologists and the like. Now, we increased that substantially a decade ago and I think the critical question that all Health Ministers have been discussing - we only had a meeting about this last week that Chris Picton was at, is first of all, whether we've got the distribution right, whether we are training enough GPS and enough psychiatrists, for example, compared to the number of surgeons we're training. And I think Health Ministers are keen to sit down with all of the colleges and work out whether really, we've got that postgraduate training distribution right.

BEVAN: Simple question. Do you need to have more domestic doctors trained in this country?

BUTLER: Well, I think the first question is whether the distribution of the current medical graduates is right and that's really the discussion happening between jurisdictions now.

BEVAN: So Chris Picton is going to rock up your next meeting saying, ‘I told you Mark, we need more domestic doctors graduating’ and you're going to say, ‘I'm not so sure about that, I think it's more of a distribution of graduates, same number of graduates, we're going to shift them around, though, more GPs, less dermatologists?

BUTLER: I think that's the point we’re at. I think we're currently rolling out about an additional 80 medical graduate or medical training positions in universities, but we're targeting them in rural and regional universities where we know there is a very clear shortage. We do have a supply problem in general practice. We do have a supply problem in psychiatry, for example. I'm not sure we have a supply problem for anesthetists or cardiac surgeons. So I want to make sure that before we jump to adding new graduate positions in universities, we're very clear that we're getting the distribution of specialties right. And that was the discussion we had as a group of Health Ministers only last week.

LEE: Okay.

BUTLER: And we want to sit down with all of the specialist colleges which have very substantial power, frankly, over this question, to have a pretty frank conversation with them about whether we've got the distribution of training right. Because all of this has huge impact on the on the community, and is substantially funded by the community, both at university level and at the postgraduate training level.

BEVAN: All right, Mark Butler, thank you for your time.

BUTLER: Thanks very much. 



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