Thoughts on bulk billing

My recollection about the initial Medicare arrangements in respect of doctor visits was as follows: patients were expected to contribute 15 per cent of the cost and the MBS reimbursement covered the remaining 85 per cent.  A doctor could decide to waive the 15 per cent but would be out of pocket for this amount.  More could also be charged (above the 15 per cent). There may have been some arrangements for concessional card holders (a much smaller number and proportion than today), but I’m not sure.

Given that many citizens are always keen on free stuff, the promotion of bulk billing at some stage became an objective of government policy – even when Tony Abbott was the Health Minister and certainly under Labor.

What I was surprised to discover is that there is now an additional fee paid to doctors who bulk bill, in addition to the standard MBS.  It is currently around $7 in the cities (apart from Hobart) and around $10 in rural and regional areas plus Tasmania (I wondered who swung that one, just another example of Tasmania being a mendicant state.)

I understand that the extent of bulk-billing among GPs has increased in recent times and now sits around 80 per cent of all consultations.  And 70 per cent of patients who are bulk-billed (not number of consultations) do not hold a concessional card.  (I would need to check these figures – I’m not sure they sound right.)

There is a real issue about the impact of bulk billing in terms of distorting the nature of general practice medicine – something that the government has not mentioned much, but something on which they should have data – eg. lots of repeat short visits of the same patients, over-servicing those who don’t have much else to do.

The government seems to have made a complete hash of explaining the impact of the sort-of imposed co-payment – Dutton seemed to imply yesterday that doctors could (should?) keep bulk-billing in certain instances.  But presumably they lose the $7/$10 bulk-billing incentive fee (I guess this will be removed from the MBS) as well as the $5 lower standard MBS fee.  That looks like a relatively big loss per consult for many GPs.

Capping the number of non bulk-billed consultations at 10 visits per year also looks quite complicated.  Who tracks the number, particularly if you don’t always go to the same GP practice?  Presumably this will be done through swiping your Medicare card.   Is the GP then reimbursed at the new MBS rate after the maximum number of visits is reached?

And why would the government think that the savings associated with the imposition of the co-payment should be directed to another government boondoggle – the Medical Research Future Fund?  If all the savings are going to be used up, how does this make Medicare more sustainable?

And please, please spare us the drivel about Australia being good at medical research (where is the evidence of that?); that there are job multiplier effects; and that there will be cost savings down the track because of all the discoveries that will be made (and will be shared with the rest of the world).  More like business class travel for medical researchers.

I think if I had my druthers, this is what I would do:

  • Exempt concession card holders and children from the co-payment initially;
  • Evaluate the impact of the co-payment on GP/pathology/imaging use (surely the government believes in collecting evidence?) for those impacted;
  • Use the savings to pay down the deficit and make this the messaging;
  • Drop the idea of the Medical Research Future Fund or scale it down drastically and without using any savings from the Medicare co-payment.

The reality is that the real waste is in the hospitals, particularly in terms of undertaking completely pointless and/or unnecessary procedures, but the states are in the driving seat when it comes to doing something in this space.

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48 Responses to Thoughts on bulk billing

  1. kae

    Medical Research Future Fund?

    Yeah. Call it what it is.

    Next time the ALP/Greens get in it will become the “Faaaark! We’re broke, what money can we steal to prop us up for a bit longer?” fund.

  2. James

    The reality is that the real waste is in the hospitals, particularly in terms of undertaking completely pointless and/or unnecessary procedures

    Yeah, this is where the red meat is, but none of the politicians and medical professionals would admit.

    Because it’s free, let’s have this scan and that scan just in case.

    If nothing is found, let’s make it a yearly exercise, with more follow up.

    No one is ruling out anything, just to be on the safe side.

    No one can point a finger to say this is waste, as sick people are poor people are voting people.

  3. candy

    And please, please spare us the drivel about Australia being good at medical research

    Are you sure about that Judith? – some recent achievements:

    Gardasil vaccine (protect against cervical cancer)
    Research baby’s sleeping position and SIDS.
    Link between folic acid intake in preventing serious birth defects
    Helicobacter pylori bacterium linked to stomach ulcers.

