During the past 18 months many doctors have experienced significant changes to their workload and practice patterns. Most successfully pivoted their working practices and business models to adjust to the pandemic - and many have bounced back but recognise much has changed.
Though Australia has been less affected by COVID-19 infections than other countries, many issues have been raised about flexibility and adaptation of health care providers to ensure the appropriate supply of medical care in ‘business as usual’ times, as well as during future pandemics and natural disasters.
"During the height of the COVID-19 pandemic in Australia there were high hopes telehealth might become part of routine care.”
So after around 20 years of expansion in medical workforce supply, what are the key issues faced today? When producing more doctors, it is essential to ensure the additional doctors are used to meet the population’s need for healthcare rather than reinforcing a paradox of overtreatment and overdiagnosis for some of the population existing alongside undertreatment for those most in need.
This includes finding the ‘right’ balance of the medical workforce between urban and rural areas, between specialties, and between generalism and specialised care. Flexibility and adaptation are central to this and are key ongoing themes of the new National Medical Workforce Strategy.
These trends and others are analysed in the latest ANZ-Melbourne Institute Health Sector Report ‘The Evolution of Medical Workforce’ which assessed the key economic forces affecting the medical workforce.
Continuing to grow
The number of doctors continues to grow and in 2019 exceeded 100,000 for the first time with the number of non-GP specialists growing faster than the number of GPs (4.5 per cent per year vs. 3.5 per cent per year). Population growth is half this at 1.8 per cent per year.
Filling rural and regional gaps
Flooding the market has meant higher numbers of doctors in training and non-GP specialists are beginning to spill over into rural areas, with more doctors working outside of major metropolitan areas. Growth in the number of doctors outside major metropolitan areas outstrips the growth inside these areas for all doctors - except for GPs. This is despite decades of policy targeted to persuade more GPs to go rural.
Regionally-based training should continue to be an essential part of all medical training. Self-sufficiency still seems a long way off as the number of international medical graduates continues to grow.
The disruption to immigration due to COVID-19 may also make it more difficult for rural and regional areas to fill vacant positions but on the other hand could create also more vacancies in major cities that will prevent domestically trained doctors from going rural. International medical graduates are likely to remain the backbone of the rural medical workforce into the future.
Spillovers into rural and regional areas could be caused by increased supply and competition pushing doctors out of major cities. There has also been increased investment in regional training of GPs and non-GP specialists and other policies that help pull doctors away from major cities. In addition, spillovers could be caused by existing non-GP specialists spending more time in public hospitals so reducing job opportunities for newly qualified non-GP specialists in major cities.
Dr Mina Gobrial is a 36-year-old GP who lives in the regional New South Wales town of Boolaroo on the outskirts of Newscastle. In 2017 he emigrated with his family from the UK and was able to fill a regional GP spot local graduates hadn’t been able or weren’t willing to fill.
Dr Gobrial says the work-life balance is far better in Australia. He believes the overall lower stress of the population is a result of the nation’s superior healthcare system. He also personally chose to move to a regional hub instead of a city for the slower lifestyle.
When asked why he chose to become a GP rather than a specialist, Dr Gobrial explains he values the relationships he is able to make with his patients over a long period of time and that he can make a real difference in their lives.
Falling over time
A stated national policy objective is self-sufficiency of the medical workforce but the number of international medical graduates (GPs and non-GP specialists) continued to grow faster than the number of domestically trained GPs and non-GP specialists until the end of 2019.
Specialty choice remains an issue as applications for GP training places fall and the number of specialists continues to grow faster than GPs. Non-GP specialists earned almost twice as much as GPs with their earnings growing twice as fast such that the gap between GP and non-GP specialist earnings has widened over time, probably aided by the Medicare fee freeze. The earnings gap is likely to widen further as there are no specific national policies to address this.
Annual fee revenue per doctor has been falling over time. The most likely reason is the number of GPs and non-GP specialists (supply) has been growing leading to more competition while the number of patients per doctor (demand) has been falling even as the population increases. The Medicare fee freeze and fall in growth of private hospital care could have contributed to this.
While fee revenue has been falling, doctors’ self-reported annual earnings (after practice costs and before tax) have been increasing. This suggests doctors are managing to maintain their take home pay by either reducing practice costs per doctor or increasing income in other ways.
Doctors have also been slowly changing their billing patterns over time with higher rates of bulk billing, especially for non-GP specialists, as well as higher fees charged for non-bulk billed services. This is likely to reflect lower fees and more bulk billing for less affluent patients balanced out by higher fees for more affluent patients.
Telehealth continues, but slowly falling
During the height of the COVID-19 pandemic in Australia there were high hopes telehealth might become part of routine care. The rapid introduction of telehealth brought the future slightly closer as many healthcare providers and patients had a taste for how this could work. Telehealth can potentially solve not only issues arising during pandemics but improve access to healthcare for vulnerable and underserved populations. The use of telehealth would also make the system more responsive and flexible to patients’ needs.
New telehealth items were funded from March 2020 to help protect patients and providers from COVID-19 as well as help circumvent the fall in demand for healthcare that led to substantial falls in income for many providers in 2020. Since then, the use of telehealth has fallen overall as the pandemic in Australia has subsided.
Video consultations are still used much less than telephone though are more likely to be used by non-GP specialists. For GPs, the proportion of attendances using telehealth for GP Mental Health Plans and Chronic Disease Management Plans are slightly lower than for usual GP visits, suggesting no additional need for telehealth for these specific patient populations.
The use of short telehealth consultations remain high and are much more likely to be phone calls. This suggests an unmet need for these short consultations, likely to be for follow up, test results, repeat prescriptions. This also saves tens of thousands of patients the inconvenience of a face-to-face visit. Medicare telehealth funding is expected to be continued in the longer term where there is a need from patients and higher rebates for video consultations could help to increase their use by GPs. However, there remains little new evidence on the appropriateness of telehealth.
Medical practitioners have continued to adapt to significant increases in medical workforce supply as well as COVID-19. Increased supply leads to more competition and the effects of this are beginning to be seen as doctors spill over into rural and regional areas and increasing pressures on fee revenue.
But after 20 years, issues such as specialty choice have not been addressed, rural practice needs continued support and the benefits of telehealth need to be better utilised.
Professor Anthony Scott leads the Health and Healthcare theme at The Melbourne Institute: Applied Economic & Social Research at the University of Melbourne. This article was written with assistance from Terence Bai.
Click here to read the full ANZ-Melbourne Institute Health Sector report, funded by ANZ
The views and opinions expressed in this communication are those of the author and may not necessarily state or reflect those of ANZ.
21 Jul 2020
20 Jun 2018