Is it time to retire the term “bulk-billing”?

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.