  4. Fibro

    A couple of points:

    1) Why doesn’t the coalition tell the truth? Because the electorate frankly is too stupid to understand the truth and there would be a political football they will never live down. The GP frequent flyer brigade I suggest are actually well known numbers, and the $7 charge will take alot of them away, just without the political pain.
    2) The MRFF is a complete no brainer to be in consolidated revenue within 3 years. I would put the house on it.

  5. Token

    And please, please spare us the drivel about Australia being good at medical research

    You need a really sharp venture capital industry to be able to achieve that.

    Australia is too small and the piddling amounts the government will throw into the pot do not change that. Add to that the fact the history of government of picking winners.

  6. Adam D

    Its not that hard is it? Introduce a $5 fee across the board exempt for children. Concession card holders are the ones who are at the doctors far too regularly. $5 is nothing for any income to see a doctor.

    Repeat process on anything that is free (thanks to taxpayers). BoltA reported one medical centre in sydneys west dropped by 50% because of the announcement. I wonder why the medical lobby are furious with this idea…….

  7. Adam D

    Are you sure about that Judith? – some recent achievements:

    Gardasil vaccine (protect against cervical cancer)
    Research baby’s sleeping position and SIDS.
    Link between folic acid intake in preventing serious birth defects
    Helicobacter pylori bacterium linked to stomach ulcers.

    How did we achieve this wothout a 20 billion medical fund???

  8. dianeh

    Are blood tests/pathology included in the bulk bill figures? I have never had to fork out for those, whereas I do for each doctor visit, any scans/xrays?

    As they are all bulk billed, that would push the figure right up.

    Also, my doctor bulk bills kids but not their parents, unless they are concession card holder. However I do know after speaking with him that he will bulk bill patients that are in need through extreme circumstances find it difficult to afford the up front fee.

    I think the co pay is a good idea. But I am not too keen on the research fund. It looks to me like another pot of money to be wasted, hijacked or use to buy special interest groups. If the business conditions were right and we had the right incentives and people, medical research would come here of its own accord. The question is why doesnt it? Throwing money at a sector of the economy hasnt worked any other time the govt tried it (insulation, cars, other manufacturing, eduction).

  9. Dr Faustus

    surely the government believes in collecting evidence?

    I’m sure the Government has an evidence-based justification for its ‘world class’ Medical Research Future Fund. It’s just odd that it hasn’t enunciated the evidence further than its lofty intention to “double our nation’s investment in finding cures for disease and better medical treatments so we can all live healthier and happier lives”.

    And who doesn’t want that?

  10. Gab

    Gardasil vaccine

    was not researched and developed in Australia. The only part played by Australia was in its expedited approval by the TGA.

  11. candy

    I thought Ian Frazer was Aust of the Year for Gardasil, Gab. I know he hails from Scotland though.

  12. Gab

    Headlines in the newspapers may have led you to believe that, Candy but in reality Frazer and Jian Zhou investigated a way to form non-infectious virus-like particles (VLPs). However, these VLPs assembled poorly and did not have the same structure as infectious HPV.

  13. sabrina

    Medical research and research in general is collaborative effort and take long time to come to fruition. Lot of the HPV work was done in Australia (UQ). The other unsung hero is Jian Zhou.
    Judith’s view is her own view.

  14. Gab

    Lot of the HPV work was done in Australia (UQ)

    A lot may have been done but no results forthcoming. And I already mentioned Zhou.

  15. Dave Owen

    One of the main problems is the risk of litigation. A relative worked in one of the major metropolitan hospitals and he was constantly told by his superiors to do this test or that. He remarked to one of his superiors in one case that the diagnosis was correct and the consultant agreed but he added that, in our litigious society, the lawyers are ever ready to pounce and the extra tests were to prevent successful litigation. He was told they must practice “defensive medicine” and this means doing very test under the sun. Blame the lawyers. There are far too many in parliament to change this system but it is seriously adding to the costs of treatment and I might add to the time it takes to treat someone.

  16. I’m sure the Government has an evidence-based justification excuse for its ‘world class’ Medical Research Future Fund.

    “Evidence-based” means having an agenda and finding facts to support it. It appears to have all the hallmarks of scientific process except that it is in fact anything but. You go to where the evidence leads, not the other way around. It’s political-speak and should be treated with the contempt it deserves.

