The Bulk Billing Paradox!

Persistent high rates of bulk billing is a weapon that politicians from all sides have used to justify the Medicare rebate “freeze”. It was not surprising that it featured in the recent Federal election along with a scare campaign over the alleged privatization of Medicare.

Paradoxically the bulk billing rate appears to rise despite the freeze.

However, there seems to be a reluctance by politicians to clarify if the term “bulk billing” refers to GP visits, or the multitude of other health services that are “bulk billed.”

It is time to apply our diagnostic skills to the “bulk billing” phenomenon.

The corporatisation of general practice remains one of the chief drivers of bulk billing. Unlike traditional practices, the corporates have the advantages of investor capital, economies of scale and diversified service provision (imaging, pathology, pharmacy and allied health) which all add to the bottom line.

For corporates bulk billing guarantees volume and keeps competitors at bay.

Government clinics in many guises, such as ambulatory care clinics, urgent care centres, community health centres, super clinics and primary care centres have all broadened the scope of GP bulk billing. To this list we can add the activities being promoted by the “Primary Health Networks (PHNs) (and soon the National Disability Insurance Scheme (NDIS)).

Being government-owned services, bulk billing is the rule. In some instances, the transactions could be described as a mechanism for cost-shifting from State to Federal government. But who is going to question, let alone police this?

So just in the two abovementioned segments of GP, we see a large percentage of permanently entrenched bulk billing.

Government is also responsible for those consults that are the bane of GPs – the red tape visits. e.g.: Centrelink forms; driver licence forms; disability parking forms; travel subsidy forms; hospital admission forms. Whenever patients present with these forms, there is an expectation of bulk billing, since they are a government requirement, not a medical service. In any case, bulk billing for these services is skating on thin ice as it is unclear if they fall within the definition of “Medicare eligible”.

Furthermore, in claiming bulk billing incentives for children and concession card holders, we are in fact in a grey area as to what is clever accounting and genuine need. We’ve all seen patients arrive in luxury cars, dripping in bling, and presenting healthcare cards, eager to claim their taxpayer-funded entitlement.

Let’s not forget the patients themselves, who have been told by politicians over many years that they are entitled to bulk billing, free public hospital visits, and in some states free ambulance services. Is it any wonder that there is little to encourage consideration of urgency and need? The co-payment aimed to address this but proved to be politically toxic.

Lastly, we general practitioners have to shoulder blame too. We all need to beat our breasts and cry mea culpa! Time is money, and we all want a return on our investment in our training and our practice. Furthermore, as directors of small medical companies, we must trade profitably. It is called our fiduciary duty. Modern GP work methods and the way the MBS rebates have resulted in a regrettable situation where it is easier and more cost-effective to practice revolving-door medicine. Patients are shuffled through the process and quickly referred to pathologists, radiologists and specialists to sort out problems on our behalf. Thorough history taking and examination is facing extinction. Enhanced primary care (EPC) items have become a financial crutch for most practices- they are almost always bulk billed for who would seriously fork out over $200 cash for them?! Until EPCs are dismantled the incentive to charge a fee or go the extra mile is really not there for the high turnover clinics; it is much simpler and more lucrative to churn out care plans.

Bulk billing is now part of the Australian culture. Paying for high rates of bulk billing by imposing a Medicare freeze is a blunt instrument. The Australian people need to know the truth. Quality medical care is not cheap, and low prices often means higher cost.

Dr Aniello Iannuzzi is a GP practising in Coonabarabran, NSW

 

References

[1] Medicare Bulk Billing is where patients present their Medicare card as full payment for their medical treatment. About three days later, Medicare pays all of the bulk-billed claims into the “provider’s” bank account.
[2] The Medicare rebate freeze was first introduced by the Howard government in 1996/97, and reintroduced by the Gillard government in May 2013, when the indexation date was moved from Nov to July 2014. It was extended by the Abbott government from July 2014 to July 2016, then to 2018 in the 2015 budget, and has now been extended for a further 2 years until July 2020.
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