Bigger incentives may be enough to tempt some GPs and practices back to bulk billing. Just don’t forget the recent past.
Social media platforms and GP groups alike have been buzzing since the announcement to Medicare changes, with reactions ranging from elation to relief to “meh”.
There are those who currently bulk bill vulnerable groups, including children, who welcome this change as it aligns with their ethos and values and enables them to lose less money while providing good care.
Equally there are practices in which contractor doctors have been trying for months to push for a move to gap fees, who have concluded on the basis of this budget that their efforts and hopes will be dashed.
While many on the forums who’ve moved to private billing recognise this as a disincentive and have no intention of engaging, there are others on the cusp who are wondering if they ought to return to bulk billing some groups, especially if the gap fee they currently charge is around $20, similar to the new bulk billing incentive for city practices.
Since no two people work in identical situations and all have individual circumstances at home to offset their needs, I break it down like this for those who’ve asked me.
We have three main groups:
- Those who currently bulk bill vulnerable groups, e.g. low income earners and kids < 16
For these GPs, this will be a reprieve. They’re committed to bulk bill these groups for as long as possible and this measure helps them.
2. Those who, due to circumstances or choice, continue to bulk bill everyone
There are those among us who work in very low SES areas, often in salaried roles, with the most vulnerable groups unable to afford any gap fees – refugees, people with complex mental health conditions, people with addiction etc. – who already provide complex care at bulk billing rates. The change will make the biggest difference for this group of clinics, especially if their patients only see them.
For them the tripled BBI, together with voluntary patient enrolment and 60-minute consultations, will have a significant effect in terms of care and also boost funding to the clinic. The difference will obviously be greater in rural and remote areas compared to metropolitan ones.
3. Those slowly moving to private billing with low gaps for low income earners
The last group is the trickiest as several factors are in play, including location; the BBI for city GPs is around $20, whereas in rural and remote areas it comes close to the current AMA recommended fee – for the latter it may be tempting to returning bulk billing.
If you were to ask me what I think about reversing course on bulk billing, my response would be: How much do you trust the government to have GPs’ backs this time, given events of the last decade or more?
How much time and effort has it taken you to get to this point where you are now charging most people, and they know they have to pay?”
And if you’re in a metro areas: Is $61 enough to cover clinic costs over your current gap fees?
Essentially, if you’ve managed to do the hard work, and now have patients who pay a gap, no matter how small, what do you stand to gain and lose by returning to bulk billing?
In rural/remote areas, where the rebate plus BBI now comes close to the current standard fee, coupled with shortages of healthcare workers, this might be a much easier decision.
In the end we must all do what we feel we must to stay afloat and to continue to serve the populations that trust us to, and these changes will help in no small way – even if they are not quite enough in metropolitan areas and still fall well short of the current costs of running a business.
My concerns as they stand are the following.
These changes do not actually come into effect until November, in six months’ time, and for urban GPs still fall well short of the costs of running a business.
By offering these crumbs, the government is shifting the responsibility back onto GPs to provide bulk billing, and not only for the groups who will benefit the most. Health Minister Mark Butler is on record as saying he hopes the revenue generated from these measures will enable GPs to consider not charging other groups as well.
By promising these changes in this budget, the government seems to have now done just enough to raise hope again about bulk billing, during an unprecedented cost of living crisis, without actually doing enough.
They’ve done enough that the practices committed to bulk billing all or most will continue to limp along, better than before but still struggling, and many that have switched to charging low gap fees reluctantly may be tempted to return to bulk billing.
What about the next time there is a rebate freeze, or lack of indexation?
Each of you knows your own circumstances and your demographic best. Whatever you choose, remember what has happened in the past decade to bring us here: a decade of grinding down rebates and scapegoating GPs who protest by charging gaps.
History is the best determiner of future outcomes and so when asked for my opinion by friends in group 3 above, this is what I tell them: to choose what is best for them, but to be mindful of what they are signing up for if they do end up returning to bulk billing, now that we know not only how bad it can get, but also how good it can be to disengage from bulk billing and to be able to charge gap fees.
Dr Imaan Joshi is a Sydney GP; she tweets @imaanjoshi.
