With the launch date for new and expanded bulk billing incentives inching closer, the government is sticking with its story that the bulk billing rate will rise to 90% by 2030.
“We looked at every single general practice in the country. We have access to every dollar they bill, whether it’s billing Medicare or charging a gap fee to a patient,” Health Minister Mark Butler told the Conversation’s Michelle Grattan last week.
“We know that the funding we put on the table would mean that three quarters of practices are better off if they move to 100% bulk billing. The other quarter might not, but they’ll still be majority bulk billing. Most of them will still bulk bill pensioners and kids and so on. That’s how we got to our 90% figure,” he said.
But it’s looking highly unlikely to succeed.
Nearly half of GPs (46%) say they are not at all likely to switch to universal bulk billing, and 20% say they’re only slightly likely, according to a national Healthed poll of over 1400 GPs last month. Just 15% say they are very likely to change.
While more than 70% of polled GPs expect at least some improvement to the national bulk billing rate once the incentives take effect, they are less convinced it will make a significant difference to their practice’s financial viability or personal income.
From 1 November, the tripled bulk billing incentive will be expanded to all patients with a Medicare card, and practices that universally bulk bill will be eligible for a 12.5% Practice Incentive Program payment to be split evenly between GPs and practices.
Unsurprisingly, GPs in bulk billing practices are much more positive about the impact of the new incentives. Around one third believe the policy will significantly improve the national bulk billing rate, patient access to health care and the financial viability of their practice.
Those at private billing practices were most pessimistic, with less than 10% saying it will significantly improve these factors, Healthed’s survey found.
GPs from mixed billing practices made up 69% of survey respondents and only 8% of them think the new policies will significantly improve the financial viability of their practices, while 31% expect a slight improvement.
In terms of personal income, 28% of mixed billing GPs expect a slight improvement and 7% expect a significant improvement once the incentives come into force, while 65% expect no change.
The survey did not ask if GPs expected things to get worse, but several commented that universal bulk billing would significantly reduce their income, particularly those offering longer or more complex consultations—with the new incentives not seen as enough to offset the loss from private billing.
GP, researcher and past president of the RACGP Professor Karen Price says the survey data shows “very clearly that the government’s claims are likely to fail.”
“The sentiment of the GPs that I hear around the traps is that we are not going back… We are not going back to a government that we don’t trust,” Professor Price says.
“We want to do our job, and the way we do that is by, in most cases, mixed billing. So they’re certainly not going to get practices in middle-class areas or wealthy areas, switching over to full bulk billing, because that will be a pay cut,” she says.
A big part of the problem is that even if doctors are better off in the short term, they may not be a few years down the road as the rebate fails to keep up with indexation.
“Most doctors are working that out. And even if they get a temporary uplift, they figure that the government won’t keep to their word, and that in two years’ time those benefits will be eroded and we’re back under the sum again… because healthcare inflation sits above CPI inflation,” Professor Price says.
GP and health industry consultant Dr Joe Kosterich says practices that bulk bill more than 85-90% of patents will probably be slightly better off, whereas those that bulk bill 50% “would be going backwards.”
But he too argues that the benefits will be short-lived for most.
“Even for those that might be in front today, from next year that value starts to erode again. And each successive year, you’re going to get further and further behind in terms of where you would have been,” Dr Kosterich says.
For those who were bulk billing but stopped because it wasn’t sustainable, to backtrack now when they’ll probably have to go back in three, four or five years is a big risk, he adds.
“For doctors who do this, then next year, if they wanted to increase their fees by $2, $3, $5, they won’t be able to. They’ll have to take the 75-cent increase in rebate the government gives them.”
The Government claims city GPs who bulk bill every visit will earn over $5,300 more than their mixed billing counterparts for the same number of services under the new model—and $24,000 more in the case of rural GPs.
But Professor Price says these figures are based on a “maxed-out” formula that doesn’t reflect how many practices operate.
“The formula they’ve used is for a really intensive general practice, multiple appointments over five days—which is not how people work… For the large majority of mixed billing practices, it will depend upon what percentage you are already providing subsidised care to,” Professor Price says.
“The government is prioritising access and forgetting about quality, and GPs will not let go of quality.”
In last week’s interview, Minister Butler downplayed the government’s role. “We don’t operate a health system like the British do, for example, where there’s a very direct lever between the Government and what happens in healthcare settings like general practices. These are all private businesses.”
“We have to put in place a pricing or a funding mechanism that leads GPs themselves and practice owners to conclude that they’re better off and certainly their patients are better off if they move to bulk billing.”
However, Professor Price says rebates are a contract between the government and patients.
“If there’s inadequate insurance from the government to meet the cost of quality care, that’s firmly on the government. It has nothing to do with doctors,” she says.
