Why Does Australia Love Bulk Billing?
The people need to ask the government
By Dr J, Sport Health, mid 1990s
There is general agreement that bulk-billing is a sacred cow in Australia. Politicians love it, the general public loves it and GPs seem to love it in the way that an alcoholic loves a beer. If you are a bulk-billing GP reading this who claims to hate it but are hooked on it, then you are an addict. You are permitted to read on, but you must be willing to quit.
If the bulk-billing system was perfect, then there wouldn?t be any mystery. Everyone would obviously love it because it was perfect. The problem is that it isn?t perfect. The system started with pimples of imperfection, but they haven?t been squeezed and they are now deep-seated cysts. Bulk-billing encourages over-servicing. Six minute medicine. Excessive ordering of investigations. Poor management of complex problems. Poor continuity of care. And the most recent addition to the list, corporate kickback deals. These are now on the list because of the growing numbers of GPs who don?t feel as if the ?system? allows them to make any money without selling out. OK, I admit ? most doctors really do hate bulk-billing, but everyone else seems to still love it.
The reason why the politicians love bulk-billing can be summarized in two words ? ?1993 election?. There is bipartisan agreement that John Hewson lost the ?unloseable? 1993 election on two issues, the proposed introduction of a GST and the proposed dismantling of ?universal? bulk-billing. Given that John Howard managed to get over the line in the last election with the GST burden, politicians everywhere have been falling over themselves to declare their total support for bulk-billing. The Liberal party was eventually prepared to gamble that the general public got it wrong on the GST in 1993, but they don?t seem to want to ask the question again on bulk-billing.
The general public supposedly loves bulk-billing because it is ?free? and ?convenient?. The important thing to realize is that there are two general publics out there. The battlers may love bulk-billing because it is free ? cost may be more important to them than convenience. If it cost $10 cash to see the GP, then perhaps many of the battlers would sit it out at the Emergency Department. The wealthy in Australia are definitely the opposite: cash-rich and time-poor. They like bulk-billing as much as the battlers because they can settle the account in two seconds. Many well-off Australians who see GPs that charge a private fee do not even bother to claim the Medicare rebate. It is more convenient for them to just pay cash or credit at the time of consultation and throw away the receipt. Filling out lengthy forms, standing in queues and posting cheques are in combination not worth $20 of their time, although the dilemma makes this group fans of bulk-billing under the present rules.
The no-brainer solution to most of the problems with the bulk-billing system is that doctors should be allowed to bulk-bill and charge a cash co-payment. This would keep the transfer of money between the HIC and doctors simple and save a lot of money that is currently been wasted on administration. It would give GPs more of an opportunity to charge a fee that allowed them to devote more time to each patient. It would lower any perceived need for GPs to accept corporate kickback deals in order to make any money. The only problem with the no-brainer solution is that the government doesn?t want a bar of it. The Liberal government is paranoid that if GPs were allowed to charge a co-payment then every single GP would do so, and the Labor Party would accuse them of ending bulk-billing and would sweep them out of office.
The government therefore needs a little persuasion. For a start, general public no. 2 (the well-off) would not be worried in the slightest by a cash co-payment, as long as they could get out of the doctor?s surgery with no further paperwork to complete. If there was a simple transaction, plus they could see their doctor for 15 minutes rather than 6 minutes, then general public no. 2 would be happy. They would also be overwhelmingly pleased by the simplification of billing in a private hospital episode. Each doctor involved could require a simple signature for the Medicare component of the fee, the private insurer could follow-suit and then there would be a much simpler (and smaller) invoice for the gap.
General public no. 1 (the battlers) represent the potential backlash, as they would dearly like to retain ?free? GP consultations. The reality is not that free GP consultations would disappear, but that they may need to shop around more if that is really what they wanted. After a short while, even most of the battlers may decide that it is better to pay a $10 co-payment and get a 15 minute consultation than have the bell-ring at 6 minutes during their ?free? consultation. If an area was so genuinely poor that the people could not afford to make co-payments for GP consultations, then competition with Emergency departments would keep the price of GP consultations down. Is there such a suburb or town in Australia that is this badly off? I think you can answer the question by naming the poorest suburb you can think of, and then look in the Yellow Pages to see how many Chiropractors, Naturopaths and Tarot-readers that can afford to run a business there (not to mention how many poker machines there are).
A priority one agenda item for the AMA and RACGP should be to convince the government to allow non-compulsory co-payments on top of bulk-billing. Part of the equation is convincing the general public that it is OK to love the convenience of bulk-billing, but that it is equally important to value quality services from a GP. The other part is persuading the government. Convincing the government about the administrative benefits and of the disincentive to overservicing is easy. Convincing the government that allowing co-payments wouldn?t be political suicide (a la the 1993 election) is the difficult part.
Obviously there needs to be a plan ?B? if the government won?t listen to carefully reasoned argument. It would be nice to think that the anti-competition bodies that threaten to fine us all $10 million if we charge the same fees as the doctor in the next room could apply the same logic to the HIC with respect to bulk-billing, but it is unlikely that they will come to the rescue. There is a simpler solution available. If a large proportion of GPs simultaneously undertook a campaign to stop bulk-billing and pressure the government to allow co-payments, they would give in within months. This wouldn?t mean hurting patients in a financial sense. Doctors who wanted to could, as part of the campaign, charge five cents over the rebate amount if they wished. In fact, it would be of political benefit if the amount charged above the rebate was minimal, particularly to pensioners etc. The key component would be to ask patients to pay up-front (with a credit card if they wished), so that they could fully appreciate the inconvenience of the current system. They need to be educated that it is their rebate, not the doctor?s rebate. For the large proportion of patients who might complain about this, they could be invited to simultaneously sign and send off a letter to the health minister asking for the right to be bulk-billed and give a cash co-payment. It wouldn?t take long for the Medicare offices to be overwhelmed with paperwork and for the pressure to mount on the government. The government wouldn?t be able to blame ?greedy doctors? if the greedy doctors were only putting up the fees for pensioners and health care card holders by amounts of less than a dollar. In fact, the government wouldn?t need to blame anyone. As soon as the general public had ?educated itself? that it was a good thing to allow co-payments on top of bulk-billing, then the government would no longer fear doing so.
It is a myth that Australians insist on free consultations from GPs. There is a growing discontent about the quality of practice ? particularly the complaint that doctors are not prepared to spend enough time with their patients. What Australians really love about bulk-billing is the convenience, which is denied to them in practices that wish to charge over the rebate amount, under current laws. Cash co-payments along with bulk-billing would be accepted by the public. In fact, they would be demanded by the public as soon as most GPs collectively abandoned bulk-billing (by increasing their fees above the rebate amount). There are enough GPs around to provide for services at both ends of the market. Some practices may focus on long consultations and charge larger co-payments, whereas others may choose to stay with six-minute medicine and not charge a co-payment. Co-payments are going to happen sooner or later, and it should be the job of the AMA and RACGP to organise GPs into a campaign to make it sooner.
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i posted some stuff on the finally finished forum, and without any explanation, they moved it.
did it suck?