News

‘We don’t want to be bulk-billing clinics’


Anastasia Tsirtsakis


14/05/2020 6:52:22 AM

As many independently owned clinics report financial strain amid the COVID-19 pandemic, GPs have expressed fears for the viability of their practices.

Stressed GP
With up to 50% of consultations being bulk billed, practices that charge a gap or privately bill have experienced considerable revenue loss.

‘We’re already stressed – we don’t need this on top. The financial stress is unnecessary.’
 
That is Dr Maria Boulton, a Brisbane-based GP and a director of the Australian General Practice Alliance (AGPA). She runs a mixed-billing clinic and, like many other GP practice owners, is feeling the financial burden of the Federal Government’s telehealth bulk-billing policy.
 
The legislation requires general practices to bulk bill Medicare Benefits Schedule (MBS) telehealth services for all patients who are vulnerable to COVID-19. For many practices, these broad and complex criteria have resulted in up to 50% of consultations being bulk billed, leading to considerable revenue loss for clinics that charge a gap or privately bill.
 
‘Medicare funding of telehealth has been great to improve access for patients and keep them and their GPs safe during the worst of the pandemic. But mandating that GPs bulk bill these services means that practices are having to change their business models at a time when they’re already stressed,’ Dr Michael Wright, Chair of the RACGP Expert Committee – Funding and Health System Reform, told newsGP.
 
‘We know that general practice viability is pretty marginal. So a lot of practices only work on a margin of 2–3% profit, and a simple change like introducing these bulk-billing restrictions will make many practices now unprofitable and not viable in the long term.’
 
Dr Boulton’s clinic normally charges $79 for a 15-minute consultation. But with at least half of her consultations having moved to telehealth, the bulk-billing requirement means they can only charge $38.20. While the Practice Incentives Program Quality Improvement Incentive (PIP QI) incentive has doubled, Dr Boulton says even that is not enough.
 
‘The way that the criteria stands, basically 50% of my business is now bulk billing,’ she said.
 
‘The Government has basically turned us into bulk-billing clinics, [but] we don’t want to be bulk-billing clinics because we don’t want to have to see eight to 10 patients an hour in order to continue to provide patients with all the services they get.’
 
Dr Mel Deery, a Canberra-based GP, says practice staff have found it difficult to navigate the complexity of the bulk-billing criteria, making it difficult to set clear expectations of which patients are bulk billed and when.
 
‘They don’t know when the patient has got chronic medical conditions or if they’re pregnant so that they should be bulk billed or privately charged,’ Dr Deery said.
 
‘So the default is we’re just needing to bulk bill everyone through telehealth because it’s far too complicated otherwise.
 
‘But then it’s quite confusing for patients because they’re bulk billed with telehealth but they’re charged when they come in.’
 
Dr Deery is concerned that long term it could create a perverse incentive for patients to prefer telehealth over face-to-face consultations.
 
‘Telehealth has its place – but it’s harder to develop rapport, especially with a new patient, and many patients do need that physical examination,’ she said.
 
Along with not being able to set their own fees for specified patient groups, many practices continue to report a reduction in revenue due to low bookings as patients have been reluctant to see their GPs amid coronavirus fears. They are also losing out on tenant rental income generated by allied health and non-GP specialists, including pathology tenants, many of whom have asked for a rental reduction.
 
All the while general practices have seen their expenses increase.
 
Dr Boulton has not been able to pay herself a wage to try to cover all other expenses.
 
‘The Government is pretty much playing with business viability and, as happy as I am to work for free, which is basically what I’ve been doing, I still need income for the fixed costs – for my staff, my rent – and the Medicare rebate is not enough,’ she said.
 
‘A lot of us have had to purchase PPE [personal protective equipment] – the prices for that are exorbitant at the moment. We’ve also had to purchase cleaning supplies and hand sanitiser, and we’ve had to put extra staff on because we couldn’t cope with the amount of phone calls we were receiving initially for COVID-19 and we needed to be responsive to the community.
 
‘We’ve also spent money on social media and websites for our patients and the community to get information about coronavirus.’
 
Dr Deery describes a similar reality. Her practice has increased staffing costs of up to 50 administrative hours per week, not to mention other fixed costs.
 
‘We’ve got our rental costs, we’ve got repayment of our fit out, and we entered into those fixed costs with the expectation that we will be running a privately billed clinic, and we can’t vary those costs with a drop in our revenue,’ she said.

Billing-MBS-correctly-hero.jpg
The legislation requires general practices to bulk bill Medicare Benefits Schedule (MBS) telehealth services for all patients who are vulnerable to COVID-19.

GPs are particularly frustrated since the Government lifted billing restrictions for specialist and allied health service providers, as of 20 April.
 
‘My patients are reporting having to pay $400 for a telehealth consultation with specialists who have gone completely to telehealth and shut their physical rooms,’ Dr Wright said.
 
‘So while they’ve shut their rooms and reduced their costs, general practices are staying open but forced to reduce what they’re charging.’
 
Despite talk of GPs playing an important role on the frontline of the pandemic, Dr Deery says the Government’s inaction has shown a ‘lack of value’ in the important role general practice plays in the health system.
 