Nevertheless, government promotions telling people they’ll only need their Medicare card to see a GP don’t frame it that way.
“They cannot speak for what GPs are going to do. Unless they have spoken to every single practice and every single doctor, they have no idea what individual practices and doctors will do. So for the government to come out and say, across the board, ‘all you’ll need is your Medicare card,’ is going to be demonstrably false,” Dr Kosterich says.
To combat that, practices will need to be organised and proactively explain to patients why they won’t be making changes, he adds.
Short term gain, long term risk
“Financially in our practice the income will improve but very wary of tying ourselves to a system when the renumeration increase each year will only be 1/2 to 1.5% when costs are going up at a much higher percentage.”
“Although we currently bulk bill all Medicare-rebateable consultations, we’ll likely vote on it. Some of my colleagues have been agitating for private billing for some time and don’t want to be locked into future bulk billing. Our concern is that if we sign up to it, we cannot trust the government to not freeze rebates again for another three decades.”
“Any advantage will be temporary as the consequent stranglehold on doctors’ fees will permit the government to completely fail to index rebates to CPI.”
“This is an attempt by government to gain greater financial control over doctors and will ultimately reduce patient choice and quality of care.”
“Can’t trust Medicare rebates to rise in line with CPI cost increases.”
“Don’t trust the government to keep pace with costs. It won’t match the income we now make.”
“Too worried about further restrictions government may implement on us if we register.”
“Universal bulk billing has been tried and failed. It will always fail to keep up with the CPI.”
“Rebates will not keep up with inflation. Once bitten twice shy to return to government control.”
“Too worried about further restrictions government may implement on us if we register.”
Different opinions within a practice
“Some GPs want to continue private billing and others happy to bulk bill. Creates a dilemma as it will cause conflict between colleagues if there is no consensus.”
“Other GP in my practice bulk bills a lot of patients so there is higher chance of us going bulkbilling even though it’s not my choice.”
“I would bulk bill, the owner thinks otherwise and makes this clear.”
Not financially viable
“I am not interested in universal bulk billing for my practice. This would still be nowhere near the private fees we charge. Medicare items are not commensurate with the value of general practice.”
“I can’t afford the major drop in income. This is especially the case given that I do a lot of long consultations and the way the incentive is structured will turbocharge the financial penalty for providing such care.”
“It is very challenging to run a good general practice on bulk billing alone, leading to patients being limited to amount of time spent with the doctor. Medicare rebate is inadequate.”
“Three doctors would stop practicing and retire because it is not viable financially.”
“Why would I forgo the extra $55 that we earn from non-HCC patients? This is the only time we are reimbursed appropriately for our hard work and subsidises the income we are prevented from earning by treating the other 80% of our patients at a heavily discounted price.”
“Still doesn’t come anywhere near covering an appropriate consultation cost, so we will continue to charge privately.”
“All doctors at the practice think that the restrictions for UBB are too difficult and we appreciate that some patients are able to pay the difference between UBB and the real cost of the consultation.”
“Crazy to change to UBB at least until we see how other practices that are ‘early adopters’ fare. Likely on principle that we won’t do it as it’s unlikely to compensate for the loss of private billing.”
“The calculation with this incentive for bulk billing is not enough for the business’ existence.”
“The increased funding is not sufficient to enable the practice to continue to provide quality care.”
“It is unlikely to improve GP incomes and is another reason graduates will not choose general practice.”
“It may well reduce the income for some practices, also it is a disincentive to give some patients long consultations that they sometimes need.”
Good for those who are already bulk billing most patients
“It will be a good choice for us as most of our patients are bulk billed.”
“Our clients already typically receive the BB incentive as they are predominately on a pension. The only advantage is that the Aus Government has been able to finally say to working non-pension Australians their health is worth the same as those who are pensioners.”
“From the brief discussions with the manager, financially this would be beneficial.”
“I am largely bulk billing already. The demographics mean that I will miss out if I don’t change.”
“In some areas it will probably be beneficial for patient access.”
Devalues or discourages entry into the profession
“Universal bulkbilling trivialises the profession. Anything provided for ‘free’ tends to be over-utilised and under-appreciated. GPs will be overloaded, worsening the waiting times.”
“What bureaucracy has made out as ‘revolutionary’ will degrade doctors and in particular the whole health system, demotivating doctors for their work and care of the patients.”
“It is unlikely to improve GP incomes and is another reason graduates will not choose general practice.”
Listen to expert interviews.
Click to open in a new tab
Browse the latest articles from Healthed.
Once you confirm you’ve read this article you can complete a Patient Case Review to earn 0.5 hours CPD in the Reviewing Performance (RP) category.
Select ‘Confirm & learn‘ when you have read this article in its entirety and you will be taken to begin your Patient Case Review.
