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Pushback against proposal to restrict MBS access to bulk-billing GPs
There are concerns such a change would create a two-tier system and ‘completely undermine’ the universality of Medicare.
Melbourne GP Dr Mariam Tokhi says the current funding model incentivises fast medicine and disincentivises working with more complex and poorer patients. (Image: AAP)
A proposed radical shakeup of the Medicare system that would only allow purely bulk billing GPs to access MBS patient rebates has been met with scepticism by the general practice community.
The controversial idea, floated by prominent health economist Professor Stephen Duckett to address ongoing health system pressures, would restrict Medicare rebate access to patients seen by GPs who exclusively bulk bill, leaving others to rely solely on out-of-pocket payments.
Outlined in an article published in The Conversation and co-authored by Associate Professor Fiona McDonald, who is co-director of the Australian Centre for Health Law Research, they say the move could ‘radically alter’ the Medicare system.
‘A new basis for Medicare could be one where practices sign up to Medicare and agree to meet Medicare’s contractual conditions such as agreement to bulk bill all patients, participation in training future health professionals and in quality improvement programs, and that practices are multidisciplinary,’ they wrote.
They go on to say that the model would need to be underpinned by ‘fair remuneration’, and that participating practices could be paid on a variety of bases including ‘number and type of patients enrolled, number of patient attendances [enrolled or not], and other payments’.
Both Professors Duckett and McDonald say that this approach, coupled with adequate workforce planning, could encourage new graduates to work in locations and specialties in short supply ‘by limiting access to rebates for specialties in locations of oversupply’.
‘This would also facilitate management of fraud and over-servicing through contractual controls, rather than cumbersome administrative law processes,’ they wrote.
‘A “participating provider” approach would transform the patient experience. Most importantly, the bulk billing lottery would end: practices displaying a Medicare sign would bulk bill all patients, not just some.’
But many GPs are concerned about the proposal and say it could result in a two-tier health system akin to that of the US.
Among the critics is RACGP President Dr Nicole Higgins.
‘My concern is that we will end up with a two-tier system – the haves and have nots,’ she told newsGP.
‘The Australian public would not tolerate the loss of a universal healthcare system and the loss of Medicare.’
Dr Cathryn Hester, a practice owner and member of the RACGP Expert Committee – Funding and Health System Reform (REC–FHSR), agrees.
She fears implementing the policy would likely decrease the bulk billing rate and believes many GPs would simply opt out of Medicare billing completely rather than ‘have golden handcuffs applied’.
‘Not only would this directly reduce GP care for communities who most need it, it would result in worsening healthy equity with two vastly different levels of care provision between mandated bulk billing and private clinics,’ Dr Hester told newsGP.
‘This would be a very sorry outcome for Australians.’
Meanwhile, Dr Mariam Tokhi – a GP in outer metropolitan Melbourne whose patient cohort is primarily from a low-socio economic background – is concerned Professor Duckett’s proposal could punish GPs who, in the face of Medicare freeze, are charging a gap fee to provide quality care.
‘I’m wary that this could really destabilise primary care provision, including for some very vulnerable people,’ she told newsGP.
‘I want to see better funding for poorer, less healthy populations, but I’m worried that removing universal access to Medicare will inadvertently cause a deepening of a private-public divide.
‘If Medicare is sidelined for the needy, will it become a neglected mechanism? I don’t trust private insurance and managed care funds to come up with better solutions for our society.’
As it stands, the Melbourne GP believes that the current funding model is ‘stuck in a bygone era’ and ‘incentivises fast medicine’ which in turn disincentivises working with more complex and poorer patients.
Rather than cutting costs by removing Medicare access, Dr Tokhi says reform should be focused on solutions to fund and mobilise good care that supports all Australians, starting with enabling all GPs to work with patients on the margins.
‘All GPs have these patients,’ she said. ‘That means building a Medicare that enables GPs to listen, think, liaise and communicate.
‘Primary care done well can prevent health crises and help patients survive and break cycles of despair and disability – [it] is an investment, not just a cost.’
Current Medicare rebate deficits, whose value is set by the Federal Government, has already seen an increasing number of GPs taking the lead of their non-GP specialist colleagues by charging a fee to cover the cost of keeping their doors open.
As such, Dr Higgins believes applying Government control over GPs’ income and how and where they work would lead to a further exodus from general practice.
‘What Stephen Duckett hasn’t acknowledged is that the Medicare rebate belongs to the patient – the Medicare rebate doesn’t belong to the doctor,’ she said.
‘We acknowledge that we need Medicare reform [but] this is forced change … [when] the Federal Government needs to bring the profession and patients along with it.
‘Forcing change will only further disenfranchise GPs, reducing the number of doctors wanting to become GPs and further reduce our workforce.’
Dr Tokhi agrees and says it is vital that the voices of those grappling with the real-world effects of health funding policy are part of the conversation on reform.
‘Australia is a lucky country, in part because of our incredible healthcare system that tries to look after us all,’ she said.
‘We mustn’t dismantle it, but we do need to strengthen its reach into poorer and isolated patient communities.
‘There are lots of options on the table.’
As the Government’s May budget looms, Dr Hester says she cannot help but see the health economist’s controversial proposal as a ‘poorly formed grasp for attention and distraction’.
‘At this point we don’t need “interesting” thought bubbles or distractions,’ she said.
‘What is quite clearly needed is a substantial injection of funding for our fee-for-service system and more support for practice owners to continue to provide world-leading care.’
And with the Budget around the corner, Dr Higgins said it is important to remember that general practice funding only
accounts for 6.5% of Australia’s total healthcare expenditure.
‘We’ve got a health system that’s in the top five systems of the world; the system works, the problem is that it’s not funded appropriately,’ she said.
‘If the Government wants to look at savings or reforming the system, we also need to [look at] the other parts that are growing exponentially, such as the NDIS and our hospital systems.
‘General practice needs to be reinvested in.’
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