What Canada can learn from the health crisis Down Under

National Post, 19 February 2023

Australia is predicting a nationwide shortage of approximately 11,000 family doctors by 2032

SYDNEY, Australia — “Medicare on life support.” A massive shortage of general practitioners (GPs). Hospitals clogged as a result. Federal and provincial governments struggling to save a collapsing system. Billions in new spending may only be a Band-Aid.

News about the latest medicare deal offered by Ottawa to the provinces? No. Right crisis, wrong country. Actually, the same crisis in two countries, Canada and Australia. The latter’s experience might mean Canada’s crisis is worse than we think.

“Medicare is a beloved institution,” begins a recent in-depth report in the Sydney Morning Herald. “Ask Australians what makes them proud of their country, and many are fiercely protective of its promise you can access the health care you need — whether it be surgery or a doctor’s appointment — regardless of your income bracket.

“But Australia’s universal health-care scheme is no longer fit for purpose. In fact, Health Minister Mark Butler, who oversees the scheme, says it’s in the worst shape of its life.”

The same applies in Canada, though our ministers do not speak so bluntly.

“General practice, which is the backbone of our health-care system, is in a truly parlous state,” Butler said.

Australia’s crisis in GPs — usually called “family doctors” in Canada — gives us some sense of how difficult it will be to solve Canada’s GP crisis. The Royal Australian College of General Practitioners found that in 2019, only one in 11 new doctors opted to be a GP. By 2032, the college predicts a nationwide shortage of some 11,000 GPs, nearly 30 per cent of the entire GP workforce.

“Not enough medical graduates, young doctors, are choosing general practice as their career because they see the difficulty of working as a general practitioner. We’ve got to turn this around,” Butler said.

That’s the heart of the problem. Even if places in medical schools were increased, even if more foreign doctors were enticed to relocate, too few of them want to be GPs.

More money is likely not the solution, though British Columbia recently tried just that, with a significant increase in payments for GPs. Yet Australia’s doctors have always had the capacity to raise their own incomes.

Called “extra billing” in Canada, and banned by the Canada Health Act of 1984, Australian GPs can charge what is called a “gap” fee. A GP can directly bill the government for a service, and the patient pays nothing out of pocket. That’s called “bulk-billing” Down Under, but doctors don’t have to do it. Instead they can charge the patient directly, who later claims back from the government the medicare rate for the visit. The difference is known as a “gap” fee.

Australian medicare pays AU$39.75 (CDN$36.72) for visits under 20 minutes. This past year, the average gap fee charged was AU$42.44, meaning out-of-pocket costs were greater than the medicare rate. That means if Australia were to ban gap fees, as Canada does, it would have to double what it pays for short GP visits just to maintain current patient loads. Anything less and GPs might wind up their practices.

The result is the same when patients can’t see a GP, either due to cost in Australia or unavailability in Canada. They end up seeking primary care in a hospital, congesting emergency rooms, or don’t get primary care at all, arriving at the hospital only when their health has reached a crisis.

The GP problem arises because being a GP is far less attractive than it was in the 1980s. GPs dealt then with acute cases — ear infections for children, pneumonia for adults, and putting teenage girls on contraceptives no matter what their symptoms were. Quick and uncomplicated quarter-hour visits for the most part, leaving time for work-life balance and getting to know generations of patients.

Today, that same GP might be spending a complex half hour or more with an elderly patient in need of a hip replacement, with chronic high blood pressure and diabetes, all the while suffering from mild dementia. After the patient leaves, the GP might have another half hour of test requisitions to order and referral letters to write. A lot more than that might be needed if the GP has to complete assessments for admission to long-term care.

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