Should bulk-billing rates be used as a measure of healthcare success?

Matt Woodley

7/06/2021 5:06:08 PM

While ‘more Australians than ever’ are accessing healthcare at no cost to themselves, GPs argue record bulk-billing rates ignore the threat posed by burnout and ever-increasing business costs.

Graph showing healthcare costs and MBS rebates.
Healthcare cost increases have outpaced Medicare rebate indexation.

According to Federal Health Minister Greg Hunt, ‘more Australians than ever’ are getting the medical care they need at no cost to themselves due to ‘record’ high GP bulk-billing rates.
‘Almost nine out of 10 visits to the GP in the nine months to March 2021 [were] provided with no out-of-pocket cost to the patient,’ Minister Hunt said on Sunday. ‘Our government’s commitment to Medicare and bulk billing remains rock solid.
‘These figures show that we are supporting the health and wellbeing of Australians more than ever before.’
However, following the announcement, a host of GPs took to social media to challenge Minister Hunt’s claims and the purported benefits for patients, while also calling for more Federal Government support for general practice, especially in the context of the ongoing COVID-19 pandemic.
From July 2020 to March 2021, bulk billing service rates reached an all-time high of 88.7% for the period, up 6.7% on the same period in 2012–13. 
But temporary telehealth items represented 24.8% of all GP consultations during the captured period, around 99% of which were bulk-billed by GPs in 2019–20.
RACGP President Dr Karen Price also told newsGP another way in which the statistics fail to tell the full story is that they only represent the number of services that are bulk billed, not the number of patients who have incurred no out-of-pocket costs.
‘The real figure is probably as low as two-thirds of patients,’ she said. ‘Moreover, what these numbers don’t reflect is the ever-widening gap between Medicare patient rebates, which were stagnant for a number of years, and healthcare inflation.
‘We don’t want to see patients suffer government gaps on their public Medicare insurance. Clearly during the pandemic, our hardworking GPs have been assisting those Australians who have been doing it tough, as well as continuing to cover the costs of rising practice overheads. 
‘General practice is the most efficient element of the healthcare system and performs an invaluable service to the community, yet many clinics are struggling to stay afloat due to a lack of investment in primary care and the ongoing effects of the Medicare freeze.’
Prominent Queensland GP and practice owner Dr Maria Boulton, who is also member of the RACGP Expert Committee – Funding and Health System Reform (REC–FHSR), was one of the GPs who commented on Minister Hunt’s Facebook post.
She questioned why funding for primary care is lower in Australia than in other countries, and wrote that quality healthcare is measured by outcomes, not costs.
‘GPs cannot continue to subsidise medical care for Australians. We have expenses – rent, equipment, staff, insurances, electricity, phone, clinical software, telehealth equipment, vaccine fridges, vaccine fridge batteries, etc that need paying,’ she posted.
‘These expenses are charged at 2021 values, not 1980s values like the Medicare rebates.
‘The Medicare rebates as they stand have not caught up with the cost of living. For the sake of our patients listen to what GPs are saying in these comments. Patients deserve more than the rebates cover.
‘GPs need more time to spend with their patients. Especially now that many of our patients are presenting with mental health issues due to the pandemic. GPs continue to do the heavy lifting, it is time for the Government to listen and help GPs as they continue to help patients.’
Another factor creating a ‘major case’ for funding reform and the need to reinvest in primary care, Dr Price says, is the changing needs of a future-proofed workforce. 
‘What is worrying, and has been for some time, is the number of young graduates seeking a general practice career,’ she said. 
‘Currently, the number of new graduates entering general practice from university sits at around 16%, whereas the number of new graduates entering GP training needs to reach 50% if we are to have an efficient health system. 
‘Given the new graduates are often heavily laden with HECS debts and are older than they used to be, some courageous and far-sighted policy is needed.’  
Dr Price said the college has been working collaboratively with the Government on improving primary care and will continue to do so by offering strategies geared towards the ‘quadruple aim’ of health system reform.
‘The quadruple aim includes population health outcomes, patient experience of receiving health care, efficiency, and the wellbeing of physicians delivering healthcare,’ she said.
‘Without any of these four components, healthcare service delivery is suboptimal.
‘Bulk-billing rates are not at all a descriptor of a health system, but one solitary marker of the responsiveness of GPs to their communities and the pandemic.’
According to the RACGP, new ways of reforming the healthcare system, such as introducing voluntary patient enrolment, are needed because the current system does not account for the increasingly complex patients being seen in general practice.
Dr Price believes the success of telehealth is an important innovation that the Government can ‘rightly claim credit for’ and for which patients have been helped through an international pandemic.
But she said health officials needs to be mindful that the continued success of a complex system is never one factor.
‘The current fee-for-service system is weighted in favour of high-volume, low-value care and is not sustainable,’ she said.
‘When did the bulk-billing rate become the measuring stick for optimal health and wellbeing?
‘We must invest heavily in preventive health and primary care before it’s too late. Burnout is being exacerbated and if the status quo continues a whole host of amazing GPs will soon be lost to the profession due to stress and exhaustion.
‘The economics of an unsupported health system and its clinicians are far more costly to patients and to taxpayers. I look forward to continued investment and reform where it matters most.’
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Dr Rodney Maxwell Moore   8/06/2021 7:09:49 AM

