If you recently received an email or text from your GP clinic saying they can no longer routinely bulk bill even concession cardholders, you’re not alone.
As Guardian Australia revealed this year, policy experts believe the high rates of bulk billing reported by the previous government were artificially inflated by noncompliant billing practices, and the statistics don’t reflect the number of people saying it is hard, or even impossible, to find a bulk-billing doctor.
The federal health minister, Mark Butler, acknowledged the difficulty in finding a bulk-billing doctor, saying, “Primary care is in its worst shape since Medicare began.”
So what is going on here?
Why can’t I find a bulk-billing doctor?
GPs who bulk bill charge what is called the “Medicare schedule fee” for appointments and services they provide, and this fee is set by the government. The GP is then directly reimbursed by the government for the service and the patient doesn’t pay anything.
But increasingly, GPs say the amount they are reimbursed is not enough to cover their costs, so they need to charge an additional amount.
The amount GPs receive from Medicare for bulk-billed services has barely changed since 2013. The government pays less than half of what the Australian Medical Association (AMA) recommends for a short consultation.
If GP clinics offer mixed billing, how do they decide which patients to bulk bill?
Dr John Saul, a rural GP and president of the AMA’s Tasmania branch, says this is “entirely discretionary” and there is no set limit on how many patients can be bulk billed.
“A lot of guidelines for clinics will say a patient at a private practice with regular employment should be charged a full private fee,” he says.
“I will usually find myself bulk billing my private patients who are palliative – which I do at a financial loss – because if someone is involving me in the final six months of their life and I can make that easier for them and their families, I will.
“But you just cannot afford to bulk bill everyone across the board.”
Some clinics will bulk bill concession cardholders, or may choose to bulk bill follow-up appointments for patients that need an issue addressed across multiple visits. It can be helpful to make your GP aware of any financial difficulties you are facing.
Most doctors are paid very well – is it true that GP practices can’t make ends meet?
As well as staff salaries, GPs need to cover facilities, rent and insurance, as well as increasing costs for new technologies and medicines, says Dr Bruce Willett, the vice president of the Royal Australian College of General Practitioners. The pandemic added costs, such as setting up outdoor vaccination clinics, purchasing PPE and adopting telehealth technology. Relying on the Medicare rebate alone will not cover these costs, he says.
A spokesman for the Australian Association of Practice Management says general industry data shows wages account for about 40% of expenditure for a practice, rent approximately 14%, equipment purchases approximately 7%, utilities about 3%. Other costs, including depreciation, comprise the remainder.
According to the staffing agency Medical Recruitment: “Based on a salary survey … a full-time general practitioner on average earns between $200,000 and $350,000 per annum.
But salaries vary depending on location, demographics of the area, the size of the clinic, whether the GP owns the clinic, hours worked, the types of services and number of services per hour offered, and other factors including the proportion of patients who are bulk billed.
For smaller practices that bulk bill and which also have to pay for rent, equipment, dressings and staff including nurses and administrative workers, doctors say it is unsustainable to make ends meet by bulk billing entirely.
Usually patient numbers are higher in well-established bulk-billing practices, which is why GP “super clinics” with multiple locations, many appointments and numerous doctors tend to be more common than small practices that bulk bill. The more patients seen, the more received from the government. The care offered by these super clinics may be less personal.
Saul says GPs who run largely private billing clinics generally “do very well”. He has owned private clinics alongside colleagues for much of his career.
Is the former Coalition government really to blame?
Butler has said: “The former government froze the Medicare rebate for six years, ripping billions of dollars out of primary care and causing gap fees to skyrocket.”
He has asked his department to examine bulk-billing data to obtain a “more complete and accurate picture” of rates, and has ordered a review into Medicare and access to affordable care.
However, it was actually the Labor government that introduced a “Medicare rebate freeze” in 2013 as part of what was supposed to be a temporary $664m budget savings measure.
When the Coalition was elected in 2014, it kept the freeze in place.
Saul says while the new government has only just been elected and he will give it time to improve the state of general practice, “so far all we have seen is the 1.6% rebate rise which was on the cards for some time, while politicians have seen their wages increase by 2.75%”.
“There’s a lot of talk about changes to occur and reviews, and I’m planning to look for those in 12 months’ time,” he says. “But plenty needs to be done now, including some emergency funding immediately for general practice.”
Would increasing the Medicare rebate increase bulk-billing rates?
While for most GP appointments the rebate did rise on 1 July this year, it was by 1.6%, an amount Willett described as “miserly”.
“This equates to 65 cents for a standard 20-minute consult – far short of the most recent inflation figure of 6.1%,” he said.
“So, some practices have little option but to pass the cost on to patients by moving to a private or mixed-billing model to avoid running into the red and being forced to close – a scenario in which no one wins.”
Dr Margaret Faux, a health system lawyer, is concerned further rebate rises will do little to reduce costs to patients.
Her PhD research found that because Medicare billing was so confusing, many clinics were claiming the Medicare rebate for themselves and then charging the patient a separate gap. That means government statistics will show the patient was bulk billed even though they paid a separate fee and were out-of-pocket.
What should happen is that either the patient is bulk billed and pays no money, or they are charged a private fee, a portion of which is rebated by Medicare directly into the patient’s bank account.
Faux says until widespread wrongful billing practices are fixed, increasing the rebate will do little to ease patient out-of-pocket costs, and GPs will just keep that additional rebate rather than passing it on to consumers.
Like Faux, the Consumers Health Forum [CHF] is also concerned “that there is some evidence that a rebate increase might also be inflationary,” its CEO, Leanne Wells, says.
CHF wants to see more sweeping reform to primary care involving funding reforms that shift the system away from fee-for-service to open up better access to a comprehensive set of services in general practice in addition to those provided by GPs such as pharmacists, nurses, dieticians and social workers.
