In Medicare’s 40th year, it's time to revamp the measures of successful general practice, says new RACGP president Dr Michael Wright.
Medicare may have been praised as one of Australia’s greatest policy achievements, but it – and bulk billing as a measure of its success – needs reform, says RACGP president Dr Michael Wright in a coauthored opinion piece.
“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,” they said.
In the article published in the Medical Journal of Australia, and cowritten with May Chin, the pair argued that, 40 years on from Medicare’s invention, it was time to reassess the term inextricably linked to the scheme: bulk billing.
The bulk-billing rate has become synonymous with Medicare access, partly due to its use by politicians as proof of policy success.
“For example, in 2021, the former Minister for Health, the Hon Greg Hunt, used bulk-billing rates to demonstrate the then Coalition government’s firm commitment to Medicare, despite also being the government responsible for extending the freeze on the Medicare indexation,” said Wright and Chin.
“Similarly, the current Minister for Health, the Hon Mark Butler, also used increases in the bulk-billing rate as evidence of the success of the 2023 Budget initiatives to triple the bulk-billing incentives for Australians with concession cards and those aged under 16 years.”
But with the inability of Medicare rebates to keep pace with inflation, or the cost of providing care, the measure had lost its relevance to access.
Part of the problem, argued the pair, was the lack of a consistent definition.
The description generally used by politicians was the percentage of subsided services that were bulk billed, which offers little insight into the accessibility of general practice, said the authors.
In contrast, GP and practice management software company Cubiko looks at the percentage of invoices that are bulk billed.
“The varying definitions and interpretations demonstrate that the bulk-billing rate is neither consistently understood nor applied by the sector,” said Wright and Chin.
“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.”
Beyond the definition, the term ignored the true value of quality general practice, read the piece.
The article used the example of the mandatory bulk-billing policy for telehealth MBS items and for covid vaccines during the pandemic.
“At the peak of the pandemic, bulk billing reached an all-time high of 87.5%, with over eight in 10 general practice consultations provided without out-of-pocket costs,” they said.
“Although this was lauded as a win for the then Coalition government, a repercussion of the mandatory bulk-billing policy led to significant losses for many general practices, as they had to absorb the increased costs of delivering these services.
“Practices in rural and remote areas were also more likely to be disproportionately affected.
“In addition to financial losses, general practitioners also experienced increased levels of stress and burnout, and the sector is only now beginning to recover.”
Ultimately as bulk billing falls and out-of-pocket costs rise, patients are the ones copping the short end of the stick.
“The proportion of Australians who, due to cost, are delaying a visit to the general practitioner increased from to 7% in 2023 to 8.8% in 2024,” said the authors.
These delays were likely to impact the rest of the health system, namely the already under-pressure emergency departments, they wrote.
“Latest health data from New South Wales suggest that while ED use and wait times are increasing, the number of general practice visits per 100,000 population has dropped back to 2019 levels.
“Such a drop in general practice service numbers could have the perverse effect of increasing bulk-billing rates, reflected only due to the drop in privately billed consultations exceeding those which are bulk billed.
“This may be a politically expedient outcome but not an accurate reflection of access.”
Related
According to Dr Wright and Ms Chin, the current model of care forces GPs to charge private fees or to provide increasingly complex care without cost, to their detriment.
“This complexity requires a funding model that better supports the longer time spent with patients, something the current Medicare rebate structure devalues,” they said.
“Although the Albanese government provided a historic $6.1 billion investment into Medicare supporting the recommendations of the Strengthening Medicare Taskforce, the limiting of the 2023 increased in bulk-billing incentives to children aged under 16 years and to concession card-holders suggests that government support for bulk-billing is in fact not universal.”
Ultimately, we need better measures of general practice success that focus on quality, outcomes and equity and reflect its integral role in the success of the Australian health care system, said the pair.