More GPs should bill privately an appropriate fee level

Dr Graham James Lovell   8/06/2021 8:43:15 AM

Minister Hunt is just using us like the horse in “Animal Farm”.
And when we die in the harness from overwork we to will find out
that we are the “Expendables”-work in a practice with a culture that focuses on excellence at a fair price, and not a focus on income at all costs.
That way you have job satisfaction and retain your self respect.

Dr Gerard Phillip Connors   8/06/2021 9:44:53 AM

Thank you to Drs Price and Boulton for taking the fight on GP owners costs to the Federal Government

Dr Louise Marie Edwards   8/06/2021 9:55:37 AM

Many, if not the major proportion of GPs do not have paid sick leave, maternity leave, family leave, personal leave, superannuation and long service leave. This also needs to be taken into account when extrapolating our incomes based on billings and comparing to similar professions.

Dr Abdul Ahad Khan   8/06/2021 11:48:15 AM

We GPs are NOT Govt. Employees.
Govt. Employees receive Annual Leave /Sick Leave / SA Contributions etc etc.
Unlike us, Govt. Employees do not need to pay for Electricity &Telephone Costs / Rental for the Premises / Insurance Cover for the other Staff, etc. , but we do pay for all those Costs.
If the Govt. of the day refuses to raise the Medicare Rebates, then SO BE IT.
We should take PRIDE that we are NOT GOVT. SERVANTS.
GPs should not be on our Hands & Knees begging the Govt. to raise the MC Rebates.
Low Medicare Rebates ought to be a Problem for the Patients
We are a PRIVATE Entity - we should charge an APPROPRIATE PRIVATE FEES, like the Private Specialists do - their MC Rebates have also not gone up- but, they are not crawling with a Begging Bowl !

We should charge Appropriate Fees & leave the Begging for higher MC Rebates to the Patients.
When the Fees that we charge are appropriate, fresh Graduates will find a GP Career as attractive.

Dr Peter James Strickland   8/06/2021 1:06:24 PM

These days all medicos can have patients' credited for the bulk-billing amount into their bank accounts within 24 hours. Simply tell the patient what the fee is above the rebate, and get them to pay on the day the full amount, and including the rebate---it is almost always a pittance compared to what a dentist charges above health benefits for any dental procedure. $20-$50 dollars for sometimes complex clinical assessment is a nothing also ---compared, say, to the motor mechanic, the plumber or electrician, and how about the lawyer? We have been too soft for too long --- everyone pays for everything else, and GPs should insist on the same, but also have empathy for those who are poor, or need frequent consultations etc. Tell the patients the problem is with governments and the rebates, and NOT you. GPs rebates were ALWAYS too low for > 30 years plus.

