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Forty years on from the introduction of Medicare, is the term “bulk-billing” still relevant in today’s complex health care landscape?
When Medicare was introduced in 1984, it was designed to ensure that all Australians had access to affordable health care. At the time, the term “bulk-billing” referred to the manual collection of paper receipts to be sent in bulk to Medicare.
In the 40 years since, Medicare rebates have not kept pace with rising inflation or increasing costs of health care. As such, access to bulk-billing no longer guarantees access to affordable or equitable health care.
In a perspective published in the Medical Journal of Australia, Dr Michael Wright and Dr May Chin from the Royal Australian College of General Practitioners have posited that the term “bulk-billing” may no longer be relevant in today’s landscape of health policy reform.
“Although Medicare and its introduction of universal health care has been praised by many as one of Australia’s greatest policy achievements, there is acknowledgement that the current system needs reform,” Drs Wright and Chin note.
“Similarly, bulk-billing has been a term associated with the success of Medicare, but no longer provides an agreed or meaningful estimate of access to health services.”
How do we measure bulk-billing rates?
Despite the widespread use of the term, there is no standard definition or interpretation of the true rate of bulk-billing, with some organisations measuring bulk-billing rates by the percentage of invoices that are bulk billed, and some by the total number of clinics that will bulk bill a standard consultation.
“The varying definitions and interpretations demonstrate that the bulk-billing rate is neither consistently understood nor applied by the sector. And importantly, most general practitioners agree that there is neither a standardised nor an accepted definition of this metric,” Drs Wright and Chin note.
“Lack of understanding and misuse of the bulk-billing metric will be amplified by new pathways to access primary care, such as urgent care centres, which receive considerable block funding from both state and federal governments to subsidise attendances and yet bill Medicare for general practice item numbers allowing these to be provided without out-of-pocket cost — confusingly also described as bulk billed.”
High bulk-billing rates do not equal affordable health care
New research published in the Medical Journal of Australia has found out-of-pocket health care costs significantly impact Australians in remote regions, despite high rates of bulk billing.
Dr Karinna Saxby and Professor Yuting Zhang from the Melbourne Institute carried out a retrospective analysis of Medicare claims data at a Statistical Area 3 Level, which provides a standardised regional breakdown of the data.
The researchers found that while bulk-billing rates are generally high, there were considerable variations between regions, and significant out-of-pocket costs.
“It is reassuring that mean bulk-billing rates are higher in the most socio-economically disadvantaged regions (86%) than in the least disadvantaged regions (73%). However, mean out-of-pocket costs for non-bulk-billed services are considerable, do not vary substantially by area-level disadvantage, and are highest for people in remote areas,” Dr Saxby and Professor Zhang write.
The researchers note that the substantial out-of-pocket costs suggest inequitable access to health care across Australia, with those in remote and socio-economically disadvantaged areas spending larger proportions of their income on out-of-pocket fees for health care.
“In particular, our findings are concerning because Australians in rural and socio-economically disadvantaged areas have poorer health outcomes, lower access to and use of primary health care, and higher rates of potentially preventable hospitalisations than other Australians,” they write.
New metrics needed
In their perspective article, Drs Wright and Chin note that 75% of practices have moved away from bulk-billing towards a mixed or private billing model.
“The current MBS [Medicare Benefits Schedule] subsidies fail to cover the cost of delivering general practice care. As a result, bulk-billing patients is no longer a viable option in many settings, and general practitioners are increasingly forced to charge a private fee,” they write.
With rising costs and longer waits to see a GP, many people are delaying seeking GP care, which may have a flow on effect in other areas of the health system.
As the population ages, health care needs are becoming increasingly complex. The perspective authors argue that the focus on bulk-billing as the only measure of health care accessibility fails to capture the full story of Australia’s health care landscape.
“The rapid rise of chronic diseases, coupled with a growing and ageing population, is the fundamental challenge for the health system. A focus on the bulk-billing rate ignores these challenges and distracts from other more meaningful measures that can tell us so much more about the quality, outcomes and the equity of general practice in Australia,” Drs Wright and Chin state.
“The successful implementation of an effective model of care for the complex nature of 21st century general practice requires the use of modern and more meaningful metrics, and this involves relegating the term bulk-billing for such purposes to history.”
Read the perspective and research in the Medical Journal of Australia.
WRT Matthew the NHS UK pays GPs via capitation and the NHS is widely acknowledged to be in a disastrous state.
