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Should we aim to bulk bill everyone for GP visits?
Five healthcare experts were asked the same question, four said yes and one said no, with many asking how high should we be aiming?
How high should we be aiming? Many Australians may assume universal health care means it should be free to see a GP, regardless of your age, income or postcode.
A new report by a GP listing company made headlines this week showing low rates of bulk billing for GP visits across Australia.
Bulk billing means the consultation is free for the patient and the GP accepts what Medicare covers (the “benefit” or “rebate”) as the full payment.
The highest reported bulk-billing rate was in New South Wales (34.5%) and the lowest in the ACT (3.3%) and Tasmania (0%). This caused the Tasmanian health minister to declare bulk billing “dead” in her state.
But does this really mean no Tasmanians are being bulk billed at the GP?
No – as federal health minister Mark Butler was quick to point out after the report’s release, the company asked 6,925 GP clinics only whether they had standard, weekday consultations available to be bulk-billed for adults with no concessions.
A range of people do have concessions – children under 16, pensioners and people with a health care card – meaning the actual bulk-billing rate is much higher, although Butler said he’d like it to be higher still.
How high should we be aiming? Many Australians may assume universal health care means it should be free to see a GP, regardless of your age, income or postcode.
So we asked five experts: should we be aiming to bulk-bill everyone?
Four out of five said yes.
Here are their detailed responses.
Brett Montgomery – yes
Senior Lecturer in General Practice, The University of Western Australia
I don’t mean we should expect GPs to bulk-bill everyone right now. Medicare rebates were frozen for years, then thawed slowly, not keeping up with inflation. The longstanding income gulf between GPs and other doctors grew.
Little wonder many GPs sometimes charge gaps and we have GP workforce shortages. Yet GPs still bulk-bill more than three-quarters of consultations.
Recently tripled bulk-billing incentive payments helped slightly, but only for those eligible (children and Centrelink card holders). Young and middle-aged adults largely miss out – and many are postponing GP visits.
So, when I answer “yes”, I mean we should aspire to eliminate financial barriers. Health care co-payments are bad because they are associated with people missing out on necessary health care and medications.
Raising Medicare rebates to levels where GPs can universally bulk-bill would improve access, among other potential strategies.
We need accessible health care for everyone, and working conditions that ensure a sustainable GP workforce.
Christopher Harrison – yes
Senior Lecturer, Sydney School of Public Health, University of Sydney
Ideally, yes. One of the core principles of universal health care is that everyone has access to quality health services without causing them financial hardship.
There are incentives for GPs to bulk-bill children and Commonwealth concession card holders. But these do not cover working Australians, for many of whom the out-of-pocket cost of GP visits will cause financial stress.
This may mean they delay care, leading to poorer health or future hospitalisation. Or they may seek care from an emergency department, where costs to the system are far higher (though lack of GP access is a larger driver of emergency visits).
The rising prevalence of people with multiple chronic conditions (most of whom are working age) is increasing the need for comprehensive, coordinated, long-term GP care. It is paramount that out-of-pocket costs are not a barrier to GP services.
In the short term, addressing the ongoing GP shortage and considering ways to further incentivise bulk billing will help.
Jim Gillespie – yes
Associate Professor in Health Policy, University of Sydney
In 1983 the Hawke government introduced Medicare as a “simple, fair and affordable” way to provide “basic health cover to all Australians”.
Bulk billing was central. It preserved “fee-for-service” – ensuring GPs received a payment per visit – and secured doctors’ compliance.
Bulk billing remains almost universal in less affluent areas. But in wealthier suburbs most patients pay a gap.
Medicare’s universality has remained contentious. 1996 John Howard reluctantly accepted Medicare, but as a “safety net” rather than a universal scheme. He aimed to limit bulk billing to pensioners and health care card holders.
Medicare’s supporters have since framed bulk billing as the key difference between parties. This closed off discussion of flaws in Medicare, particularly the fee-for-service model which is not optimised for the growing burden of chronic illness.
Bulk billing enables better access to the current system, but we need to explore methods for integrating care.
Jo Enticott – yes
Associate Professor, Monash Centre for Health Research and Implementation, Monash University
Every Australian has the right to the highest attainable standard of health. Our health-care system is often called “universal” and accessible to everyone. But in reality this isn’t true.
Evidence consistently shows disadvantaged Australians experience the highest levels of ill health, including mental disorders. Yet they access less health care.
This inequity occurs even within major cities. For example, in Broadmeadows, a socioeconomically disadvantaged suburb of Melbourne, people with the most need average just two visits a year to Medicare-subsidised Better Access mental health services with a GP. In nearby affluent Darebin South, the average is more than ten.
Expanding bulk billing for all Australians – and ensuring GPs are paid properly – should be a priority in tax reforms.
Bulk-billing everyone will help move Australia towards our obligations as a signatory of the international treaty supporting the right to health, regardless of a person’s wealth. This approach to health benefits everyone.
Yuting Zhang – no
Professor of Health Economics, The University of Melbourne
No – but we should make them more affordable. For some people this means they will be free, but those who can afford it should still pay a small amount.
Appointments for children should be bulk-billed. Making health checks regular and accessible during childhood is an effective long-term investment which can delay the onset of disease.
GP visits should also be free for people on low incomes and those in rural and remote areas. This would help close the rural–urban gap in access to primary care, and improve health outcomes for those who’d otherwise struggle to pay.
The rest of the population should pay A$20–30. A small fee helps discourage unnecessary visits when resources are limited.
But the A$60 many of us currently fork out is too expensive. Cost can lead to people skipping GP visits, meaning our health-care system may have to shoulder the cost of expensive hospital care down the track.
First published in The Conversation. Read the original article.
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