Explainer: Bulk-billing rates are at record highs – or are they?

RACGP President Dr Harry Nespolon this week questioned Australia’s widely-touted bulk-billing rate, officially at a record high of 86.1%.
 
So what’s the issue?
 
What is Australia’s official bulk-billing rate?
The Department of Health’s Medicare statistics for the 2017–18 financial year show that 86.1% of general practice services were bulk billed.
 
That is up from 81.2% six years earlier.
 
What is the issue with this statistic?
As Dr Nespolon pointed out, this statistic represents the number of services that are bulk billed, not the number of patients.
 
Patients who receive many services each year – such as older patients with chronic diseases – are likely to both receive more services, due to being sicker, and be bulk billed, due to holding concession cards.
 
This inflates the percentage of services bulk billed each year, but it doesn’t change the number of patients bulk billed each year. The Government does not report the number of patients bulk billed every year.
 
The RACGP’s 2018 General Practice: Health of the Nation 2018 report states that ‘while it is true that 86.1% of general practice services are bulk billed, the proportion of patients fully bulk billed (and who therefore face no out-of-pocket costs for care) is actually much lower’.
 
According to survey results in this RACGP report, only 23% of GPs bulk bill all of their patients.
 
Do we know what the real figure is likely to be?
This data is not made publicly available.
 
We do know, however, that a recent Australian Institute of Health and Welfare (AIHW) report on out-of-pocket costs found that only 66% of patients had all of their GP services bulk billed in 2016–2017.
 
That means one third of all patients paid an out-of-pocket cost for their GP care in that time period.
 
The same report found half of all patients accessing Medicare-subsidised services (including GP services, as well as other health services such from other medical specialists, allied health, pathology and diagnostic imaging) had to pay something from their own pocket in that year.
 
What impact does this have on patients?
The AIHW report found that one million Australians reported delaying or avoiding seeing a GP due to cost concerns.
 
Patients spent approximately $3 billion a year on non-hospital Medicare services around Australia, according to the same report.
 
Patient out-of-pocket costs for a GP visit have increased by 140% since 2005–06, while the patient rebate for Medicare Benefits Schedule (MBS) item 23, the most common item for which GPs bill Medicare, has increased by only 19% over that period.
 
The AIHW report found the median total out-of-pocket cost per patient over that time period stood at $142 Australia-wide.
 
The average out-of-pocket expense for a GP consultation is $37, according to 2018 Medicare statistics. This cost is increasing annually at double the rate of consumer price index (CPI).
 
The RACGP last year released analysis showing average out-of-pocket costs are expected to rise to more than $40 this financial year if no action is taken.
 
If this occurs, out-of-pocket costs will surpass the patient rebate for the first time in Medicare’s history.
 
Do we know why bulk-billing rates have increased?
Two health economists described it as a ‘bit of a mystery’ in The Conversation this week, given that the Medicare rebate freeze has effectively reduced real growth in Government funding for general practice services since 2013.
 
The freeze has since been gradually lifted, though the RACGP has pointed out that general practice is still underfunded by more than $1 billion as a result of the freeze and years of inadequate indexation.
 
We do know that the rate of increase in the number of services bulk billed is slowing, with annual Medicare statistics showing growth has slowed from 1.2% in 2013–14 to 0.2% in 2017–18.
 
If this trend continues, the bulk-billing rate is likely to begin declining in the 2019–20 financial year.

bulk billing freeze MBS Medicare rebate