  17. And please, please spare us the drivel about Australia being good at medical research (where is the evidence of that?); that there are job multiplier effects; and that there will be cost savings down the track because of all the discoveries that will be made (and will be shared with the rest of the world). More like business class travel for medical researchers.

    Emphatically agreed. One Barry Marshall swallowing germs doesn’t make a summer.

    I think if I had my druthers, this is what I would do:

    ■Exempt concession card holders and children from the co-payment initially;
    ■Evaluate the impact of the co-payment on GP/pathology/imaging use (surely the government believes in collecting evidence?) for those impacted;
    ■Use the savings to pay down the deficit and make this the messaging;
    ■Drop the idea of the Medical Research Future Fund or scale it down drastically and without using any savings from the Medicare co-payment.
    The reality is that the real waste is in the hospitals, particularly in terms of undertaking completely pointless and/or unnecessary procedures, but the states are in the driving seat when it comes to doing something in this space.

    Loud chorus of Amen.

  18. Senile Old Guy

    Are blood tests/pathology included in the bulk bill figures? I have never had to fork out for those, whereas I do for each doctor visit, any scans/xrays?

    It depends but I can’t tell you what it depends on. Sometimes I pay; sometimes I don’t. There must be a schedule somewhere.

  19. Ant

    Abbott should have campaigned on “If you like your economy wrecking Medicare entitlements you can keep your economy wrecking Medicare entitlements.”

    Worked for Obama.

  20. Dr Faustus

    My apologies BW, I have demonstrated that sarcasm is the lowest form of wit.

    The reality is exactly as you say. The MRFF is a policy thought bubble, no planning, no plans, no business case – and, as a new government spending initiative, it is as inconsistent as the PPL in terms of managing the structural deficit. Only not quite as expensive as the NBN.

    I can only imagine it is a cunning political landmine laid out for Labor and the Greens, clearly marked “Danger: Cunning Political Landmine”.

  21. Simon

    I thought the ulcer thing was done by a maverick doctor who was told by the research community he was mad.
    The easy fix is to comp children, workers and their spouses 100% coverage and then create generalized private health coverage for all those receiving government payments, the price will be deducted from their payments mandatorily so you can hold back on any increase in those payments for a few years. It will also stop the punishment of private health funds and be welcomed by public and private hospitals as an income boost since they will now be receiving paying customers for the majority of their work.

  22. Bruce J

    Whether your blood/pathology tests are bulk billed outside hospital depends entirely on the boxes your doctor ticks/crosses on your referral, in particular the one labelled “bulk bill”. I have 6 monthly blood tests and so far the doctor’s record is about 50/50 over the last 7 years.

  23. Chris

    Its not that hard is it? Introduce a $5 fee across the board exempt for children. Concession card holders are the ones who are at the doctors far too regularly. $5 is nothing for any income to see a doctor.

    Do you have any actual evidence that its the concessional card holders that are seeing the doctors too much? And the $5 is just the start – what if they need to have blood/pathology tests as well?

    Are blood tests/pathology included in the bulk bill figures? I have never had to fork out for those, whereas I do for each doctor visit, any scans/xrays?

    Yes, blood tests/pathology are included in the bulk bill figures. What the government doesn’t seem to have considered is that many of the pathology sites currently do not handle any cash – its just one, maybe two nurses on a very small site. The extra cost of having to have handle cash plus probably now an extra person to provide security will be non trivial.

    One of the main problems is the risk of litigation. A relative worked in one of the major metropolitan hospitals and he was constantly told by his superiors to do this test or that.

    Not so long ago I ended up in emergency of a major public hospital. The doctors were pretty sure it was just a really bad migraine and it was only after my mother kept insisting they do more tests (ended up with a CAT scan I think) that they realised I had bleed in my brain. Without that test there’s a reasonable chance I would have ended up dead and on the “oops” list. Sometimes fear of litigation is a good thing.

    Judith – I reckon if the government had proposed what you suggest in your post especially around exempting children and concessional card holders then the backlash would have been significantly less. After all the majority of people are used to having some sort of co-payment anyway but at the same time there’s a lot of people who don’t want to see anyone who needs to see a doctor or have a pathology test not to be able to because of lack of money (no matter what that reason may be).

