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Being able to afford health care is a pressing issue for many Australians. And encouraging GPs to bulk bill is one measure the government is taking to ease the strain.
So what would it take for GPs to bulk bill everyone? In our recent paper, we calculated this is possible and affordable, given the current health budget.
But we show recent incentives for GPs to bulk bill aren’t enough to get us there.
Instead, we need to adjust health policies to increase bulk-billing rates and to make our health system more sustainable.
How do the incentives work?
In recent years, the government has introduced various incentives to try and encourage GPs to bulk bill (so patients pay nothing out-of-pocket).
The most recent has been the “triple bulk-billing incentives” or “triple bonus” for short. These have been in place since November 2023.
Under these incentives, GPs in metropolitan areas are paid a A$20.65 bonus if they bulk bill concession card holders or children under 16 years. GPs in rural and remote areas are paid $31.35-$39.65 extra. These bonus payments are in addition to regular Medicare rebates GPs receive.
But when we looked at whether these latest incentives are likely to work to boost bulk billing, we found a city-country divide.
City GPs may not be convinced
We worked out the triple bonus will not help most people in metropolitan areas.
That’s because in these areas the bonus is much lower than what patients currently pay out-of-pocket. In other words, if GPs did bulk bill these groups, their income would be lower than what they could have charged. So the bonus wouldn’t be enough incentive for them to bulk bill.
For example, we found in greater Melbourne, the average out-of-pocket costs for a non-bulk billed GP visit is about $30-$56 depending on the suburb. This is much higher than the $20.65 triple bonus amount in metropolitan regions. We see similar patterns across all metropolitan areas.
But country GPs may be swayed
The picture is different in rural and remote areas. Here, the average out-of-pocket cost for a non-bulk billed GP visit varies substantially – around $28-52 in rural regions and $32-123 in remote areas. The highest cost on the mainland was $79 but GP visits on Lord Howe Island were the most expensive overall, at $123.
For patients living in areas where their actual payment is less than the bonus amount, the incentive does help. In other words, it would be financially advantageous for GPs to bulk bill these patients, but not where the out-of-pocket costs are higher than the bonus.
Our online map shows where GPs are most likely to bulk bill. The map below shows how out-of-pocket costs vary around Australia.
How about bulk billing for all?
The picture is a little more complex when we start talking about bulk billing all GP visits – regardless of location or patients’ concession card status.
We worked out this would cost about $950 million a year for all GP services, or $700 million a year for face-to-face GP consultations.
This is within reach under the current budget, especially for face-to-face GP consultations.
The government has earmarked $3.5 billion over five years for the “triple bonus” incentives. That’s $700 million a year.
We can afford to, but should we?
Introducing free GP visits for all would require careful consideration, as it would encourage more GP visits.
This might be a good thing, particularly if people had previously skipped beneficial care due to high costs. However, it may encourage more people to see their GP unnecessarily, taking away limited resources from those who really need them. This could ultimately increase wait times for everyone.
So providing free GP visits for all may not be efficient or sustainable, even if it’s within the budget.
But paying more than $50 for a GP visit, as many do, seems too expensive and also makes the health-care system less efficient.
That’s because primary care is often considered high-value and preventive care. So if people can’t afford to go to the GP, it can lead to more expensive hospital and emergency room costs down the track.
So we need to strike a balance to make primary care more affordable and sustainable.
How do we strike a balance?
One, concession card holders and children should get free primary care regardless of where they live. This would allow more equitable care to populations who need health care the most. Bulk bulling children is a long-term investment, which may delay onset of diseases, and prevent intergenerational poverty and poor health.
Two, the government could also provide free primary care to all people in rural and remote areas. It can do this by lowering the triple bonus to match what GPs currently charge. Over time, GPs and the government can evaluate and negotiate fair prices for GPs to charge. This can be adjusted in line with inflation and other measures.
Three, the government can increase Medicare rebates (the amount Medicare pays a doctor for a GP visit) so patients not covered above only pay about $20-30 a visit. We consider this an affordable amount that will not result in more use of primary care than necessary.
Four, the government can design a policy to reduce unnecessary GP visits that take away limited GP time from high-need patients. For example, patients currently need to see GPs to get referral letters although they already have an established specialist for their ongoing chronic conditions.
Five, the government can provide GPs funding needed to improve patient outcomes and reward GPs who provide high-quality preventive care. The current fee-for-service funding model hurts good doctors who keep their patients healthy because doctors are not paid if their patients do not come back.
Yuting Zhang is a Professor of Health Economics at The University of Melbourne.
