Issue 3 / 2 February 2015

NEW research reveals surprising findings about which patients are most likely to be bulk-billed by GPs, as the backlash continues against the federal government’s plans to impose a copayment.

The MJA study examined factors influencing GP bulk-billing, finding practices with just one or two doctors were more likely to bulk-bill than those with more practitioners, defying the stereotype of big corporate practices driving high bulk-billing rates. (1)

Also unexpectedly, patients with private health insurance were more likely to be bulk-billed than patients without cover, after adjusting for income and presence of a chronic disease.

The study was based on an online survey of more than 2000 Australians, with 71% saying they were bulk-billed at their last GP visit.

Unsurprisingly, bulk-billing was more likely for concession card holders, patients with chronic diseases and low-income earners. It was less likely for people in regional areas, which the authors put down to less price competition.

There was no association between bulk-billing and the duration of a GP visit, which the authors noted was also against the conventional wisdom that bulk-billed consultations tended to be shorter.

The authors concluded that “additional copayments would be novel for many patients … [and] could cause difficulties for a substantial proportion of those individuals”.

The findings come after the federal government backed down on its earlier plans to reduce the Medicare rebate for some consultations. The new Health Minister Sussan Ley said she supported a “modest co-payment”, and is holding firm on plans to introduce a $5 GP copayment on 1 July “for those who have the capacity to pay” and to freeze the indexation of Medicare rebates. (2)

Professor Mark Harris, executive director of the Centre for Primary Health Care and Equity at the University of NSW, told MJA InSight the study raised grave concerns for the future of small general practices.

“There are a lot of smaller practices dealing with relatively low-income patients; often overseas trained doctors working as solo GPs in disadvantaged areas such as parts of western Sydney”, he said.
“If patients are strongly affected by the introduction of copayments and stop coming, that will have a dramatic effect on small practices, that have the least capacity to absorb a sudden reduction in income.”

Professor Harris was cautious about drawing inferences from the small positive association that was found between private health insurance and bulk-billing as the study did not model how variables might interact and have an impact on the likelihood of being bulk-billed, such as income, chronic disease and private health insurance.

The study authors postulated that private health insurance holders were likely to be healthier individuals, and might be more willing to discriminate between GPs on the basis of bulk-billing.

Dr Frank Jones, the president of the Royal Australian College of General Practitioners, said this finding rang true to his own experience.

“It’s surprising when patients you have bulk-billed for many years ask to be privately referred for a knee replacement or other procedure”, he said.

Asked whether patients who could afford private health cover should be expected to make a GP copayment, Dr Jones said it was “a very difficult topic”.

“Certainly GPs are going to be under immense pressure to charge patients if the federal government succeeds in its plans [to introduce a copayment]”, he said.

Dr Jones warned that while some patients may be able to afford to make a contribution, it could have unforseen negative consequences.

“If you introduce a price signal, patients are likely to present later, with more advanced illnesses, and are more likely to end up requiring care in hospital,” he said.

Professor Harris also warned that attempts to impose copayments could have a “perverse effect”.

“You’re really rolling the dice”, he said.

Even if concession card holders were exempt from copayments, there were many “working poor”, particularly in rural areas, who would be disadvantaged, he said.

If safeguards were put in place so that everyone with a chronic disease or who lived in a remote area was bulk-billed, Professor Harris said the system would likely become “intolerably complicated, for a pretty small gain”.

Professor Harris said that efforts to reduce the health budget may be better directed at containing inappropriate imaging and pathology.

Associate Professor Lucie Walters, president of the Australian College of Rural and Remote Medicine, told MJA InSight people in rural areas already suffered from reduced access to primary care, and copayments could have “different and confounding impacts on patients in rural and remote communities”.


