Drop in national bulk billing rate signals increasing out-of-pocket costs

In a recent statement, Federal Health Minister Greg Hunt noted a surge in Medicare bulk billing rates across the health system, with ‘record highs’ in general practice.
 
The Department of Health’s (DoH) latest quarterly Medicare statistics show bulk billing rates were 88.4% in the 2021 December quarter, 0.3% higher than December 2020, with rates lowest in the ACT (70.7%) and highest in New South Wales (90.9%).
 
The release compared the percentage of bulk billed medical services to that of December 2012 – nine years prior – with the current rate, which stands 6.4% higher.
 
But what it failed to mention is that the bulk billing rate is actually down 1.2% from the previous quarter (89.6%). Further to that, the average patient contribution per GP service peaked in Q3 of 2020–21, at $42.79.
 
Speaking to newsGP, RACGP President Dr Karen Price said the data indicates that members are starting to take action to ensure the sustainability of general practice, by passing on costs to patients where suitable.  
 
‘It’s a challenging conversation, but this is about trying to provide access and to continue access for vulnerable groups by doing what the Government won’t do themselves – and that is to cross subsidise,’ Dr Price said.
 
‘This is about the sustainability of general practice, and we can’t maintain that if we bulk bill everybody. We just can’t.’
 
Dr Emil Djakic, Chair of the RACGP’s Business Sustainability Working Group, agrees and says the way the data is being presented distorts the true picture, as the figures show the number of services that were bulk billed, rather than the number of patients who were bulk billed for all GP services.
 
‘These findings diminish the evidence of increasing out-of-pocket costs,’ Dr Djakic told newsGP.
 
‘I want to know why they bothered to use a figure that compared us with 2012? That is ridiculous.
 
‘It tries to imply that there’s been a massive increase in investment in that time when there simply hasn’t.’
 
The Productivity Commission’s Report on Government Services 2022, shows in 2020–21 just 67.6% of patients had all GP services bulk billed.
 
‘So there’s a lot of patients actually paying for services already,’ Dr Djakic said.
 
The number of services delivered by GPs peaked in Q1 2021–22, at 51.6 million and dropped to 46.7 million in Q2.
 
But while 89.1% of these services were bulk billed, Government requirements due to COVID-19 meant GPs often did not have a choice.
 
For example, COVID-19 vaccine suitability assessment items, which must be bulk billed, comprised 16.2% of the recorded services, while bulk billing rates for COVID-19-related telehealth services also remain higher than for non-COVID services.
 
As a result, Dr Djakic says the pandemic has become an additional burden for many practices, which should be recognised.
 
‘Most of that was enforced bulk billing,’ he said. ‘But it’s very clear bulk billing for phone consultations is [now] changing very quickly.
 
‘People are realising that if they continue to meet the demand of patients for no out-of-pocket costs, ultimately they’re going backwards, and the patients are not getting the full level of service.’
 
Since starting out as a junior doctor, Dr Price says practice costs have increased significantly, from practice set up and equipment, to on site allied health services.
 
Meanwhile, she says neglecting to fund general practice at its true cost has further fuelled the challenge of attracting new graduates to the profession.
 
‘We’ve already got a rural health workforce crisis and it’s quickly becoming apparent that we’re going to have an urban one,’ Dr Price said.
 
‘On one of the forums I saw, someone said, “I’m only able to bulk bill all of my patients because my husband works and has a good job”.
 
‘It’s outrageous that other professions are effectively subsidising the medical care of patients, particularly for women in general practice.’
 
But Dr Djakic says the push towards mixed billing is not about practices abandoning bulk billing altogether. Rather, it is about understanding the costs and value of a practice to ensure expectations are being met.
 
‘We’ve got a reduced number of undergraduates coming into general practice in an increasingly complex world and an increasingly complex healthcare system, and if we don’t assert our value, then we will go over the cliff,’ he said.
 
‘And that’s where we’re heading right now.’
 
Dr Price shares the sentiment. She says despite implementing mixed billing at her own practice, patients identified as not having capacity to contribute to the cost of their care are bulk billed for every service.
 
‘I’m not about trying to leave those people out of the loop,’ she said. ‘But there are many others who are able to pay, and so that allows me to maintain a high-quality service for all of my patients.
 
‘With continued high bulk billing rates, there doesn’t seem to be an impetus for the Government to increase investment in general practice services.’
 
Despite many patients accepting that there is often a cost associated with high quality gnereal practice, it can be challenging for practices to navigate the introduction of a fee to patients who are used to being bulk billed.
 
Dr Price acknowledges this and encourages anyone having challenges with the transition ‘to talk to us’. But she is also sensing that the tide is turning, with many patients starting to recognise the value of the care they receive.
 
‘I have many patients who now say “No, no, I’m very happy to pay you; I know how hard GPs work”,’ Dr Price said. ‘That’s something that I’ve never really heard.
 
‘People are now starting to become aware that the amount they’re paying for general practice care compared to other health services is really quite small.’
 
Dr Djakic agrees.
 
‘I think a lot of patients who are paying out-of-pocket costs don’t see it as a problem, as long as they feel like they’re getting value for money,’ he said.
 
While the need for reform has been recognised by both sides of politics, Dr Price says it is clear that now is the time for action.
 
‘If we’ve got a Medicare system that operates like it did 50 years ago, it’s not going to work,’ she said.
 
‘We’ve got a 10-year plan – how about we go back to implementing it for the sake of all Australians, because we’re not going to be able to afford a health system like America where it’s more expensive and leads to fragmentation of care and poorer outcomes.’
 
Dr Price and Dr Djakic will present a webinar on how to introduce mixed billing in your practice on Thursday 24 March at 7.00 pm (AEDT). To register, visit the RACGP website.
 
For assistance on managing billing, GPs can access a range of resources on the RACGP website. Members are encouraged to bookmark this page for easy access.
 
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