Karinna Saxby is a Research Fellow at the Melbourne Institute of Applied Economic and Social Research, The University of Melbourne.
This article is republished from The Conversation under a Creative Commons license. Read the original article.
given the various governments’ disregard for the whole field of general practice, (including a ‘freeze’ on rebates under the last Coalition government) GPs should be reluctant to put their remuneration in the hands of the bureaucracy. Rebates are already at least 45% behind a fair or reasonable level for a GP to make a living and grudging adjustments on an irregular basis do not sound workable.
Nothing wrong with re-inventing the wheel! For goodness sake, Scotton and Deeble had all patients, with the possible exception of the indigent, paying as gap of 15% of the schedule fee. That would be $15 on top of an $85 rebate for a 15 minute standard consultation, about what it should have been if annually adjusted from the 1990s.
The architects of Medicare were alert to the risk of Edelsten/corporate practice of turning a single treatment episode into multiples and all the other malfeasance I saw as a Member of the original Professional Services Review Tribunal. Also it was to make patients think about need without debarring them from attending.
The reason everyone should pay a small amount is to stop the rampant profiteering of those who discredit their and our Profession and whose behaviour has caused the diminution of rebates over the years. [I was also a Menber of the Medicare Benefits Advisory Committee. Unable to put the genie back in the bottle, both parties allowed the capping of the rebate pool]. Hence or problems. A compulsory Gap would level the playing field.
Governments will not get a universal switch to bulk billing (outside of making it mandatory) unless they address the following.
It is worse than the govt playing catch up ever since the first 15% obligatory discount to bulk bill in the mid 1980s. Ever since, they have increased the Medicare rebate at much less than half the CPI. So now the rebate is more like 45% of what a reasonable fee is for our services.
I ran the figures a year before I closed my community practice in December 2021, where I was only bulk billing DVA patients, and I did not have too many of them. At the time my non concession out of pocket payment for a standard consultation was around the $40 mark and for a concession card holder $24. If I had bulk billed everyone, my total take home salary would have been a bit less than that paid to driver of the Cleanaway Truck who took away my garbage, and my hourly rate compared to the Cleanaway driver would have been a lot less, given that as a self employed GP I needed to work many more hours than the truck driver to generate that income, not to mention lack of long service leave, holiday pay, sick pay, employer provided workers compensation, sponsored superannuation etc, etc. Needless to say, I did not bulk bill, let the quality of my service speak for itself, set my own fees and attracted a clientele prepared to pay for it, and was basically totally run off my feet all of the time. That is not to say that I did not have socially disadvantaged people, people with a need for frequent attendances etc, who received discounts down as far as bulk billing on occasion, but that was at my discretion, not an expected right from the patient.
The average co-pay for mental health care by GPs in the national mental health survey is $10 per service and $16 per patient. But i think there are a lot of people benefiting from the narrative of greedy GPs, less than a vaccination at a pharmacist, and way less than an interaction with a nurse at the walk-in clinic.
I don’t think this is an issue around money, it’s an issue around narrative. Perhaps we really are looking at the issue that every system needs a scapegoat? (https://www.medicalrepublic.com.au/every-system-needs-a-scapegoat-mental-health-in-the-swamp/18332)
“Two, the government could also provide free primary care to all people in rural and remote areas. It can do this by lowering the triple bonus to match what GPs currently charge. Over time, GPs and the government can evaluate and negotiate fair prices for GPs to charge. This can be adjusted in line with inflation and other measures”.
This is advice that could only come from salaried academics unexposed to the economic realities of running a business .
We have seen nothing in the last thirty years that would suggest Government is capable of valuing General Practice .
Where the patients rebate (plus loading) approximates the value of the service , the rebate plus loading may be acceptable to the medical practitioner providing service.
Cost is a barrier to access should be weighted far more highly than concerns about excessive use of GP services. Delays in accessing GPs will almost certainly result in higher costs downstream (missed early diagnosis, more hospital service use).
And of course we can afford it, it’s just that governments choose not to. The recent submarine boondoogles demonstrate that money can be found; they would just rather fritter it away on bad defence deals.
It seems such low hanging fruit for a political candidate to run on 100% of GP fees to be paid by the government with realistic yearly adjustments based on AMA recommendations
Basically the government lost the opportunity to get GPs to switch to bulk billing at the outset of Medicare when they only offered 85% of the schedule fee as reimbursement citing savings in administration costs to practices. Most of us in General Practice at the time saw it as a devaluation of our skills. They have been playing catch up ever since.