Introduction by Croakey: As The Guardian today publishes important new findings showing considerable variation across the country in bulkbilling rates for GP services, health policy analyst Charles Maskell-Knight takes a deep dive into the data and reports his analysis below.
One important implication is that while health reform typically presents a one-size-fits-all response to policy problems, diverse solutions may be required to restore affordable access to GP services in different areas, depending upon local context and circumstances.
“In areas of chronic workforce shortage, improving access to bulk billing will be a necessary but not sufficient step to improving access to adequate primary health care,” he writes.
Charles Maskell-Knight writes:
Last year Melissa Davey, medical editor of The Guardian, approached the new Federal Government seeking the release of GP bulkbilling statistics by electorate. Her article today reports on the process and the data she eventually received, which includes the percentage of GP services bulkbilled and the proportion of patients who were always bulkbilled for GP services, by electorate, over the last three financial years.
In this article I set out the results of some additional analysis of the data I’ve carried out. I’d like to make several preliminary points.
First, all health policy researchers should applaud Davey’s initiative and persistence in seeking and obtaining this data. Information on how many people are bulkbilled and where they live is far more useful than information on the number of services that are bulkbilled nationally, which until now has been the only regularly released and available data.
Second, since the data was released to Davey the Department of Health has now committed to regular release of data on the number of people bulkbilled as well as the number of services bulkbilled – an excellent development.
However, the data will be broken down by the 31 Primary Healthcare Networks, rather than 151 electorates.
This is an unfortunate decision, as the PHNs are so large that significant variation across different areas will be lost. For example, the Hunter, New England and Central Coast PHN starts on Broken Bay on the northern edge of Sydney and extends to the Queensland border, covering in whole or in part a dozen electorates, and an area the size of England. Gosford and Glen Innes are very different, and including them in the same unit for analytical purposes makes no sense.
By contrast, electorates are uniform in size, and under section 66 of the Commonwealth Electoral Act 1918 are determined having regard to community of interests, including economic, social and regional interests, and means of communication and travel.
Third, the Department told Davey that the data she received included bulkbilled COVID vaccinations, which inflated the proportion of people who received all bulkbilled services by 0.1 percentage points in 2020-21 and 1.5 percentage points in 2021-22. In other words, the decline in the proportion of people who received all bulkbilled services was greater than the electorate level data released to Davey showed. However, the Department did not release an adjusted electorate level dataset.
As a result, the following analysis needs to be read subject to the caveat that the underlying level of bulkbilled patients is lower than reported here. However, there is no reason to think that inclusion of bulkbilled COVID vaccinations is the reason for the substantial disparity between states and electorates in the level of bulkbilled patients.
National trends
At the national level the data shows the proportion of GP services that are bulkbilled increases from 87.5 percent in 2019-20 to 88.8 percent in 2020-21, before declining to 88.3 percent in 2021-22. (The uptick in 2020-21 presumably reflects the high number of bulkbilled telehealth consultations at a time when the government still took COVID seriously.)
While the average number for 2021-22 is higher than two years previously, the quarterly data suggests that the rate is falling.
The proportion of people who received all bulkbilled GP services also increased between 2019-20 and 2020-21 from 67.1 percent to 67.6 percent, but then fell in 2021-22 to 65.8 percent, 1.3 percentage points below the 2019-20 rate. As indicated above, the Department has now indicated that the 2021-22 number adjusted to remove bulkbilled COVID vaccinations is 64.3 per cent, a 2.8 percentage point reduction on 2019-20.
This means about 700,000 people who were receiving all bulkbilled GP services no longer are.
From a policy perspective this decline is more concerning than the reduction in the number of bulkbilled services.
If people of limited means cannot be sure they will receive GP services free of charge, they are more likely to seek care from public hospital emergency departments. The rest of this article will focus on the proportion of people who received all bulkbilled GP services, rather than the rate of bulkbilled services.
Location – a complicated pattern
An initial examination of the data shows that the proportion of people who received all bulkbilled GP services differs considerably between states and within the larger states, as do the changes in the rate between 2019-20 and 2021-22.