‘In the long term there has been a lack of value, I feel, from the Government of general practice,’ she said. ‘But I’ve actually never felt that so strongly as I have in the last few weeks with this mandatory bulk billing of telehealth when everyone else can privately charge.’
 
Dr Wright agrees.
 
‘I think we’ll look back on this pandemic and see that despite the rhetoric about primary care being the crucial frontline of our health system, there have been failings in terms of funding and PPE that show that general primary care has been given a lower priority,’ he said.  ‘That needs to change.’
 
GPs are reporting immense pressure across the board. While they navigate changing policies, they continue to deal with PPE shortages and face the threat of exposing themselves, their staff and families to infection. The added stress is not only affecting finances, but also taking a toll on their wellbeing.
 
‘I think you’re going to find once things calm down a bit, there’s going to be a lot of burnt out GPs – a lot of us GP practice owners are already feeling completely burnt out. Yet we still keep coming to work,’ Dr Boulton said.
 
‘We don’t need this.
 
‘GPs are not feeling supported by the Government and we feel that they make decisions without considering the financial and practical realities that affect general practices.’
 
There is no denying the pandemic has highlighted the need for a telehealth service, with Federal Health Minister Greg Hunt reportedly planning to expand access long term.
 
But Dr Wright says rather than restricting billing, any future reform should focus on restricting the availability of telehealth, warning that the current approach could result in fragmented care and reflect badly on general practice as a whole.
 
‘The question is, should patients be able to have Medicare-funded telehealth consults with GPs or practices that they’ve never seen before?’ Dr Wright said.
 
‘We know that there have been services which are setting up that just offer telehealth services. Some of them don’t have the capacity to see people and they also don’t have access to a patient’s medical history.
 
‘So they’re really not providing the high-quality care that we would expect from a GP.’
 
If the bulk-billing requirement remains as is, there are fears practices will buckle under the strain, closing their doors for good and leaving vulnerable patients without access to quality primary care.
 
‘Practices will shut down, patients’ choice of practices will shut down. Patients will lose the choice to see anyone other than at large practices with high turnover,’ Dr Wright said.
 
Dr Deery shares this sentiment. She believes such an outcome would ‘undermine the viability of small, privately owned practices’.
 
‘I’d hate to see a rise in [the] corporatisation of medicine where we don’t have that relationship with a GP,’ she said. ‘Because that’s such an important part of their quality care’.
 
The RACGP has been a strong supporter of telehealth during the pandemic to ensure GPs are supported to deliver care to patients, but the college does not support the inconsistent requirement for GPs to bulk bill telehealth consultations.
 
The RACGP recognises the pressures GPs are facing as a result, and is advocating for the Federal Government to recognise the need for telehealth consultations to be billed as determined by each practice, as is the case for all other Medicare patient rebates, and as per the Medicare rules for other medical specialties.
 
The RACGP’s submission to the Senate Select Committee will highlight GPs concerns about mandatory bulk billing of telehealth items for specified patient groups.
 
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Dr Adele Frances Stewart   14/05/2020 7:29:37 AM

I agree. High quality GP practices are really unfairly affected by the rules around bulk billing Telehealth.


Dr Emma Coldwell   14/05/2020 8:59:31 AM

While I agree largely with many of the issues here, I think the bigger problem is the medicare fee/rebate system. It is redundant and it is what is making it hard to return to private billing. Where is the conversation around ending the fee/rebate system?

For clarity, it is a bigger problem to me because we already bulk-bill concession card holders and kids. The 'COVID vulnerable' bulk-billing numbers are a positive when you find yourself having to bulk bill anyway due to the pandemic. I think removing the 'give us lots of money and we'll give you most of it back' system would actually go further to helping the financial viability of small clinics.
People are happier (and often more able) to pay a 'gap'.


Dr Gonasagaran Ruthnam   14/05/2020 10:36:20 AM

The COVID-19 crisis is wake up call for every facet of society and we are all affected as consumer in the same bubble is not debated but the historical trends within society is time for dissection if we wish to avoid more pain. Medicare introduction provided more benefits than losses but the Private Doctors group especially through Dr Jodhi Menon raised many issues that now come home to roost. Representative bodies including RACGP and AMA were blindsided albeit in a democratic manner.
Systems of Health Care as in U.S. are proving to be most vulnerable and have the worst outcomes for societies and unfortunately Australia follows the same trajectory. Now is the time to change course when everyone’s attention is acutely focussed with fear of personal demise including General Practice as we understand it and expect of it.
Governments at all levels repeatedly in their self centred , short sighted and lobby prone goal setting ways have eroded the nations health care .


Dr Alice Helen Frampton   17/05/2020 9:05:10 AM

Thank you for this article, clearly describing all of the real issues and concerns that GP practice owners are facing at the moment. I for one haven’t had the time or energy to put this in writing due to all of the factors discussed.


Dr Peter JD Spafford   18/05/2020 11:41:27 AM

The major problem is the Government thinking Medicare is the full payment for a service provided. It is not. Burnt out - yup. Tele-health and patient rego are not going to save this practice. Borderline viable is now non viable. Thanks Harry.