Of course the term bulk-billing should be ditched. I realised the significant danger in the specific and somewhat unique way the term is interpreted here in Australia, (mandated in the Medicare Act), almost the minute I got off the plane here from NZ. There the term was used to describe the bulk sending of rebate claims, (direct billing, if you like), to the Health Dept. but the providers were still entitled to charge a reasonable gap above the rebate. This usually varied a bit from area to area depending on the SES of the area. It allowed Drs to also consider the patients individual situations, and charge accordingly. Also the rebates were not the one size fits all as here under Medicare – skewed by the BB incentive which only applies to certain eligible patients – but the levels reflected this issue in a different way, by those for pensioners and card holders being higher than non-eligible, and child rebates were even higher.
It was not a perfect system either, but did provide a sensible and flexible version of ‘bulk billing’, which lasted quite a long time, until sadly, just like here, inadequate indexation killed it off, and not long after I arrived here in 1989, (ie, the mid 90s), they were forced to re-jig the system completely, and adopt the present system of bulk-funding via a type of capitation, plus gap fees at the practice discretion. However, these latter fees have been creeping up steadily for again…unbelievable though it may sound – govt again not indexing properly. Sound familiar..? Do they never learn..? No, they don’t, because it’s different people inheriting the problem all the time.
So, where to re our Aussie system..? Well, as the article illustrates, although this weird Medicare interpretation has allowed the system to limp on way past its best-by date, it has resulted in marked and increasing distortions, created by the discriminatory way the rebates are still one-size-fits-all, with only certain classes of patient being eligible for the so-called BB incentive, with the inevitable gap for those not eligible steadily increasing and woeful indexation behind it all, to the point we are hearing more and more are forgoing health care because of cost. The govts like to imply that’s the profession’s fault, when clearly it isn’t, but hey, why let the truth get in the way of a good story – especially one that they think ensures votes.
Ok, so what’s the solution..? Well dear people, it will come as no surprise to many of you that for actually decades, (and based on experience in two countries), I have advocated that GPs anyway, would best and most fairly be remunerated by a properly structured salary and career pathway, (a la public service – they do ok), funded in part by rolling over primary care Medicare money – boosted by some of the now absolutely necessary increase in funding – but not free at point of care, but contributed to by a modest, indexed, very affordable (by virtually all), user pays contribution at the desk. It’s simple really. Will it ever be adopted? – I believe eventually it will – it will have to be.
Perhaps all primary care should take place in federal government clinics. General practitioners are paid a salary to care for a defined patient list and/or geographical area. They do something like this in Denmark; a country which has high quality and quantity of life.
When I returned to Australia to work as an adult, having left Australia as a child before Medicare existed, as I commenced work in “bulk billing” practices I had to confirm what ‘bulk billing’ was.
On the Medicare website the description of ‘bulk billing’ was ‘when your doctor accepts the Medicare rebate as full payment’
This is misleading. Bulk billing is when the provider sends the Medicare invoice to Medicare in bulk, ie more than one patient at a time.
Not being able to legally charge ‘out of pocket’ expenses is a consequence of the action of bulk billing, not the action itself.
The way to bring Medicare into the 21st century is to allow practitioners to send the Medicare claim directly to Medicare and still be able to legally charge out- of – pocket expenses, such as is done in other jurisdictions such as New Zealand.
I spoken to a lawyer to discuss this who stated constitutional lawyers had concluded that this was not possible under the Constitution.
I cannot see a provision in Constitution thst prohibits this approach.
Such a legislative change would instantly make healthcare more affordable by reducing the immediate out of pocket expenses and would probably increase the bulk billing rate as it is easy for both patients and practices.
The term bulk-billing implies that healthcare is a uniform commodity, whilst in practice proper knowledge of the patient confirms their uniqueness and so the inappropriateness of care being driven by political ideology rather than a patient-centred approach. Noting that Australia’s life expectancy from birth has fallen again for the second year and dropped in global rankings, there is an urgent need find a better approach to ensuring the vitality and sustainability of General Practice, and reliance on bulk-billing to achieve this satisfies Einstein’s definition of insanity.
I see today a Clinic in Maryborough is offering $400,000-$600,000 for a GP .8 hour shifts. Must still be some $ in bulk billing clinics .
Perhaps the government should publish their expectation for fully qualified doctors for the following: hourly rate, paid leave entitlements such as annual leave or sick leave, similar conditions in the hospital doctors EBA, a comparison for qualified GP specialists vs hospital doctors- trainees or specialists.
Some calculations re how say four patients per hour, no cost to patient, might fund these minimum wages would be a reasonable request.
Provision of facilities and funding for urgent care clinics would highlight that this funding gap is significant and only being partly addressed for urgent care. GP services at no cost to patient should be government funded for including an appropriate wage for highly qualified staff.
Bulk billing assumes an out of date payment system that is in conflict with the required model of care is locked in. Well funded primary care with few access barriers is what we need to underpin the health system that Australia deserves.
The economic reality for general practice is that even with private billing, costs are moving faster than patients capacity to pay.