Pushback against proposal to restrict MBS access to bulk-billing GPs

Anastasia Tsirtsakis

12/04/2023 4:39:02 PM

There are concerns such a change would create a two-tier system and ‘completely undermine’ the universality of Medicare.

Medicare cards.
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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Dr Fiona Therese Manning   13/04/2023 6:49:13 AM

As a newly fellowing GP, I got to be honest and say a change such as that proposed here would incentivise me to LEAVE general practice. Others would never enter the speciality in the first place. Are you trying to kill general practice, health economist? That is not a good idea.
Just pay us a proper rebate for the comprehensive, complex, lengthy care we provide alongside funding our practice nurses and their roles better, and we can look after the Australian community.

Dr Anthony Francis Dique   13/04/2023 7:52:57 AM

this is a stupid idea. Allowing the government to set remuneration for what is effectively a private business. Allowing government even more control over our (private practitioner /business) lives. I hope this idea dies the death it deserves.

Dr Patricia Montanaro   13/04/2023 8:58:23 AM

Has anyone heard of the NHS? The UK have tried it…and it doesn’t work!
Reason .. idealised system an never enough money put in to start or adequately make up for inflation and other cost rises… eg Medicare rebate now compared to its inception!!
Great idea and utopia, terrible plan

A.Prof Christopher David Hogan   13/04/2023 9:11:10 AM

What these unimaginative rigid thinkers think they are offering is a binary choice of either join Medicare & get a pittance or stay independent & starve.
Choices are rarely binary for they assume GPs are the lowest rung on the medical ladder & are not smart enough to go into other disciplines.
This is patently inaccurate.

Dr Richie Yumdo   13/04/2023 10:03:11 AM

The bottom line is, they do Not appreciate good health-care. They prefer fast food medicine

Dr Philip Ian Dawson   13/04/2023 10:33:48 AM

Medicare is supposed to be a compulsory exclusive insurance system that all taxpayers have to pay. It was never intended to be anything compulsory for GPs. For the insurer to now say it will cover a lot less than it used to, but for the same insurance premium, unilaterally without consulting its customers ( everyone who pays the Medicare Levy) is FRAUD. If any other insurance company tried that they would be prosecuted! Privat insurers including Medibank Private are excluded from insuring against private doctors fees. What do they propose for that?

Dr Richard Peter Shorrock-Browne   13/04/2023 11:43:16 AM

"They go on to say that the model would need to be underpinned by ‘fair remuneration.’"

Heavens! Why don't they just do this now, and there would not be practices having to charge a co-payment - problem solved.

They are essentially admitting that they are currently not paying "fair remuneration."


Dr Siva Kumar Raju Muppala   13/04/2023 12:15:35 PM

Patients have to choose see a bulk billing doctor or pay full fee. weird ideas killing quality and confusing Australian public.

Dr Graham James Lovell   13/04/2023 1:54:25 PM

“Killing the Golden Goose “- that’s what I have watched & felt as a General Practice Owner over the last nearly 40 years. “ Tortured “ on the Rack of endless Medicare Freezes and alway below the true increased annual cost of running a practice. Altruism “flogged “ out of us by ignorant Health Department Bureaucrats, while we face endless
“ shaming “ if we complain about being unable to survive on Bulk billing by Politicians and Media. Whilst we inevitably have largely faded away from these decades of being both “used” & abused to being a largely corporate run fast throughput service.
Governments have brought General Practice to its knees-even the corporates stated recently that many weren’t viable…

SD   13/04/2023 3:27:39 PM

This move may lead to complete privatisation of general practice. On one side will be completely private practices and on other the government funded bulk billing clinics.
This will make private GP care unaffordable to general population and also give rise to private medical insurance companies covering GP visit fees.

Dr Michael Paul Mears   13/04/2023 10:17:47 PM

This is a provocative and poorly thought through proposal by Prof Duckett whose ideas are designed to destroy General Practice as we know it. It will lead to a UK style patient enrolled health system with the government setting the agenda and constantly shifting the goalposts. Typically funding appears attractive to draw people in to start and then tightens. Any GP autonomy will disappear and targets will be set by economists who know the cost of everything and the value of nothing. Box ticking will increase and patient centred care will disappear in favour of disease centred care.
It’s why I and many many GPs left the NHS.
General Practice already has a recruitment problem and this will destroy it.
Just fund Generalism properly and give it the respect it deserves rather than overfunding the ever growing legions of Partialists who cost the the health system far far more.

Dr R   15/04/2023 11:11:37 AM

Mr Duckett and many others like Margaret Faux are Hostile to General practitioners and will do anything to slander, demoralise and disenfranchise hard working GPs. The health department bureaucracy and governments are happy to listen to them. Clearly they want a UK style system forced upon us. They don’t realise that it will be a complete disaster
I for one will never accept Government coercion and slavery . I have enough patients that value my superior level of care and will pay a private fee, especially when very few practices will be around because of these kinds of “reforms “ I am happy to work less and retain my professional independence rather than be enslaved by government bureaucracy Interesting that they can’t touch our specialist colleagues who continue to thrive and Charge what they Like( gaps of 300 dollars are routine) whereas a 30 to 40 dollar GPGap fee is seen as a crisis!

Dr Patrick Fergal McSharry   15/04/2023 8:47:42 PM

I could not agree more than the statement made by one of the other GP's below
"Choices are rarely binary for they assume GPs are the lowest rung on the medical ladder & are not smart enough to go into other disciplines."

I also see a lot of comments from Doctors who left the NHS .
We are our own worst enemies really I feel.
We are responsible for letting "Volume Based Medicine Primary Care" take hold and be institutionalised .
There are many other ways to raise us from Being "just a GP" (Specialist) to being a Primary Care Specialist . (There are many other Models Internationally -Some are Fee-Per-Service - FPS <Not meaning ...Focused Psychological Strategies :) >)
Let's be open minded and look at "enrolled patients " payment for performance /quality in Chronic Disease Management and others Compensation/Reimbursement Models in addition to maintaining FPS.
Let's get those patient back into Primary Care (and out of the Hospitals OPD's)

Dr Fiona Jane Henneuse-Blunt   16/04/2023 3:49:36 PM

Dr Michael Paul Mears, I am one who left the NHS and could not have articulated my sentiments better than your comments. I completely agree with all you have written.

Dr Elysia Goldie Snoke   17/04/2023 7:09:32 PM

There have been so many bulk-billing GP practices that have closed in recent months, so clearly being an 'exclusively bulk billing' GPs is not a financial viability, and I'm surprised it would be suggested by an economist as even an option. What about having an MBS item number for an additional payment to GPs who provide a bulk-billing service for patients who are concession card holders/DVA/pensioners/etc, which would mean there is funding to see those already with low financial security?

Dr Kia Alizadeh   19/04/2023 10:36:52 AM

Undeclared agenda. Make the system a mongrel child of UK/US madness. riiiiiiiiiight.