Medical Rural Bonded Scheme
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The Medical Rural Bonded Scheme is a scheme introduced by the Australian federal government in 2000 with the aim of increasing the number of medical practitioners in rural and remote areas. It operates by offering scholarships to new medical students, on the condition that "they agree to work in a rural community for six years once they have completed their basic medical training and GP or specialist fellowship." However the mechanism of supply of Medical practitioners, is by taking away access to medicare for the medical practitioner if they do not go to a particular area. This contrasts with other rural services, such as telecommunications (Telstra) which require subsidy. Mr Prosser identifes a casue of the issue,
The general problem that rural and regional Australia experiences can in part be attributed to long-term economic trends that would have occurred and will occur beyond the control of government. These trends, including mechanisation, have meant that Australia's population has shifted. Whereas at the turn of the century two-thirds of Australia's population lived in rural areas, now just over one-third live in regional areas.
A flow on effect of the scheme is that Australian citizens who are not party to the bonded medical practitioners decisions, will also lose the ability to access Medicare with these medical practitioners.
If the contract (signed before the doctor began their study of medicine) is breached by the contracting doctor, as well as repaying scholarship monies, that doctor will not be able to receive Medicare rebates, meaning that patients will not be able to use their Medicare card to obtain treatment with them, for a period of typically 12 years by operation of section 19ABA of the amended Health Insurance Act (1973) Cth.[1] This restriction may apply to an estimated 10% - 20% of all medical students who are in some form of bonding, including other schemes such as the bonded palces scheme, which allows practitioners to practice in areas of need, which may include outer metropolitian areas.
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[edit] Application
Given the severity of the contractual ramifications, there is an issue of how to make students enter into such contract? Typically this has been achieved by offering scholarships to applicants to medical degrees, who did not receive sufficient marks in the interview part of the medical entrance exam to gain a ‘standard’ place. These applicants (not yet students) are offered a ‘MRBS’ place if they sign a contract. That is these applicants can only study and hence practice medicine on the condition that they agree to work in a rural community for six years once they have completed their basic medical training and GP or other specialist fellowship. This may produce a serious constitutional issue (see below). This selection criterion indicates that rural areas are receiving Medical Practitioners who are less 'suitable'[1]. Given that the undergraduate degree, internship, registration and specialty training must all be completed before going to a rural area, a period of at least 10 years, indicates the initial selection procedure is flawed.
The parliament in Hansard shows overwhelming concern that entrance into the scheme must be voluntary (to avoid the constitutional civil conscription prohibition see below) and that the positions would be offered and would be taken by applicants already offered a place, Ms MACKLIN
I understand that a person eligible for admission to a university medical school will be able to apply for these scholarships but has to take one of the additional medical school places. [2]
Mr NAIRN
The scheme is open to any student [3]
Mr LIEBERMAN
The universities will select the scholarship holders through the normal medical school admission process. Students, I understand, will apply to the universities through their medical schools for the bonded scholarships and for a place in the medical school in that university. [4]
That is the scheme must be entered into after receipt of a offer of a university place, only after the applicant is a student. Not that a medical school place is contingent on entry into a bonding scheme. It is also vitally important to note that the scheme is separate to the University place denoted by the use of the disjunctive 'and' in bold above.
The reality has been the severity of the contractual conditions cause Universities to fill places by a second chance draw mechanism [5]. The University of Sydney's admissions policy is prototypical
"Offers of places are made by the Dean of the Faculty to those applicants who are considered to be most suitable, progressing through the suitable categories until all places have been offered.'[6]
| Quota [7] | Number |
|---|---|
| Scholarship places (no fees or other financial liability) |
4 |
| Commonwealth supported places (formerly HECS) | 143
|
| Medical Rural Bonded Scholarship Scheme Places (MRBSS), Commonwealth supported places (formerly HECS) | 9 |
| Bonded Medical Places (BMP), Commonwealth supported places (formerly HECS) | 55 |
The Universities involved are given an incentive to fill the places by extra funding. Where an applicant has been given no choice but to sign a contract, this raises the constitutional issue squarely. The differentiation between standard and 'MRBS' place is one of funding for the University in question.
All students who are in the MRBS scheme also partake of HECS, or as they are now Commonwealth Supported places. The result of this instance on voluntariness and the funding arrangement means that as long as a student leaves the Commonwealth contract without penalty as they provide if withdraw before the commencement of the third or second year (the contracts have changed over time). There is no penalty. At this point the University will typically dis-enroll the student.
