Getting down and dirty with debt

In print

Getting down and dirty with debt

Emma Dunning

Emma Dunning

Emma Dunning - neary a turnip

If I’m too scared of rejection to ask for what I’ve earned, then it’s not much of a relationship anyway

Back in the day, ye olde GP would have ridden his weary nag to visit the patient at home, diagnosed a putrid sore throat, dispensed a concoction, received a coin into his hand and plodded home on his even wearier nag to his now cold dinner. Possibly without the coin but with a chicken or a bunch of turnips on his doorstep the next day.

We’ve become rather removed from all this, including the coin in the hand. I’ve never had to concern myself much with actually charging for my services. It’s been a squiggle on a piece of paper or, latterly, an electronic Quick Bill, and the receptionist has taken care of the transaction.

For most of my career, I’ve been salaried or paid as a proportion of the amount billed not the amount paid. Chasing unpaid bills has been the administrator’s domain. By creating this distance, we can imagine ourselves as above all that, as purveyors of expertise and care, rather than providers of a service in return for payment.

But the new practice is addressing the issue of bad debt. We expect payment on the day, and have cash, eftpos or credit card options. But there are a fair few who promise to pay later, or the amount to charge is not immediately obvious and clinician and receptionist are busy – so we agree to give or send them an invoice.

And there are the increasing number of repeat scripts faxed to pharmacies. Invoices are sent at the end of each month, at 60 and 90 days, either by letter or text. They have our bank account number on them for online payment. We invite them to contact the practice administrator to arrange a payment plan.

Now that I'm a business owner...

Now that I’m a business owner, I have responsibility for paying the rent and the staff, so patient debt has become my concern. I’m also paid in part as proportion of fees paid rather than fees billed, so unpaid bills have a direct effect on my pay.

I have been given a list of 30, 60 and 90-day debt, and I need to instruct whether to write them off, ask the adminstrator to phone them, or turn the debt over to a debt collector. The debt collector charges 22 per cent of monies collected, so either I say goodbye to some of my income in favour of getting anything at all, or I add $30 (the minimum fee) to the bill of a patient who is already struggling to pay.

I’m finding this a mite confronting. The thought of a sick patient not coming to see me because they hadn’t or couldn’t pay their bill is repugnant. That’s not why we chose to practise medicine. I don’t want to humiliate people who are already having a hard time. How do you maintain a therapeutic relationship with a person you’ve sicked the debt collectors on?

If it were me, I’d be off to another practice. Moreover, if I’m too scared of rejection to ask for what I’ve earned, then it’s not much of a relationship anyway.

We need our service to be valued and expecting payment is part of that. That includes our position relative to our hospital colleagues. It is difficult to attract medical students to a specialty with poorer pay; also, working for free (which is essentially what forgiving debt or not charging fully amounts to) affects our incomes. Female GPs earn less than male GPs (adjusted for employment type and hours worked) so that’s an added incentive not to sell my skills short.

My list of debtors includes people who can well afford to pay, but who have repeatedly ignored invoices and just not got around to it. For three months.

It includes people who requested that last repeat prescription just before they left the country for good. It includes people who never paid for any consultation in all the time they were registered – they came for a few consultations then moved on, probably to your practice to do the same to you. It includes people for whom I’ve signed disability allowance forms for including GP visits, who are receiving government money to pay me but aren’t using that money for the intended purpose.

It includes patients that I already applied discounts to but who haven’t paid the small amount I charged, and patients I should have recognised needed SIA funding at the time. It has helped me identify patients for whom I need to apply our long-term conditions funding.

I’ve noticed in the past, a patient with an outstanding bill is far more likely to pay it if I draw their attention to it gently at the end of the consult, than if our administrator sends a third text.

And the sooner this is done, the better the yield. But most GPs don’t like doing it – it doesn’t fit with our image of ourselves and, besides, it’s yet another thing to add to the list of things to be achieved in the golden 15 minutes.

We do need to let our patients know what to expect.

If we’ve let them run up a $200 bill they have every reason to believe we’ll let the next $200 slide. It’s clear there is no point in invoicing an amount that will never be paid – if they already have an $800 bill then invoicing them is futile.

If I write off the debt for a patient on an income of $30,000, that’s not fair on the other patient on $30,000 who has prioritised differently and made sacrifices to pay their medical bills on time and in full.

It’s possible to believe that I should both charge what I am worth and expect payment, and be compassionate to patients who are struggling to make ends meet– hence my internal conflict.

I guess I’ll maximise funding for those eligible, and hang my head in shame while I hand over that list of 60 and 90-day defaulters to the debt collector.

Emma Dunning is a Wellington GP



The practice should have a system for contacting all patients who go over time with [not] paying their bill, suggesting weekly small automatic payments till it's paid off, and offering pre-payment the same way as an option.  The reception staff should be used to arranging this, so all you should need to do is raise it with the patient and hand them over to the reception staff to organise it.

As a pharmacist in rural Kaeo we have made allowing prescription accounts, a way of life

Without us doing this, the fallout is on secondary care and makes no sense. We spend an enormous amount of time and effort helping people get help.

I remember talking to the renal hypertension specialist at the Goodfellow symposium who acknowledged a lot of his referred patients simply were not taking their pills

The patient payment system for pharmaceutical is old, hard for Gp and patients to understand and is ready for change .If we cannot do the basics well then we can expect this to be part of the big burden to or hospitals.

Bring on the new health minister... hopefully Annette King is still helping behind the scenes and the bridges between the ministry of social development and the healthcare sector will work better than they currently do and a newer more modern system where people who can pay more, can pay more and those who really could do with help get it.. without the "whakama" or  shame that they often forced to experience"