  24. notafan

    lack of money

    No-one in Australia really lacks money, it is a matter of making different choices on how you spend your money. If it is a genuine emergency you can go to hospital. Even being harsh if it is a choice between say eating two minute noodles and going to the doctors or eating lasagne and not going to the doctors if you really need to go, you go.
    And as Mr Abbott keeps pointing out abolish the carbon tax, energy bills go down on average $550, pensioners keep their carbon compensation can afford to go to the doctor.

  25. Pedro

    All good points Judith.

    An opthamologist friend was recently telling me about the inefficiencies he is forced to adopt when he does his public days because the hospital needs it done that way so the hospital can recover the costs from the Govt (which one I’m not sure).

    I’m in favour of a co-payment with appropriate carve-outs.

    “No-one in Australia really lacks money.” Jeez, that’s stupid. Obviously there are people who are struggling with lack of money. “Even being harsh if it is a choice between say eating two minute noodles and going to the doctors or eating lasagne” That’s not harsh, it’s fucked.

  26. dan

    The reality is that the real waste is in the hospitals

    No…
    I did a general practice rotation.
    From memory it seemed like a huge proportion of consultations were simply a waste of everyone’s time and money. Anything that was actually ‘done’ like vaccines could have been done by someone else. Everyone was either popping in for their weekly chat, god knows why, or showing up for one of the following:
    -medical certificate
    -paperwork related to insurance especially travel insurance (we worked next door to a hotel)
    -coughs and colds
    It’s true that a fever and aches and pains can be a sign of some grave disease, and as a parent that’s indeed what happened to my child, but in the end it was us who decided things were frightening enough for lights and sirens to be summoned.
    Locally they are to a large extent lifestyle doctors, predominantly but not exclusively female, who work a day or two per week, don’t really offer any continuity of care and can’t make any decisions, so they send people home with a sheaf of pathology, radiology forms and prescriptions and tell the patients to get them done or filled if they think they need to in a week’s time.
    That’s my two cents anyway.

  27. sabrina

    Blame the lawyers. There are far too many in parliament to change this system but it is seriously adding to the costs of treatment

    Absolutely true, and the accountants – they have infested all layers of the society.

  28. john malpas

    I am faily sure that in the past there was, for a while, supposed to be s $5 co payment to GPs. But the public wouldn’t cough up.

  29. newchum

    how will they know when you reach 10 visits ?
    you will need to sign up for ehealth.

  30. notafan

    I should have been clearer,the chronically ill are exempt. Everybody here who is a PR or a citizen gets welfare. If you really can’t afford food, say because you had to pay a bill Sallies or Vinnies will give you a voucher or food from the food bank. No-one in Australia starves.
    Doctors can waive the fee if they wish, some might even agree for people to pay next time they come in. Even in my retail shop I do that.
    You really think many people don’t have $7 at least once a pension pay day for discretionary spending?

  31. How I would transition to free(ish) market for GPs:

    “Rebate” the scheduled fee directly to the GP, but let them charge whatever amount they want above it, on the condition that every $2 above scheduled fee, they lose $1 of rebate. Then leave the scheduled fee as it is, and let inflation wear it down over the years until we have a [mostly] free market for GPs. You might need to play with the numbers a bit (which I just plucked out of my arse), but if you started with the right numbers, you’d notice very little difference initially, and the rebate would simply disappear over time.

    Hospitals are another matter… I don’t even know where to start there. Terje once suggested some type of HECS style funding, which is an excellent idea in some ways, but very bad in others (namely, that some would never pay it back anyway; and, I fear it would ultimately be settled out of their estate by a future greedy government – ie, it would result in de-facto death duties, which would in turn require gift taxes, etc…)

  32. dan

    He remarked to one of his superiors in one case that the diagnosis was correct and the consultant agreed but he added that, in our litigious society, the lawyers are ever ready to pounce and the extra tests were to prevent successful litigation. He was told they must practice “defensive medicine” and this means doing very test under the sun. Blame the lawyers.

    I really think this is way exaggerated. In my practice the only defensive thing I do is extraordinarily careful documentation. You know if you order an unnecessary CT scan and the patient gets cancer it’s just as bad, people can be badly injured during angiograms, and so on. In fact we are discouraged from previously “routine” practices such as abdominal X-rays for children’s constipation because the little information we may receive is outweighed by the risks of radiation.