'If an applicant nominates either MRBSS, BMP and decides not to take up the offer, the University will not be in a position to provide the applicant with a place in the program. If a student accepts a MRBSS or BMP place, he/she is unable to transfer to any other type of place. Please note that withdrawal from a MRBSS, BMP or fee-paying place at any time prior to completion of the USydMP will mean that the MRBSS, BMP place will be terminated and enrollment in the USydMP will be cancelled.'[8]
While this may be the Universities position, the Hansard shows that parliament mandated that those who breach the contract must still be entitled to work as medical practitioners, but they can not access Medicare rebates for 12 years. The Universities ability to implement this claim, is invalided by way of the civil conscription prohibition, receipt and purpose of HECS - Commonwealth Supported monies, and the intent of the extent of the effect of the breach under s19ABA HIC (Cth). Without a court determination, the University in question lacks power to determine the force of such stamens regardless if they are in by-laws or contracts. The University will merely have a nullity. The legal and practical fact is a student is not transferring between places; the student merely leaves a federal contractual arrangement, upon which the Commonwealth may change funding to the University. This funding is an issue between the University and the government. This is proved as the student was and always is a HECS student. It is the Federal government that transfers funding.
[edit] Parlimentry Commentary and Effects
Mr Gbbions “MP” said the scheme must be treated with extreme cynicism, given the history of the Howard federal government on university funding
This so-called initiative must be viewed with total cynicism, because the Howard government, especially with Dr Kemp as minister, has been relentless in its obsession to reduce education spending
This is because the federal government stands to save 10%–20% of all Medicare costs for the period of provider number prohibition, which are far in excess of the funding of this scheme.
The concern of the effect of the scheme is expressed in the parliament by rather florid exchange
Mr Snowdon—What other Australian has to suffer this obligation?
Mr Ian Macfarlane—You should be supporting this bill.
Mr Snowdon—I supported bonded scholarships, but I don’t support this crap!
Mr Ian Macfarlane—It will help us in rural areas.
Mr Sidebottom—I don’t think I would be running after this one!
Mr Sidebottom indicating how he feels no rational person would voluntarily enter such a scheme.
A flow on effect of the scheme is that Australian citizens who are not party to the bonded medical practitioners decisions, will also lose the ability to access Medicare with these medical practitioners.
If the contract (signed before the doctor began their study of medicine) is breached by the contracting doctor, as well as repaying scholarship monies, that doctor will not be able to receive Medicare rebates, meaning that patients will not be able to use their Medicare card to obtain treatment with them, for a period of typically 12 years by operation of section 19ABA of the amended Health Insurance Act (1973) Cth.[2] This restriction may apply to an estimated 10% - 20% of all medical students who are in some form of bonding, including other schemes such as the bonded places scheme, which allows practitioners to practice in areas of need, which may include outer metropolitan areas.
[edit] Legality, Civil Conscription
Questions have been raised over the constitutionality of the scheme, as section 51(xxxiiiA) of the Australian Constitution prohibits legislation inroducing any form of civil conscription for medical services.[3] Speaking in the House of Representatives, Michelle O'Byrne said
On 10 September 1998, in a press release, the minister stated: The scholarships are probably unconstitutional due to the limitation in section 51 preventing civil conscription of doctors."[9]
Countering the view that the scheme constitutes civil conscription is the argument that the scheme is entered into voluntarily. Government minister Ian Macfarlane said,
If the people who are considering taking these scholarships are not prepared to take the conditions, the answer is simple: don't sign them. This is not a compulsory scheme; this is a voluntary scheme."[10]
Ian Macfarlane highlighs the key issue that the scheme is voluntary. Many are in the scheme because they were only offered a position to study medcine if they joined the scheme. This has ramminfications for the conscription arguments.
Mr PROSSER (Forrest) also highlights the voluntary nature of the (scheme) contract (11.43 a.m.)
For each medical student who enters this contract—and remember they do so voluntarily' [11]
A conscription argument is that refusing qualified doctors (and the Australian public) access to rebates because the Practioners have defaulted on their contracts effectively renders them unable to make a living as medical practitioners. Mr Dick Adams (Lyons) said about the bill
As I said, this bill is really about bashing people to achieve a goal. It sets out conscription on people which might be a contractual arrangement for 17 years and then you take away the Medicare ticket so they cannot get payment. Therefore, working as a doctor would be pretty difficult because you would probably work for nothing. I do not think that is the solution....[this is] a bill to bash people about the head with and make them stay somewhere where they probably do not want to be.'
"[12]
[edit] See also
- Medicare (Australia)
- Medicare card
- Medicare Australia
- Department of Health and Ageing
- University of Sydney Faculty of Medicine
[edit] References
[edit] External links
Department of health and Ageing Scheme information
commentry [13]
Analysis and action resource [14]
