Why I Rip My Patients Off!

Dr Marcus De Brun explores a hypothetical rationale behind the current financial structures in general practice (IMN)



Mary works part time at a local supermarket. She has a three-year-old daughter, Annie. Mary’s husband, Ben, is a bus driver. Mary and her family are just outside the eligibility threshold for a medical card. Mary has had diarrhoea for four days and cannot go to work. Annie has also picked up the ‘bug’ and has diarrhoea.
Mary needs a letter for work and she is worried about Annie. Ben is also unwell, but he goes to work as ‘someone has to hold the fort’.
Mary and Annie come to my surgery in Dublin. I confirm that Mary has gastritis and a yeast infection. Annie also has gastritis and is a little dehydrated. Mary needs a note for work, some medicine and ideally someone to help her look after Annie. She gets the note for work and the medicine… we do not live in an ideal world.

Pharmacy mark-up
Mary must pay €80 (€55 for herself and €25 for Annie) for the privilege of seeing me. When she gets to the pharmacy, she must pay €30 for her medicine (including the pharmacy mark- up of 100 per cent). Mary’s supermarket does not pay sick pay for part timers and the crèche gives no discounts for non-attendees.
Mary is silently stunned and confused when she gets home and looks at what remains in her purse after she has paid €110 for a pack of Imodium and 20 minutes at the doctor’s. The groceries will just about be paid this week, but the crèche will have to be put on the long finger.

Fair deal
As a doctor, I feel comfortable ripping Mary off, because I am highly qualified and far better educated. I understand relativity. And I should be rewarded with an income ten times higher than both Mary and her husband combined. Besides, look at the bankers and Pat Kenny at RTÉ, at solicitors and accountants and the financial regulator etc, ad infinitum. Compared to any number of patently inferior social contributors, I make a mere pittance.
For my 900 medical card patients I receive €130,000 per annum from the HSE. I receive another €50,000 per annum for cervical smears, pregnancy care, blood tests, childhood vaccinations, insurance claims and contract commitments.
From my private patients, I receive between €100,000 and €150,000 per annum. My surgery opens for 30 hours per week, but much of the work I do is behind its closed doors.
Fortunately, I receive a grant from the HSE  for a practice nurse and practice manager, in addition to free courier services, free clinical waste collection and a grant to invest in ‘improving my practice’ with computers and equipment, if and when I need it.
Fortunately, I also receive holiday pay, study leave, sick leave, a grant for living in the country and, thanks to the vigilance of the IMO, a reasonable pension.
My indemnity insurance and college fees are also paid for me, my out-of-hours is paid for by D-Doc and it pays me €90 per hour if I choose to do my rostered shifts. All of this reduces the stress… just a little.

Fortunately, I do not have to worry about competition from any other doctor. My medical card patients belong to me; they are my property, my chattel. Should another GP try to move into my town, my medical card patients have no choice but to stay at my practice, unless that other doctor enjoys the special relationship I enjoy with the HSE.
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Unless that doctor has a GMS number, he can be as qualified and as nice as he likes, but he is of no competition to me. Fortunately for me, if another doctor wants a GMS number, he must buy one from the College of General practice.   Or,  he/she  can buy into my practice, agree to work for me as an indentured labourer for a number of years, after which I might make him my partner and give him a share in my herd.

Still, my salary is only half of Pat Kenny’s, and a Dublin barrister or government advisor would hardly get out of bed for it.

On the bread line
Recently, I have been thinking on how unfair the system is, of how Einstein’s relativity has me almost on the bread line. Therefore I have decided to take a stand. I will employ a doctor to mind my patients (a foreign doctor would be best, as these are often a little cheaper).
I will devote some of my relatively paltry income to my election campaign. If I make it as a TD, that will bring my gross income from €500,000 to €600,000 per annum, and if I manage to get a ministerial post, that will bring my income to almost €700,000 per anum and at last I might just be able to get by.

Of course, I will still be well short of what Pat makes, but I will be close enough, and at least I will have conquered the moral high ground. I will have taken a stand for what is right and fair.
I will have made a difference.