    Low rates of test-ordering are not associated with litigation. By far the biggest contributor to litigation risk is poor communication. Just need to explain to the patient why a long list of investigations are more trouble than they are worth.

    People aren’t successfully sued for failing to go on a fishing expedition. They are when doctors are accused of not ordering completely obvious and routine tests that would be considered imperative in the situation by one’s peers.

  33. Firstly, I was surprised by the apparent high rate of bulk billing. In the NT and Kimberley it is hard to find a bulk billing Dr. Even pensioners are not automatically bulk billed, it is up to the discretion of the Dr. My GP bulk bills me because old age has given me some chronic ailments but even then I still rarely see a doctor more than 3 times a year. I usually just go for a check up and renewal of scripts.
    What also surprises me is the number of times children are taken to a doctor. I was raised in an era where the doctor wasn’t called unless it was an emergency. Mothers handled everything from measles, to skin sores, scratches, sprains etc. Now apparently children need medical attention for a cold. I would say this would account for part of the blow out in Drs visits.
    As for the super fund, I’m all for it. Disease prevention and cure is going to be one of the big cost savers of the future. And speaking of inventions, wasn’t the bionic ear an Australian one?

  34. johanna

    Big Nana, apparently the NT and the ACT have the lowest rates of bulk billing.

    In the ACT, I’m guessing it is because the population is pretty affluent and can easily afford to pay a bit extra.

    Don’t know about the NT though. Perhaps some factors might be a shortage of dcotors, plus higher costs for running a practice in remote locations?

  35. Aristogeiton

    Big Nana
    #1320262, posted on May 26, 2014 at 6:01 pm
    [...]
    Now apparently children need medical attention for a cold.

    They don’t, but it’s a great way to avoid responsibility for your parenting decisions.

    If you are the same commenter who posts on The Drum, then I will add that I always enjoy your contributions.

  36. Boambee John

    “Everyone was either popping in for their weekly chat, god knows why, ”

    A passing thought – it might be cheaper for the lonely OAPs to drop in on a doctor occasionally for a chat than to let the social workers’ mafia get them into their clutches. Before you know it there are case workers assigned, regular meetings to discuss progress, house visits (with associated travel costs and allowances for the social workers) and the rest of the bureaucratic waste that is inevitable once a government department is involved in anything.

    To expand slightly on my earlier comment on the other thread, a better version of the scheme would have been to impose a co-payment (including in emergency departments and hospital wards) for people presenting with problems caused by poor lifestyle choices such as smoking, excessive alcohol consumption, abuse of dangerous (illegal) drugs, and injuries caused by dangerous activities such as driving at excessive speed, and double payment for speeding while drunk.

    Something like $20 per doctor visit (including specialists) and emergency department visits, and $40 per day in a hospital ward would be a useful start. It would start the movement towards making Medicare a genuine insurance scheme, with payments linked to risk factors.

    The left are keen on “sin” taxes, this would be one aimed specifically at sinners, not the whole community, and hard for them to oppose.

  37. Chris

    I should have been clearer,the chronically ill are exempt.

    That appears not to be true. The only item which is exempt from the co-payment is the charge once per year for making the chronic illness management plan. All other visits during the year will still by default attract the co-payment.

    http://www.news.com.au/national/who-pays-the-7-gp-fee-the-prime-minister-and-the-treasurer-dont-understand-their-own-policy/story-fncynjr2-1226926025926

    how will they know when you reach 10 visits ?
    you will need to sign up for ehealth.

    The government already track all your visits through your medicare number which you give to the GP or when you submit your medicare rebate form. That’s how the GP gets paid by the government. And they also track total out of pocket spending anyway in case you hit the out of pocket expense limits at which point they start to cover more of the gap between the scheduled fee and what you actually get charged by the health provider.

  38. mundi

    I am surprised by the high amount of people who say they have no bulk bill doctors around. In SE QLD it can be hard to find a random doctor who *doesn’t* bulk bill.

    Infact in SE QLD you can have GP’s do house calls – all totally bulk billed.

    Just goes to show you that the market prices set by the government seem a little to high.

    (Yes you get what you pay for: but if you know your ailment and simply need a doctor for prescription – you might as well house call a free GP).