1. MJA 2015; 202: 87-90
2. Sussan Ley 2015; “Government to consult on Medicare reform” 16 January


Should GPs include financial decision-making capacity in assessments of older patients?
  • Yes – it can impact on health (39%, 49 Votes)
  • No – not a GP’s role (34%, 43 Votes)
  • Maybe – with good parameters (27%, 34 Votes)

Total Voters: 126

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13 thoughts on “Perverse copayment effects

  1. Anne Paton says:

    Preventative primary health care is essential in reducing health care costs, this is not rocket science. Patients attending ED/hospitals costs the health budget more. GP clinic services cost the health budget significantly less and aid in reducing the likelhood of the patient attending the costly hosptial system. Making GP clinics more affordable to ALL communities, having well funded servcies within this primary health care setting has a win win scenario for both the patient and the governments health budget.

    Cost saving needs to be directed towards the territary system but mainly at the non direct patient care services.

  2. Sue Ieraci says:

    A potential flaw in the study appears to be that the sampling was distributed by age according to the percentage of the population, not according to the percentage of people VISITING GPs in each age band. Therefore, the vast majority surveyed were aged under 60 years, with an under-representation of the elderly compared with the population of patients. I suspect there is a cohort of older people who have always held private health insurance but who have chronic illness and need to visit the GP regularly, but do not necessarily have much disposable income.

  3. dr nerida finch says:

    The copayment will disadvantage practices in low socioeconomic areas as many of their patients are working poor who will be reluctant to pay even a modest copayment. Often they have (or say they have ) no cash at all and most doctors will not refuse to see them (can we medicolegally refuse?) 

     I am also worried about the patients we currently bulk bill for dressings (sometimes daily or second daily if needed) or INR s, we have been informed by medicare we cannot charge for dressings or other supplies. At present the rebate  will just cover costs and we do it as a service to our elderly and infirm patients , but if the rebate goes down, we will no longer be able to supply this service. The district nurses are already overloaded  and cannot absorb large numbers of new patients .I think this is a great service we provide and would like to continue but we will not do it if we are going backwards.

    Bear in mind there is no longer a nurse payment.

  4. shambleton@amamember says:

    Well I agree with most of the findings of the authors but NOT their assertion that there is no link between bulk billing and shorter GP consultations.  Their survey was not powered to answer this question.  The time frame asked was < 5 minutes, 5-19 minutes,  23-39 minutes….   So there is no way they could examine what happens between 6 and 10 minutes – the bit the government was recently interested in.

  5. Peter Bradley says:

    I have always felt – and will continue to do so till the day I die – that it is fundamantally wrong to expect any service provider, to have to run a mini means test on each and every patient every time they are seen, yet this imposition has always been imposed.  There may have been some justification historically, back when physicians were able to live in a strata far above their patients, but this is certainly no longer the case.

    If it is the philosophy of an enlightened society, and a majority believe it is, that certain disavantaged groups should have either free, or certainly access with a lower financial barrier to that service, then it is encumbent on that society, via its government, to provide suitably tiered subsidies to allow that.  The povider should be able to expect the same reward for their time whatever the patient descriptor, and not be blythely expected to prop up the welfare system out of their own pockets as we are now.  It’s really that simple.  If co-payments are considered detrimental to society’s health, then subsidies have to be raised significantly and indexed to the patient’s socio-economic status.

  6. Leeton Hocking says:

    A number of specialist colleagues of mine repeatedly state that the medicare rebate covers your costs only. In order to run a business and make some form of profit, you have to charge above your costs. I believe this applies to general practice as well. It’s about time we all admitted it. To provide quality medicine, we have to charge.

    All the hysteria about patients waiting to get sicker etc. are blown out of proportion. I for one will not continue to bulk bill as the default in future.


  7. Dr Brian Morton says:

    The conclusions drawn from this study make me question an appropriate evaluation based on the findings. What is the hypothesis of the link with Private Health Insurance? The inferences are not only unexplained but not nuanced to the potential implications. Is it that those with private health insurance are more mobile or is it that if they can pay for insurance then they can afford a copayment or should we continue to speculate. There is very little here for the coming winter for General Practice only the reassurance that GPs allocate time to medical need.


