Few people would dispute that Medicare is no longer fit for purpose for either patients or doctors, and one of the major casualties is plummeting bulk billing rates, as Cathy O’Leary explains.
One of the first challenges in unpicking dwindling bulk billing rates is getting reliable figures, with a wide variation of estimates across industry and government.
Cleanbill – a website that has collated and published GPs’ fees since 2017 – recently calculated that fewer than half of metropolitan practices still offered universal bulk billing, including fewer than 30% of practices in Perth.
It collated its figures by hiring contractors – in the guise of would-be patients – to call more than 4000 GP practices between August and December 2022, without indicating the information would be published.
It subsequently released other survey results which it claimed showed the high and lows of GPs fees, again using contractors who contacted practices directly.
Cleanbill said doctors in one inner-city Sydney suburb were charging an average of $117 for a standard consultation – with an out-of-pocket cost for patients of nearly $77 – while the cheapest postcode was Perth’s Rivervale, with a fee average of $57.
Lies, damn lies and statistics
Official health statistics paint a different picture, with data released at the end of last year suggesting bulk billing rates among GPs had fallen to about 83% – the lowest figure since December 2013.
But industry analysts argue the figures do not tell the full story because they are based on services billed rather than the percentage of patients who have all their costs covered.
In the past 12 months, increasing numbers of GP clinics have written to their patients advising they would no longer bulk bill, with competing practices in suburbs even working together to scrap bulk billing from the same date, to prevent patients from jumping ship from one practice to the other in the hope of avoiding a gap fee.
And as far as the much-hoped increases to Medicare rebates are concerned, there were no clear indications of what lies ahead from the recently released Strengthening Medicare report.
The Australian Medical Association has been calling for at least a doubling of the rebate, with the peak doctors’ lobby saying general practice needed urgent immediate funding before it could start planning for long-term changes.
While Federal Health Minister Mark Butler agreed more needed to be done to improve access to general practice and primary care – and he did not rule out increases to the Medicare rebate – he added it was “not just about more money” and that would become clear on Budget night.
Official health statistics paint a different picture, with data released at the end of last year suggesting bulk billing rates among GPs had fallen to about 83% – the lowest figure since December 2013.
The Royal Australian College of GPs cautiously welcomed many measures in the report but said there was “a high level of ambiguity” and “the devil is in the detail”.
RACGP WA chair Dr Ramya Raman told Medical Forum that some of the college’s recommendations to government featured in the report, including voluntary patient enrolment.
“But again, there is little detail on the proposed model and it is critical that we get this right,” she said. “In the United Kingdom, the capitation approach has seen many GPs doing a lot more for less, at the expense of patient care, and that must be avoided at all costs.”
Deep concerns
Dr Raman said the decline in bulk billing was deeply concerning because it was making it harder for people to access the care they needed. Healthcare costs were continuing to rise due to the increasing costs of consumables, rent, insurance, new technologies and medicines, and the wages of a skilled labour force.
“Meanwhile Medicare rebates are simply far too low – they were never properly indexed and the freeze ripped $2 billion from general practice patients … and counting,” she said.
“And this is putting pressure on GPs who just want to do the best to care for their patients, and too often end up subsidising patient care, such as billing a short consult when we’ve spent longer with patients because they need more time to talk through all their concerns.”
Dr Raman said the decline in bulk billing was likely to be particularly challenging for people with complex health needs, as they often required more time with their GP to address their health concerns.
“That’s why we continue to push for increased rebates, particularly for longer consultations, to allow GPs to spend more time with their patients and get to the root of health issues they present with.”
And while there are calls for the rebate to be increased substantially, many industry commentators say it not politically realistic – or appealing – to hand GPs a bucket of extra money for seemingly nothing in return.
And GPs hoping for a substantial increase in Medicare rebates across the board might be disappointed, with political chatter suggesting increases will be targeted.
A ‘team sport’
A report by the Gratton Institute late last year argued that GPs’ work has become much more complex but how general practice was structured and funded had not kept up. It advocated making general practice “a team sport” with many clinicians working under the leadership of a GP to provide better care.
To achieve this, the Federal Government would need to dismantle the regulatory and funding barriers that forced GPs to go it alone. To accelerate the change, 1000 more clinicians such as nurses and physiotherapists should be employed in general practices in the communities that needed them most.
The report argued that GPs should be able to choose a new funding model which supported team care and enabled them to spend more time on complex cases such as combining appointment fees with a flexible budget for each patient based on their level of need.
In the meantime, while the current rebate for an item 23 is $39.75, the fee most GPs are now charging for that service is thought to be $85 or more, based on the fee calculated by the AMA, to be reasonable.
Dr Raman said the rebate for item 23 was a clear example of government funding not keeping up with the cost of providing care.
She said the patient rebate for the average GP consult (Level B, less than 20 minutes) increased by a “paltry” 1.6% or 65 cents to $39.75 on July 1, 2022. By comparison, the Consumer Price Index rose 1.9% in the December 2022 quarter and 7.8% annually.
“Band-aid solutions will not solve the crisis Australia is seeing,” she said.” Long-term, we need major health system reform and serious investment in general practice care because this is what keeps people healthy and out of hospital.
“Any long-term health funding reform must build the role of GPs as the stewards of patient care, working hand-in-glove with multidisciplinary health professionals.
“The government also needs urgently to stem the bleeding and provide relief for patients struggling to access care.”
Dr Raman said this required short-term measures, including improving access to care by tripling bulk billing incentives and increasing Medicare rebates by 20% for longer, complex consultations.
In addition, funding needed to be improved for primary care services for people aged over 65, and those with mental health conditions and disability, while funding was also needed for patients to see their GP after an unplanned hospital visit, she said.
While the bigger picture needed the GP workforce to be boosted by fast-tracking entry for international doctors, reinstating the subsidy for their training, supporting junior doctors to intern in general practice, and introducing payroll tax exemption for independent tenant GPs to prevent more practices closing.