It seems that the Australian Government is constantly telling us that Bulk Billing rates are at an all-time high. The numbers they show certainly would seem to suggest that the rates are very high indeed. They claim over 86% GP bulk billing rates, however, the Royal Australian College of General Practitioners (RACGP) disputes this.

The RACGP claims the Government is fudging the numbers slightly, to make them appear more impressive. They claim that the statistics refer to the number of services bulk billed, not the number of patients. An important distinction.

While it is true that 86.1% of general practice services are bulk billed, the proportion of patients fully bulk billed (and who therefore face no out-of-pocket costs for care) is actually much lower

General Practice: Health of the Nation 2018 

According to the report from the RACGP, the number of GPs who fully bulk bill their patients, also known as universal bulk billing, is far lower. In fact, it’s barely a quarter of what the Government suggests, sitting at around 23%.

What is bulk billing?

Bulk billing is when a registered provider accepts the Medicare rebate as full payment of the services rendered to you, by them. This can be for consultations, investigations, procedures. In fact, anything in the MBS schedule can be bulk billed, but there are rules that apply.

What bulk billing isn’t

Despite popular belief, bulk billing is, unfortunately, not free. Bulk billing simply means no out of pocket costs. You are still paying for the consultation, just not directly. You are paying through your taxes via the Medicare levy. The more consultations are bulk billed, the higher the Medicare bill is, and that is passed ultimately on to you, the public.

There are some things which cannot be bulk billed

Medicare has a lot of rules, but there are 2 big ones that doctors must be aware of:

  1. For a medicare rebate to apply the patient (not just a relative or parent) must be present
  2. To bulk bill a patient, the Medicare rebate must be the only charge levied (with a few exceptions such as vaccinations)

Medicare does not cover extras such as dressings or vaccines. It also does not cover cosmetic medicine or anything related to work. For example, if you have been unwell, but are better, but your workplace tells you to get a medical certificate for absence from work, then Medicare will not pay for this (give you a rebate).

What happens if Medicare won’t give me a rebate?

This is where the Government figures start to look a little off, and what the RACGP is referring to. There are two options if you can’t be bulk billed. You either pay for the service, or the doctor (or clinic) provides it for free.

This happens more often than you might think and is a causing a very real problem for some clinics. Examples of things which can’t be bulk billed (or otherwise have a rebate):

  • Worker’s compensation
  • Work medicals
  • Commercial drivers licence medicals
  • Consultations for relatives without them being present
  • Telephone consultations or telehealth (other than a few specific exceptions)
  • Dressings
  • Vaccines

This presents a very real problem for bulk billing clinics. Do they charge for these things, or do they offer them for free?

The next problem is, if they charge for them, then they cannot bulk bill any associated service. A notable exception to this rule is vaccines.

Bulk billing is when your doctor bills Medicare directly and accepts the Medicare benefit as full payment for their service.

https://www.healthdirect.gov.au/bulk-billing-for-medical-services

An example – wound care

If you see your doctor for a wound consultation, for example, if they bulk bill the consultation, they cannot charge you for any dressings. No matter how it is dressed up, facility fee, dressing fee, associated items fee, miscellaneous, etc, it is still not allowed.

The numbers demonstrate the problem clearly. The following example assumes the doctors has bulk billed an item 23 (standard consultation) which gives the clinic approximately $15 income in service fees.

ExpensesIncome
Nurse time = $20$15
Dressings = $20
Dressing pack and other miscellaneous = $2
Total Expenses to the clinic = $42Total Income = $15

Total loss to the clinic = $27

So from one consultation, that clinic has lost $27.

The clinic and doctor now have a choice to make. They have 3 options. Do they absorb that cost? Do they charge the patient (or ask them to buy it themselves)? Or do they simply ask the patient to not come back because they are costing them money? If they choose to absorb the cost, and many will do, how long can they do this for?

Costs

The vast majority of the funding General Practice gets is directly from consultations with patients. This is the doctor’s income, of which a large portion goes to the practice to pay for running costs.

Clinic costs include business rates, insurance, utility bills, equipment, supplies, and of course staffing costs.

Doctor costs include the service fees they pay the clinic, equipment, medical indemnity insurance, training courses, and the other usual day to day expenses.

Costs are always rising, and unfortunately, Medicare rebates were frozen for a long time. There is a very large gap between the AMA suggested rates and Medicare rebates.

To provide high-quality care costs money. Money that many clinics just do not have. This is one of the main issues with bulk billing, it is very hard to earn enough income for clinics to run a successful business. Not just to turn a profit, like all businesses are trying to, but even just to stay afloat.

