What we stand to lose with a bulk-billing revival

For better or for worse, a bulk-billing revival is upon us. As announced in the 2023–2024 federal Budget, $3.5 billion of funding will be directed towards increasing the rebate for standard GP consultations, but only if these consultations are bulk billed and only for certain groups.

Eligible patients include those aged under 16 years and holders of Commonwealth concession cards, which is estimated to be over 11 million Australians. As such, bulk-billing, which many thought was on its last legs, will remain firmly embedded within the primary care landscape, at both the policy roundtable and the clinic reception desk.

Although a high bulk-billing rate remains an aspiration for the government, and directly benefits patients as it removes any financial barrier to accessing health care, in recent years it has grown to be an almost offensive term to GPs as current rebates are so low they don’t cover operational costs, let alone a decent wage.

The funding injection to general practice is a welcome change from a decade of disappointing Budget announcements that have gradually eroded the financial viability and overall morale within general practice. It is most definitely a step in the right direction as it is worlds apart from last year’s funding increase for GPs that saw the bulk-billing incentive in metropolitan areas increased by just five cents.

However, many remain more cautious than optimistic. It is important to consider how these changes can meaningfully improve access to primary health care for Australians, and if the funding will ensure the sustainability of general practice as an essential health service that nine out of ten people will need during an average year.

A promising health budget, but not enough to undo a decade of neglect

The most obvious issue with the funding increase is that in some areas it is simply not enough. For metropolitan clinics, even with the bulk-billing incentive, the rebate for a standard consult still falls considerably short, by around $25, of the Australian Medical Association’s recommended fee of $86 — a fee that has been indexed with inflation.

In the most remote regions, it will come close, with the standard rebate and increased bulk-billing incentive amounting to around $80. It can therefore be reasonably expected that in certain areas this will lead to meaningful change — and a well deserved pay increase for GPs working in challenging and often isolated environments.

However, for clinics in other regions, this means that even with the increased rebates, GPs are still expected to personally subsidise the cost of health care for their patients. This is deeply problematic as it is financially unsustainable if large numbers of patients are bulk billed, which is the end goal of targeted funding for bulk-billing. It is this funding shortfall that has been reported as one of the reasons why GPs are quitting in droves and why young doctors are no longer interested in pursuing the specialty.

Some have already declared that for these reasons they will continue to privately bill, as clinic owner and GP Dr Sarah Lewis points out “altruism is not a sustainable business model”. Dr Lewis is not wrong, and by giving bulk-billing a conditional lifeline without committing to increasing the rebates for standard consults for all, the tiresome battle for GPs to be paid appropriately and not be expected to personally subsidise health care will continue.

Millions will benefit, but the majority will see increasing out-of-pocket costs

The significant increase in bulk-billing incentives confirms that the standard rebates fall well short of the true cost of the service provided. Thus, bulk-billing for those without eligibility for the incentive payment remains at a level that GP clinics cannot rely on to stay financially afloat and keep their doors open.

The maths is simple, if approximately 11 million people will benefit from bulk-billing incentives, that leaves around 15 million people who won’t. For most Australians, bulk-billing rates will continue to decline and out-of-pocket costs will likely stay on their current trajectory and only increase with time. Bulk-billing may now, paradoxically, be limiting universal health care.

Are the incentives targeted to the right patients?

The eligibility criteria for the incentive are tied to many factors, including age and income, and patients aged under 16 years will be automatically eligible – for children and their primary carers this is good news if it translates to improved access to health services with no out-of-pocket expenses.

Bulk-billing incentives will also be available to holders of Commonwealth concession cards. For people aged over 65 years, there are fairly generous eligibility criteria, which don’t include an asset test. This is not to say that this group is undeserving of bulk-billing, but it does not seem fair. Younger generations are drawing a very short straw here, especially at a time where cost of living pressures are being felt most by working families, housing affordability has reached crisis point, and student loans are about to be indexed at a record rate. Unless there are expanded eligibility criteria for bulk-billing or a commitment to increase general rebates, younger generations, who have the financial odds stacked against them, also stand to lose affordable access to basic health care.

Ensuring the longevity of general practice

For a GP working in a high turnover clinic and practising “6-minute medicine”, the bulk-billing incentive will be a sizeable windfall. For the GP working with complex patients, dealing with a large volume of mental health or women’s health, which usually require longer consultations, the increase in funding will be significantly diluted or non-existent if the patient is not voluntarily enrolled at the clinic.

Given all of these pitfalls, it is hard to see how medical graduates and doctors in training will be more likely to pursue a career in general practice, especially doctors with overwhelming student loans. It may potentially act as a further deterrent, given bulk-billing is synonymous with being underpaid, and the government, while rightly increasing funding, is directing a significant proportion of that funding towards bulk billed services alone.

Where to from here?

Bulk-billing for certain groups has been given a lifeline at the eleventh hour, but the funding announcement is fraught with complexities. Only time will tell if these measures will provide relief for the ailing primary care system, or whether in the long term they will do more harm than good due to the lack of universal investment and promoting unsustainable billing practices that encourage short consultation and do little to improve GP trainee numbers. For GPs who accept a reduced fee for their services by bulk billing, continued wage stagnation that does not keep up with inflation will likely ensue.

Although an investment in general practice is a welcome change and hopefully a sign of better days ahead, for now it has served struggling GPs with another set of hurdles to navigate.

Dr Alisha Dorrigan is a Sydney-based GP.

The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.

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