Is the term bulk-billing still relevant in today's landscape of health policy reform?

Abstract

As Medicare enters its 40th year and we reflect on its achievements, it is timely to assess the usefulness and relevance of a term that is closely associated with it: bulk-billing.

The term bulk-billing originated when Medicare was first introduced in 1984, and it referred to the manual process where a medical practitioner would submit collected paper receipts in bulk to Medicare. Although the practice of physically sending bulk receipts to Medicare has long since disappeared, the term bulk-billing has persisted.

The state of the Australian health system looks very different now than it did 40 years ago when Medicare was first introduced. In that time, the term bulk-billing has become synonymous with marker of access to general practice and in the delivery of health care with zero cost to the patient. This is in part due to current and past governments using the bulk-billing rate as a political indicator of health policy successes and as an indictment by opposition parties on the government of the day's commitment to health care access and equity. For example, in 2021, the former Minister for Health, the Hon Greg Hunt, used bulk-billing rates to demonstrate the then Coalition government's firm commitment to Medicare, despite also being the government responsible for extending the freeze on the Medicare indexation.¹ Similarly, the current Minister for Health, the Hon Mark Butler, also used increases in the bulk-billing rate as evidence of the success of the 2023 Budget initiatives to triple the bulk-billing incentives for Australians with concession cards and those aged under 16 years.²

At the time of its introduction, Medicare was designed to ensure all Australians have access to affordable health care by subsidising 85% of the cost of general practice services, increasing to 100% in 2004. Since then, Medicare rebates have not kept pace with increasing inflation nor the costs of care. From 1995 to 2022, increases in Medicare rebates averaged just over 1.1% annually,³ compared with general inflation reaching up to 7.3% during the same period.⁴

Although the bulk-billing rate has been used as metric for general practice access, there is no standardised definition or interpretation. The bulk-billing rate typically quoted by politicians reflects the reported percentage of subsidised services that are bulk billed — the volume of bulk billed general practice services — and provides little insight into patient access to general practice.

Organisations such as Cubiko and Cleanbill have attempted to further interpret the bulk-billing rate with key differences. Cubiko, in their 2023 Touchstone report refers to the bulk-billing rate as “the percentage of invoices [that are bulk billed]” recognising that multiple Medicare services can be provided at one time distorting bulk-billing metrics.⁵ Cubiko also defines a “predominantly bulk billing practice” if “bulk billing as a percentage of invoices exceeds 80%”.

Cleanbill, on the other hand, defines the bulk-billing rate as the “[total] number of clinics that will bulk bill all adult patients without concessions who attend for a standard consultation (MBS [Medicare Benefits Schedule] item 23) during regular, weekday business hours”.⁶ To confuse matters more, a practice is considered to be a bulk-billing practice if there is at least one general practitioner who bulk bills, and if the clinic bulk bills during regular, business hours.

The varying definitions and interpretations demonstrate that the bulk-billing rate is neither consistently understood nor applied by the sector. And importantly, most general practitioners agree that there is neither a standardised nor an accepted definition of this metric. Lack of understanding and misuse of the bulk-billing metric will be amplified by new pathways to access primary care, such as urgent care centres, which receive considerable block funding from both state and federal governments to subsidise attendances and yet bill Medicare for general practice item numbers allowing these to be provided without out-of-pocket cost — confusingly also described as bulk billed.

During the coronavirus disease 2019 (COVID-19) pandemic, the mandatory bulk-billing policy of telehealth MBS items facilitated the rapid uptake and expansion of whole-of-population telehealth services by general practice, and mandatory bulk billing of COVID-19 vaccines was also introduced.

At the peak of the pandemic, bulk-billing reached an all-time high of 87.5%, with over eight in ten general practice consultations provided without out-of-pocket costs.⁷ Although this was lauded as a win for the then Coalition government, a repercussion of the mandatory bulk-billing policy led to significant losses for many general practices, as they had to absorb the increased costs of delivering these services.⁸ Practices in rural and remote areas were also more likely to be disproportionately affected.⁹ In addition to financial losses, general practitioners also experienced increased levels of stress and burnout,¹⁰ and the sector is only now beginning to recover.

According to data from Cubiko, 75% of practices have transitioned away from bulk-billing towards a mixed or private billing business model.⁵ Another notable data point is the continued rise in out-of-pocket costs ($42.03 in September 2023 v $46.64 in September 2024).¹¹

With fewer bulk-billing general practitioners and rising out-of-pocket costs, patients ultimately are the most negatively affected. The results from the Australian Bureau of Statistic's latest Patient Experience Survey show that 28% of Australians are waiting longer to get a general practice appointment, and an even larger proportion (46%) reported a 24-hour or more wait to see a GP for urgent medical care [Correction added on 29 November 2024, after first online publication: the second sentence has been amended.].¹² The proportion of Australians who, due to cost, are delaying a visit to the general practitioner increased from to 7% in 2023 to 8.8% in 2024.¹² Unsurprisingly, this is more acutely felt by those living in rural and remote areas.¹²

Delays in seeking general practice care are likely to place increased pressures elsewhere in the health system, most notably on already stretched and resource-intensive services in hospital emergency departments (EDs). Latest health data from New South Wales suggest that while ED use and wait times are increasing, the number of general practice visits per 100 000 population has dropped back to 2019 levels.¹³ Such a drop in general practice service numbers could have the perverse effect of increasing bulk-billing rates, reflected only due to the drop in privately billed consultations exceeding those which are bulk billed. This may be a politically expedient outcome but not an accurate reflection of access.

These statistics reveal two key things. The first is something many general practitioners and practice owners have long known: the current MBS subsidies fail to cover the cost of delivering general practice care. As a result, bulk billing patients is no longer a viable option in many settings, and general practitioners are increasingly forced to charge a private fee. Second, many general practice services continue to be provided without cost to patients despite the increasing complexity of health care. This complexity requires a funding model that better supports the longer time spent with patients, something the current Medicare rebate structure devalues.

Although the Albanese government provided a historic $6.1 billion investment into Medicare supporting the recommendations of the Strengthening Medicare Taskforce, the limiting of the 2023 increased in bulk-billing incentives to children aged under 16 years and to concession card holders¹⁴ suggests that government support for bulk-billing is in fact not universal.

Australia ranks first out of ten countries overall in a recent international comparison of health systems performance.¹⁵ This result, and Australia's relative success in navigating the COVID-19 pandemic, can partly be attributed to the central role played by general practice.⁸ The rapid rise of chronic diseases, coupled with a growing and ageing population, is the fundamental challenge for the health system. A focus on the bulk-billing rate ignores these challenges and distracts from other more meaningful measures that can tell us so much more about the quality, outcomes and the equity of general practice in Australia. The limiting of the 2023 bulk-billing incentives further reduces the utility of the bulk-billing rate as a marker of appropriate access.

Although Medicare and its introduction of universal health care has been praised by many as one of Australia's greatest policy achievements, there is acknowledgement that the current system needs reform. Similarly, bulk-billing has been a term associated with the success of Medicare, but no longer provides an agreed or meaningful estimate of access to health services. The successful implementation of an effective model of care for the complex nature of 21st century general practice requires the use of modern and more meaningful metrics, and this involves relegating the term bulk-billing for such purposes to history.

No relevant disclosures.

Not commissioned; externally peer reviewed.