  8. Dr Louis Fenelon says:

    Is this the medical profession commenting here again? Not one mention of the fact that the largest financial waste in the delivery of health care in Australia is not associated with direct patient care? Not one comment that the system of fee for service, primary care in Australia that is being poisoned by polititians and bureaucrats is the benchmark of financial and outcome efficiency in public health?

    When are we going to stop basing what we represent on some misguided, non-medical and arbitrary bunch of restrictions, rules and exclaimers cooked up by non-doctors? Have we no respect for our profession? We are better than Medicare. I seriously fail to understand why all of the voice pieces for our profession appear obligated to the manipulation of faceless people getting paid a lot more than us and doing NOTHING to actually benefit the health of Australians. If you want to cut the cost of health care delivery in this country, then stop looking at general practice as the killing field. It is more than insulting. It’s just plain stupid.

  9. Lawrence Tay says:

    Patient demographics and socio-economic status is the key to bulk billing rate.

    Forget about the small-number practice vs large-number practice, corporate vs private practice etc.

    If the town is retirement town, forget about private billings.

    If the town is relatively self-contained and self-sustained and is improving both macro and microeconomics, then regardless how the setting of the practices, doctors private bills and patients happy to pay.

    not rocket science.

    no need any special researches etc.

  10. Lilon Bandler says:

    Talking about “a price signal” is to fail to recognise that simple market economics are not at work here.  Healthcare, including a visit to the GP, is not a discretionary purchase, like a dress or a computer, or an accountant or cleaner.  People may reduce their visits to GPs – but as Dr Col says “they don’t always make good choices” – because they shouldn’t have to.  Yes – there are the Worried Well, but there are also the Unworried Unwell – and we’re the ones who have the skills to distinguish between them.  We can teach our patients to make judgements about their need for medical attention.  However we should be there (and financially available) as a fall back position when they’re not sure.

  11. colin case says:

    The whole point of applying a price signal is to reduce patient attendances at the GP surgery.  It makes people think before they attend – and they don’t always make good choices.  In remote ares like where I work, bulk-billing  supplements my hospital income which does not include anything for being on call 24/7 or for overtime.  It barely covers that anyway because this is a small one doctor town with a very low average income. People who are on low incomes will still get to see the doctor for a while because they have the option of presenting to the free hospital emergency department where I will still see them.  Emergency departments are the wrong place to go for general practice problems.  This price signal compounded by pegging the rebate while costs continue to rise for the next four years will mean the private practice becomes financially not viable and that means my town will lose their doctor. 

  12. Philip Dawson says:

    Price signals to reduce use are a blunt instrument. What the federal Government is attempting to do is to reduce health expenditure because it believes too much is being spent. It has to believe this because it has a deficit it wants to fix. The figures speak otherwise. Australia’s health spending is around 8% of GDP, towards the bottom of industrialised nations. What is apporpriate is to reduce spending on inappropriate and futile treatments and encounters. This can’t be done with a blunt instrument. If (for argument’s sake) 1/3 of patients access the health system approprately, 1/3 underutilise it (eg, diabetics who won’t come for their checks) and 1/3 overuse it (the healthy anxious who get too many tests and procedures; drug adicted doctor shoppers; doctors doing too may tests and treatments for fear of missing something or being sued, or (heaven forbid) entrepreneual doctors using the system to make extra money). How should public policy respond? We don’t want a price signal to discourage the appropriate and under users from coming. It would be reasonable to maintain the option of bulk-billing for health care card holders, those with chronic disease, and those with  serious illness requiring frequent visits, and make all others ineligible for bulk-billng, but set a fixed “gap payment”. Does anyone have any other ideas?

  13. Department of Health Victoria Clinicians Health Channel says:

    More of the same. An extremely long bow is drawn to say that a copayment will mean the end of civilization. Dr Jones says “”If you introduce a price signal, patients are likely to present later, with more advanced illnesses, and are more likely to end up requiring care in hospital,” he said.”

    Based on what? So privately insured patients who insist on bulk-billing will refuse to pay and say “out of principle I’m not going to pay $5 and I’ll let myself get sick…. Out of principle”. There is actually an article in this issue of the MJA which looks at these sort of extreme claims

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