As the following table shows, NSW, Victoria and the NT have the highest proportion of people who received all bulkbilled GP services. The two largest states did not experience any substantial reduction in this proportion between 2019-20 and 2021-22, and about half of the electorates in these states actually saw an increase in the proportion of people who received all bulkbilled GP services.
The remaining three mainland states have a lower than the national average, and saw a decline in the rate between 2019-20 and 2021-22. Of the 55 electorates across these states, only four did not see the rate decline.
Tasmania, where the proportion of people who received all bulkbilled GP services was already low compared with the national average, saw a further decline in four out of five electorates. The ACT, with the lowest such rate in the country, experienced a further marginal decline.
The NT, with the highest proportion of people who received all bulkbilled GP services in the country, saw a substantial decline driven by a reduction of nine percentage points in Solomon, which covers urban Darwin.
As the table shows, there was a considerable variation across electorates within the larger states in the proportion of people who received all bulkbilled GP services, and the rate of change in this rate. Residents of the central coast in NSW where the proportion dropped about eight percentage points would think the decline in bulkbilling was a very real issue, while those in North Sydney and New England, where the proportion of people who received all bulkbilled GP services increased by three percentage points, would be unconcerned.
The Australian Electoral Commission (AEC) places electorates into four categories based on whether or not they are in a city or include a major provincial centre. As the next table shows, outer metropolitan electorates have the highest average proportion of people who received all bulkbilled GP services, despite a decline of 1.7 percentage points from 2019-20 to 2021-22. Over three-quarters of the electorates in this group saw a drop in the proportion of people who received all bulkbilled GP services.
However, the largest decline was in provincial electorates, where the proportion of people who received all bulkbilled GP services fell by 2.0 percentage points. This partly reflects the fact that one-third of the group are Queensland electorates, almost all of which saw the rate drop.
While the proportion of people who received all bulkbilled GP services in rural electorates is on average five percentage points below the national average, even the lowest ranking electorate still has almost half of the population bulkbilled.
No analysis based on electorate data would be complete without a breakdown by party – even though it has no explanatory power. The average rate for electorates held by the major parties is close to the national average of just under 66 percent.
However, for both the Greens and the Teal independents the average is 46 per cent, reflecting the concentration of these electorates in inner metropolitan areas with a low proportion of people who received all bulkbilled GP services.
Socioeconomic status
It is often suggested that many GPs have a practice of bulkbilling pensioners, other social security recipients, and patients they consider in need, while billing other patients directly. On this basis there should be some relationship between socioeconomic status and the proportion of people who received all bulkbilled GP services.
An article in The Guardian in the lead-up to the last election contained a table setting out for each electorate the percentage of the population in the bottom 30 percent of the ABS Index of Relative Socio-economic Advantage and Disadvantage (IRSAD), which takes into account factors such as income, education, unemployment, rent and mortgage payments, and family size.
There are 22 electorates (the “most disadvantaged” group) in which more than 50 percent of the population are in the bottom 30 percent of IRSAD. For these electorates, on average 68 percent of people received all bulkbilled GP services in 2021-22, a decline of 0.8 percentage points over 2019-20.
However, there is considerable variation within this group: Fowler (outer metropolitan Sydney) had a rate of 96 percent, while at the other end of the spectrum Lyons (rural Tasmania) had a rate of 52 percent.
Of the 22 electorates, the four in metropolitan areas had an average rate of 89 percent, while the four provincial electorates and 14 rural electorates had rates of 72 percent and 62 percent respectively.
At the other end of the spectrum, there are 28 electorates (the “least disadvantaged” group), where fewer than 0.5 percent of people are in the lowest 30 percent of IRSAD. All except two of these electorates are in metropolitan areas, and on average 63 percent of people received all bulkbilled GP services in 2021-22, a decline of 0.5 percentage points on two years earlier. Again there is substantial variation within the group, from 93 percent in Greenway in outer metropolitan Sydney, to 38 percent in Curtin in inner metropolitan Perth.
It is striking that the least disadvantaged electorates have a marginally higher average proportion of people who received all bulkbilled GP services (63 percent) than the 14 most disadvantaged rural electorates (62 percent). Where a patient lives on the city-country continuum has more of an impact on their likely bulkbilling experience than the socioeconomic profile of the electorate they live in.