  39. siltstone

    Spot on Dan. Old codger I knew went down to the Doctor’s every week to meet his mates and talk about their respective coloured pills (he who has more pills wins) – a nice social outing on the taxpayers expense.

  40. hzhousewife

    And they also track total out of pocket spending anyway in case you hit the out of pocket expense limits at which point they start to cover more of the gap between the scheduled fee and what you actually get charged by the health provider.

    We hit our limits recently due to major surgeries and get a nice statement from Medicare telling how many hundreds of dollars have been paid on our behalf for procedures. Most people never hit the limits and don’t know this happens.

  41. Petros

    Dan I disagree with your comments about ordering tests. My doctor friends admit to ordering lots of tests to cover their arses. Maybe with children it’s different but with adults it’s nothing to do scans and blood tests. Many people seem to expect it, too. I feel the lawyers are a large part of the problem. To err is human.

  42. Grigory M

    The government already track all your visits through your medicare number which you give to the GP or when you submit your medicare rebate form. That’s how the GP gets paid by the government. And they also track total out of pocket spending anyway in case you hit the out of pocket expense limits at which point they start to cover more of the gap between the scheduled fee and what you actually get charged by the health provider.

    Chris – it’s good to see you on here – someone who actually knows what he/she is talking about.

  43. Perpetual Motion

    Judith, you’re history is pretty much correct.

    Successive governments have increased the Schedule fee well below the rate of inflation. GPs were outraged annually.

    If you bulk-billed you got paid within 2 weeks initially, now within 24 hours. If you didn’t bulk-bill you got paid in 6 to 8 weeks if the patient bothered to mail you the Medicare cheque. Otherwise, Medicare would re-issue the cheque directly to the doctor after 3 months.

    This heavy-handed approach saw bulk-billing rates over 80%.

    Some practices tried to stay completely private and charged the patient up-front and left them to claim the rebate from the local Medicare office. This was only possible outside of the capital cities, and only until Medicare started closing the local offices.

    Then there was the big scare of a doctor shortage, and lots of substandard doctors from the sub-continent were imported, and Australian medical schools started multiplying and increasing intakes.

    At that stage, privately-billing GPs over most of the country saw their patient numbers halved as patients fled to bulk-billing clinics, and so had to start bulk-billing themselves.

    This was the green light for corporatised medicine with companies such as Primary Health Care buying out disillusioned GPs, and paying them a salary to see 10 patients an hour, and referring them for as many pathology and radiology investigations as reasonably possible to make vertical profits.

    This is where we are today, cheered on by doctors with vested interests like Steve Hambleton, now ex-AMA President, who was one of the first bulk-billers.

    General Practice today is a toilet characterised by 6-minute medicine, with thousands of poorly-trained, overseas doctors.

    Thankfully, I exited the field quite a while ago.

  44. Perpetual Motion

    There is no GP shortage.

    There is an abundance of both patients and doctors abusing the system.

  45. Andre Lewis

    What is the difference between a public service officer in a State/Federal health department and a doctor who bulk bills all patients?

    The doctor can adjust work practices to achieve any income wanted. But as all their income is from the public purse in what way are they a small business as usually claimed?

  46. Petros

    Andre, the doctor has to pay the receptionists, nurses, typists, gardener, cleaners, public liability insurance, PAYG tax, quarterly BAS statements, medical indemnity insurance, computers, software, medical equipment etc. They are running a business in that sense.

  47. mizaris

    The reality is that the real waste is in the hospitals, particularly in terms of undertaking completely pointless and/or unnecessary procedures, but the states are in the driving seat when it comes to doing something in this space.

    The profligate waste within the health/hospital system is so appalling that it is utterly impossible to comprehend or quantify. Consultants and public “servants” are the worst. They have no accountability and no shame. I’ve seen it first hand for years and now I hear about it still, and what I hear is still going on is compounded of the worst of the worst which I actually saw. And no-one – no Minister; no Director of any hospital; will speak out about it. For too long the health/hospital system has been a money tree for the profligate greed of many of those working within the system. They have it all nicely tuned to redirect taxpayer funds their way and bugger the patients, nursing staff, registrars etc…ie the people who actually do the hard yards in the system.

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