Dr Gisela Renee Boston   8/06/2021 3:41:25 PM

Primary care in the UK is falling apart after longterm lack of investment, input and funding and high levels of stress. I'm one of the hundreds of NHS GPs that fled that system to Australia and now I see the same thing happening here. This country's entire healthcare system will also fall apart if the rock which is primary care (the bottom of the big triangle) is not invested in.

Dr Cynthia Filipcic   8/06/2021 6:24:54 PM

Until patients realise that good quality health care comes at a cost and are willing to pay a fee instead of expecting to get ‘free’ health care we will be fighting a losing battle. We need patients and the government to recognise the value of good quality general practice and the importance of adequately funding primary care instead of encouraging bulk-billing and 6 minute medicine.

Dr Rasanga N Seneviratne   8/06/2021 7:52:41 PM

If all GP's start charging a private gap fee for all patients except pensioner's, healthcare card holders and DVA patients and may be children, the bulkbilling rate will go down and then government will do some changes. Otherwise why should they. In my opinion GP's themselves drag the profession down by bulkbilling all or most patients unlike other specialists.

Dr Abdul Ahad Khan   8/06/2021 9:40:24 PM

All the GPs combined will constitute < 1 % of the Population.
No Politician will care a damn about our Votes.
It is the other 99% of the Votes all Politicians will care about.
A famous Writer has stated something to this effect : " It is FOOLISH to keep trying the same thing & expecting a different Result - one needs to first of all change the Mindset ".
We GPS have been literally BEGGING for years & years. Yet, there has been no Result - why are we surprised ???

We need to change our Mindset first.
We are NOT Govt. Employees.
Medicare & the Govt. are NOT our Employers.
The MC Rebate is for the Patient .
When Patients ( the other 99% ) commence to Complain & demand from the Govt. a higher MC Rebate, things WILL happen.
Take Pride in yourselves my fellow GPs & charge an APPROPRIATE FEES & let the CRY come from the 99%.

Dr Irandani Anandi Ranasinghe-Markus   8/06/2021 9:53:58 PM

Thanks Karen Price and Maria Boulton for your advocacy. ‘Bulk Billing’ is a bad word, sadly forced upon General Practice and accepted by us for far too long. In what other profession does one get to train for over 10 years (sometimes longer) and then have to accept $100 for an hour of your service? Bulk billing rates are in no way a reflection of the standard of health care but is a constant reminder of how dismally the hard work of GPs is valued by those in power. Sadly most patients don’t understand this and the fact that governments need to pay doctors what their services are worth. Would those in government be happy accepting a fraction of what their service is worth? How are new graduates expected to be attracted to such career prospect? Bulk billing is not a sustainable option unless the rebates start meeting the actual cost of providing these services!!

Dr Abdul Ahad Khan   9/06/2021 11:57:27 AM

Dear Irandani Anandi,
I can only re-iterate the Root of the 'Problem ' :

You need to change your Mindset first.
You are NOT a Govt. Employee.
Medicare & the Govt. are NOT your Employers.
The MC Rebate is for the Patient .
When Patients ( the other 99% of the Populace ) commence to Complain & demand from the Govt. a higher MC Rebate, things WILL happen.

Take Pride in yourself my dear Colleague & charge an APPROPRIATE FEES & let the CRY come from the 99% of the Populace.

Dr Helena Spencer   9/06/2021 2:29:20 PM

I agree with you wholeheartedly Dr Khan.
I have a 2 doctor practice with therefore relatively high overheads.
I charge everyone on the day of consult (discounted but not free for pensioners and HCC holders with discretionary bulk billing for frequent attendance or extenuating circumstances).
Even the poorest patients find money for what they value, which may include alcohol and cigarettes, so why not their preferred doctor?
Provide a good service, give the patients the time and service they want and need, and they are generally appreciative and happy to pay.