A categorical mistake: Is bulk-billing a reliable indicator of access to GPs?
Where I work in regional NSW, patients have difficulty finding a GP who is prepared to bulk-bill them for their medical care. The phone call to the practice receptionist ends, so often, with, “The doctor’s books are full”. At the same time we’re told that 83% of Medical Benefits Schedule (MBS) services are “bulk-billed”. Like everyone else, I thought this fact would mean increased access and affordability for patients to a local GP.
Had I thought more thoroughly about the problem and scrutinised the MBS data, the penny would have dropped.
The explanation comes from Evan Ackermann, a Queensland GP, Chair of the RACGP Expert Committee on Quality Care, who tells us why “bulk billing” is no longer an appropriate measure of access to GPs. He makes the obvious point, that “… 83% of services are bulk-billed – not 83% of patients are bulk-billed”. (1) To equate numbers of services provided – with – number of patients treated – is a categorical mistake.
As more people survive severe illness, injuries and chronic disease, and as the population ages, patients with multiple and complex needs present more often for treatment. The Health Council of New South Wales, chaired by John Menadue, in 2000, found a quarter of the patients presenting to public hospitals had already been admitted on multiple previous occasions. (2) Dr Ackerman makes the same point about GP attendances, “The very high and frequent GP attenders are more likely to be older, have multiple chronic diseases and live in areas with the most socio-economic disadvantage. These 12.5% of patients are the ones who significantly account for much of the bulk-billing figures, which leaves the majority of the population with much lower rates of bulk-billing.” (1)
He also points out that primary health services funded by the Commonwealth’s MBS items have become wider than those usually provided by the family doctor; as they should. Bulk-billing, which is used to supplement the base funding of a range of health organisations, now enables increased access to MBS items through primary health services which may not involve the local GP directly. For example, the Royal Flying Doctor Service, Aboriginal medical services, bulk-billing clinics in public hospitals, headspace clinics, medical services for the homeless, family planning clinics, alcohol and drug services and centres, academic (hospital-based) general practice units, not-for-profit rehabilitation centres, women’s health centres and refugee health centres.
Furthermore, bulk-billing through corporate models of vertically integrated GP, allied health and specialist services, generating high throughput and profits, distort the patterns of bulk-billing and lessen their relevance as a proxy measure of access to GPs. Also the Commonwealth’s initiatives in promoting access to mental health services, support and suicide prevention in the community are areas which enlarge the scope for bulk-billing.
Being able to afford medical care in the community is affected by factors apart from access to treatment and the out-of-pocket expenses of medicines and medical supplies. In a recent post on this website, ‘Mind the gap in doctors’ fees – it is all around us’, Professor Peter Brooks describes the unanticipated gaps in medical fees, the upfront payments required by some specialists and the wide variations in fees charged for surgical procedures. (3)
Dr Ackermann concludes, “Hence, the bulk-billing indicator is misleading and “dirty” in that it does [not] relate to the traditional view of general practice. It does not truly reflect either the adequacy of GP financing or the affordability for patients.” (1)
Bulk-billing of GP services through Medicare must be protected as, for the foreseeable future, it is the closest we will get to medical services available to everyone according to their need and not their ability to pay.
- Ackerman E, Bulk-billing indicator no longer useful, MJA Insight Monday 6th June, 2016.
- NSW Health Council Report, Chair Mr John Menadue, March 2000; NSW Department of Health
- Brooks P, Mind the gap in doctors’ fees – it is all around us, John Menadue – Pearls and Irritations, 26/05/2016.
Ian Webster is Emeritus professor of Public Health and Community Medicine, University of New South Wales.