The effect of rising costs on practices

We are always hearing about GP clinics closing or the lack of clinics available. Just this week another story from ABC news about a town struggling with a shortage of GPs. It is stated that Katherine, a major town in the Northern Territory, has only 2 GPs for a population of 10000 patients.

The Federal Government — which is responsible for GP services in Australia — has not kept Medicare rebates for general practice in line with the rising costs of providing the service

NT Health Minister Natasha Fyles

Practices all over the country are struggling to maintain the services they can provide, and bulk billing doctors are struggling to provide the kind of care they want to.

The AMA’s Dr Parker agrees the Medicare rebate freeze has been strangling bush medical practices over the six years in had been in place.

“The lack of GPs puts significant pressure on the health system — doubles the number of avoidable admissions. And it’s a very significant cost to the territory of looking after people in remote areas,” he said.

ABC news

It should be noted that the practice in question in Northern Territory stated they now privately bills because they cannot provide the care their patients need whilst bulk billing.

How can some doctors offer bulk billing still?

There are some doctors, like me, who still offer bulk billing to some of our patients. Also known as Mixed Billing, this is effectively asking some patients to subsidise others so that we can maintain our services whilst offering bulk billing to those who need it.

There are still some doctors and clinics who offer bulk billing for all Medicare consultations. Some of those that do offer fantastic care and maintain an excellent level of service, but often with a huge sacrifice to their own personal income.

This is very noble, but perhaps not sustainable. To maintain a reasonable level of income they may have to work very long hours. How long until those doctors burn out, or leave for greener pastures?

This is having a potential impact on recruitment as well, with many practices struggling to recruit doctors in areas of need.

Options for doctors still bulk billing

In the environment of ever-increasing fees and reducing medicare rebates in real terms, there are 3 main options that doctors and clinics have to maintain bulk billing

  1. Accept a much lower income, effectively subsidising patient care with their own wallet
  2. Reduce the levels of care, for example, cut the length of appointments or have multiple appointments at the same time. The so-called ‘6-minute medicine’.
  3. Offer non-medicare services to subsidise bulk billing (The government conveniently ignores these stats)

How do shorter appointment help?

medicare rebates showing shorter appointment times generate more income
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The graph above demonstrates how medicare rebates realistically drop over the duration of a consultation. The longer the consultation lasts, the less the doctor and clinic earn per hour. The ‘sweet spot’, if you can call it that, is at the point where it just switches over into a new category.

As you can see though, by far the largest income per time spent is at the 6-minute mark (hence the phrase). By seeing as many patients as they can at this level the doctor can maximise their income and adjust for the loss of medicare rebates. However, as evidence shows, this often leads to poor care and is against current advice to make consultations longer. Long consultations provide better patient care. Your government however, as you can see, appears to prioritise shorter consultations.

More consultations = higher scrutiny

The Government appears to prioritise frequent, quick consultations. However, simultaneously, they are cracking down on doctors providing high numbers of services. There is increasing scrutiny via the PSR team, and now they have started mailing out letters cautioning doctors and other health providers about the services they are providing. Most of those receiving letters are not providing anywhere near dangerous levels of services, so one wonders what the reasoning could be.

The rules in the MBS about what a health provider can claim through medicare are complex. The MBS handbook (which is the guide to medicare benefits) is over 1300 pages long and is written in complex, difficult to understand, quasi-legal language.

There are often difficulties interpreting the MBS, and there are numerous reports from doctors facing Medicare audits that the AskMBS team, the go-to service for advice on the MBS (Medicare Benefits Schedule) often disagree with the PSR (Performance and Standards Review) team.

Doctors claim that the initial advice from AskMBS, which they follow in good-faith, is often overturned at the PSR level, potentially with disastrous consequences. Often the AskMBS team will even disagree with itself, giving different answers to the same question if asked again. The latest example of this is the latest controversy around billing physical items alongside mental health items.

This leads to many doctors ‘underbilling’. That is, not putting claims in for services they provide, out of fear of the audit process. This ultimately reduces rebates and of course, income if bulk billing. The other option is that the doctor ignores the mental health problem, for example, and focuses on the physical problem. This is leading to poor service.

How long can bulk billing last?

With costs ever-increasing, income ever-reducing, increasing scrutiny, longer hours and increased workload and stress, the question remains, how long can bulk billing really continue in its current form?

We do not know.

What we do know though, is whilst GPs continue to offer bulk billing at an all-time record high, there is absolutely zero incentive for the government to ever increase medicare rebates. There is no incentive for Medicare to adjust rebates to prioritise longer consultations, and there is no reason for them to ever allow copayments to ease the burden of large upfront payments for medical services.

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