Looking at the relationship the other way, of the 20 electorates with the highest proportion of people who received all bulkbilled GP services (ranging from 83 to 96 percent), only one (Blaxland) is in the list of the 22 “most disadvantaged” electorates. Three of the electorates are in the list of the 28 “least disadvantaged” electorates.
Of the 20 electorates with the lowest proportion of people who received all bulkbilled GP services (ranging from 35 to 49 percent), six are in the list of the 28 “least disadvantaged” electorates. But this group includes the Tasmanian electorates of Bass (49.3 percent of the population in the lowest 30 percent of ISRAD), Clark (37 per cent), and Franklin (21.6 percent).
This analysis suggests there is not a strong relationship between the proportion of people who received all bulkbilled GP services and the socioeconomic status of an electorate.
Regional patterns
These findings – and particularly changes in the proportion of people who received all bulkbilled GP services – start to make more sense when examined regionally.
For example, the six electorates stretching north from Sydney through the Central Coast and the Hunter (Robertson, Dobell, Shortland, Newcastle, Hunter, and Paterson) had an average reduction in the proportion of people who received all bulkbilled GP services of five percentage points from 2019-20 to 2021-22, compared with the overall NSW average of -0.1 percentage points.
In Western Australia the three electorates running through Perth’s northern suburbs (Cowan, Moore, and Pearce) had an average reduction of 9.6 percentage points, compared with the state average of -4.6 percentage points.
In the Northern Territory the electorate of Solomon covering urban Darwin had a nine percentage point reduction.
It is hard to imagine any demographic shift that would lead to such rapid changes in bulkbilling levels.
It is more likely due to changed doctor behaviour, as practices with long waiting times and little competition realised that they can change their billing practices without losing patients (and revenue).
Once a few practices successfully make the switch, others in the region realise that they can follow suit.
On the other hand, the persistence of high bulkbilling in the ten western Sydney electorates where 89 percent or more proportion of people received all bulkbilled GP services is due to doctors continuing the practice, even in areas which generally are not the most disadvantaged.
Policy implications
Perhaps the most striking aspect of the data is that it shows there were still 40 electorates where more than three-quarters of the population were bulkbilled for all their GP attendances in 2021-22.
Excluding bulkbilled COVID attendances might reduce the number of electorates by two or three, assuming those attendances were evenly distributed across electorates, but it would still be true that a quarter of electorates saw three-quarters of patients receive all their GP services bulkbilled.
This suggests that it was still possible to offer a high level of bulkbilling while maintaining a viable practice as recently as eight months ago. This calls into question demands from some doctor groups for a doubling of the MBS rebate to restore the viability of general practice. Such a policy change would cost billions of dollars, much of which would flow to doctors who are already bulkbilling most of their patients.
The second aspect of the data is the heterogeneity of the level of bulkbilling across Australia.
Electorates in the same AEC category, with similar socioeconomic status, had hugely different proportions of people who received all bulkbilled GP services.
While some of this may be due to doctor supply (I was unable to access workforce data at an electorate level), much of it will be down to doctors’ culture and practices. To some extent these will be driven by whether a general practice is owned by a corporate entity or a group of doctors. Again, as far as I am aware there is no publicly available data on the location of corporate as distinct from doctor-owned practices.
While the architecture of Medicare generally requires a one-size-fits-all response to policy problems, the diverse levels of bulkbilling in different areas suggest that diverse solutions may be required to restore affordable access to GP services in all areas. In areas of chronic workforce shortage, improving access to bulkbilling will be a necessary but not sufficient step to improving access to adequate primary health care.
In conclusion
Greater public availability of more meaningful bulkbilling data into the future is vital to a better-informed public discussion of the problems facing the health system, and consideration of the policy options for addressing them.
While it is disappointing that the data will be published on the basis of Primary Health Networks, let’s hope that some independent Senator will be moved to put a regular question at Senate estimates for the production of the data on an electorate basis, now that the precedent has been set.
Charles Maskell-Knight PSM was a senior public servant in the Commonwealth Department of Health for over 25 years before retiring in 2021. He worked as a senior adviser to the Aged Care Royal Commission in 2019-20. This article was co-published with The Guardian, which published an edited version.
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