Tasmania has some of the lowest bulk-billing rates in the country – and they’re getting worse, a nationwide investigation by Guardian Australia reveals.
Data obtained exclusively by Guardian Australia shows the percentage of patients who did not have to pay any fee to see their GP in a given year and were entirely bulk billed. Bulk billing is when the full cost of a consultation is paid for by Medicare.
The data set also shows a separate figure of the total percentage of all GP services delivered in an electorate that were bulk billed. During an appointment, a patient might get one service bulk billed, such as a vaccination, but pay out of pocket for a separate service, such as an extended consult.
The rates of GP patients being fully bulk billed are low in affluent, metropolitan electorates such as Warringah and Wentworth in Sydney, as well as the electorate of Canberra. Experts say this likely represents the ability of wealthier communities to pay for visits.
But the bulk-billing rate is also low in several less affluent, regional and rural electorates, including Dawson in central Queensland, Eden-Monaro and Shortland in New South Wales, Indi in north-east Victoria, as well as Tasmania’s Franklin, Clark and Bass.
“This probably reflects doctor shortage and reduced competitive pressure to bulk bill,” said Charles Maskell-Knight, a health funding analyst and former senior public servant in the health department.
The problem is particularly pronounced in the Tasmanian electorates of Clark and Franklin, in and near Hobart, where only about 37% of people had all of their GP appointments bulk billed in the 2021-22 financial year, well below the national average. That has dropped from 41% two years earlier.
You can find bulk-billing data for your electorate in this map:
‘He was sick for months’
As Guardian Australia previously revealed, residents of the Glamorgan-Spring Bay council on Tasmania’s east coast are being charged to prop up bulk-billed GP services as part of their council rates. Yet with a median age of 56 and a high proportion of retirees, many are chronically ill and struggling to make ends meet. The median weekly household income in eastern Tasmania is $854, far short of the national median of $1,438.
When Grant Jenkins from Bichenot on Tasmania’s east coast became ill after being let go from his job in hospitality last year, he avoided going to the doctor because he couldn’t afford the $70 out-of-pocket cost of a visit. He hoped the illness would go away on its own.
“But he was sick for months, and months and months,” said his wife, Nicole Jenkins.
Jenkins had no choice but to pay for weekly visits on top of blood tests, bringing the total to $130 a week over eight weeks, until he was diagnosed with glandular fever.
The couple, who were living off Nicole’s income from contract shift work at the local hotel, were only able to afford the added expense by eating one meal a day.
“I never let the kids go without but we’d miss breakfast and lunch and have tea,” she said. Her husband was not able to access any bulk-billing GPs because there are none in the area.
A collective of healthcare practitioners on Tasmania’s east coast has conducted a survey of more than 100 residents. The results, provided to Guardian Australia, found 40% said it was not easy for them to travel to Launceston or Hobart for health appointments.
Almost a quarter said it was “never” easy to see a physiotherapist, occupational therapist, dietician or podiatrist, while 45% said their healthcare provider did not fully understand or even know what other treatments and appointments they were having.
What can be done?
The federal government’s Strengthening Medicare taskforce report, published this month, found that a system of GPs working in isolation and delivering episodic care without coordination with other health professionals is failing the most chronically ill. The taskforce recommended a move to team-based, multidisciplinary care.
A report from thinktank the Grattan Institute, published in December, found most GPs have steady profit margins and that simply increasing Medicare rebates for GPs will not entice them to rural and remote areas or address patchy access to healthcare, nor help with coordination of care among different providers.
“Australia has many GPs, with more on the way,” the report said. “And general practices have survived the four-year Medicare Benefits Schedule freeze battered but intact, with higher take-home pay and steady profit margins”.
The report said other health professionals – including nurse practitioners, physiotherapists and physician assistants – should be allowed to bill a broader range of consultations and treatments to Medicare, and that requiring GP approval before Medicare rebates can be applied for consultations by other health professionals is adding to fragmented and delayed care.
This type of model did exist nationally in the 1970s, emerging out of the battle for universal healthcare under the Whitlam government. The community health program involved GPs, allied and mental health professionals, and nurses, and it existed in every state and territory. But it was abolished by subsequent governments, and states were left to prop up community healthcare alone. Most absorbed community health services into the acute care system.
Victoria was the only state to retain a comprehensive network of 24 community health services across metropolitan and rural areas, funded by a mix of state and federal money. One of the largest, Cohealth, provides “one-stop shop” access to GPs, nurses, dental care, mental health care, homelessness support, alcohol and drug treatment, and allied health services from 30 sites across Melbourne’s city centre, and the northern and western suburbs.
Richard Di Natale, who is Cohealth’s health policy adviser and a public health doctor and former leader of the Greens, is leading a project to bring this model to east Tasmania. Partnering with councils and GPs, and using funds from a federal government grant, the group will work with the community to establish a health clinic.
Di Natale said once established the community clinic would be a litmus test for how the federal government manages an increasingly ageing and chronically ill population, and responds to the needs of rural, regional and disadvantaged populations.
“It is very clear there is a real appetite to try and build this multidisciplinary, community health model in this community,” Di Natale said. “What we want to do is demonstrate just how effective this can be, and eventually expand the model potentially throughout Tasmania and into other states.”
Not all states are struggling
Tasmania stands out as a particularly tough state to find affordable care. Maskell-Knight said the data showed overall there were 40 electorates throughout Australia where more than three-quarters of the population were bulk billed for all their GP visits in 2021-22, with many of these in the most populous states.
NSW is home to nine of the top 10 electorates for bulk billing. These include Blaxland, Chifley, Fowler and Werriwa, where more than 96% of patients always had their GP appointments bulk-billed.
You can search the data to see the rates for your area here:
Maskell-Knight said the figures showed it was “still possible to offer a high level of bulk billing while maintaining a viable practice”.
“This calls into question demands from some doctor groups for a doubling of the Medicare benefits schedule rebate to restore the viability of general practice,” he said.
“Such a policy change would cost billions of dollars, much of which would flow to doctors who are already bulk billing most of their patients.
“But there are other options than GP-led care, and just paying more money to GPs to encourage GPs to bulk bill.”
But Bruce Willett, the vice-president of the Royal Australian College of General Practitioners, who has been working at his practice in south-east Queensland for almost three decades, said many GPs were paying a “compassion tax” by continuing to bulk bill. He said he maintains “relatively high bulk billing rates”.
“I could decide not to bulk bill any of my patients and I would still be fully booked,” he said. “I have a four to six week waiting list, which is not something I enjoy as some patients are dealing with chronic health issues.
“You don’t have that kind of waiting time and continue to offer a discounted service unless you really care about your patients. It’s not a market-driven decision to keep bulk billing at all – it’s driven by the care I have for patients I’ve been seeing for 20 to 30 years.”
Willett said reforms were sorely needed, including lifting Medicare rebates so that doctors get more back from the government for bulk billing their patients. Any moves towards integrated community healthcare had to be “built around GP practices”, he said.
“In the UK, there has been too much priority placed on access to care rather than continuity of care, and there are lots of complaints now being made about how impossible it is to see a GP there, and about how you’re referred to a pharmacist or nurse instead,” Willett said.
“People really want to see their GP for the continuity of care, and if people are seeing a number of different people and practitioners, it leads to duplication and confusion.”
How has bulk billing changed in your area? Contact melissa.davey@theguardian.com if you have a story to share
Notes
Guardian Australia requested bulk-billing data from Services Australia by electorate, which was provided by the Department of Health and combined with census data for our analysis. You can download the original data here.
