Recently in Croakey, former senior public servant, Charles Maskell-Knight, argued for the increased availability of meaningful bulk billing data in order to inform a public debate around primary healthcare reform.
In the post below, he analyses some additional Medicare datasets, just released by the Department of Health, which provide important details about access to bulk billed services across Australia and also raise further questions, including about the impact of changes in bulk billing rates on hospital emergency department presentations.
Charles Maskell-Knight writes:
Several weeks ago I wrote an article analysing Medicare general practice bulkbilling data by electorate obtained by The Guardian from Services Australia. At the time the Department of Health foreshadowed that it would be releasing its own data on bulkbilling.
On 20 February it did so, including a range of datasets not previously available.
The most useful of the data sets released by the Department presents data by Primary Health Network (PHN) for the years 2009-10 to 2021-22 on the percentage of patients who were always, usually (50 to <100 percent), sometimes ( >0 to <50 percent), or never bulkbilled for GP services. The data excludes bulkbilled COVID vaccinations.
While data on the proportion of people bulkbilled by GPs is more helpful than data on the proportion of GP services bulkbilled, the data could still be improved. In particular, the cut-off of 50 percent for “usually bulkbilled” seems unduly generous: if a person requiring monthly monitoring is bulkbilled every second month, is it realistic to count them as being “usually” bulkbilled?
Unfortunately, the data does not include information on the number of services patients in each billing category receive. For example, if the “always bulkbilled” category includes many patients who only receive two or three services, a high rate of “always bulkbilled” may not indicate a high level of affordable access. In this article I am assuming that the number of services per patient in each category is broadly similar and has not changed over time.
Despite its limitations, the fact that the data goes back a dozen years allows long-term trends to be identified, and recent movements considered in a broader context.
As the chart shows, at a national level between 2009-10 and 2021-22 the proportion of patients always bulkbilled increased overall by 6.6 percentage points from 57.7 percent to 64.3 percent.
It is true that the rate has dropped off in the last two years. In the last full pre-pandemic year of 2018-19 the “always bulkbilled” figure was 66.3 percent, and by 2021-22 it had fallen by two percentage points. But it is still higher than the rate applying in 2014-15 or any previous year in the dataset.
Indeed, the rate of people “always bulkbilled” increased every year from 2009-10 to 2020-21. In the light of these figures Health Minister Mark Butler’s claim that the previous Government had masked “a shocking decline” in bulkbilling is somewhat exaggerated.
Combining the “always bulkbilled” and “usually bulkbilled” categories, the proportion increased from 74.1 percent in 2009-10 to 87.0 percent in 2020-21, before dropping to 84.7 percent last year as bulkbilled telehealth consultations dropped off.
As the next chart shows, the same broad pattern is evident across most states: strong growth in “always bulkbilled” from 2009-10 to 2018-19, followed by a small decline.
The pattern of growth in “always and usually bulkbilled” is also reflected at a state level.
The outstanding exception is Tasmania, where the “always bulkbilled” proportion fell slightly from 50.9 percent in 2009-10 to 49.3 percent in 2018-19, before falling to 44.8 percent in 2021-22 – over six percentage points lower than the starting point.
Implications for emergency departments
The national results are surprising, given the recent narrative about the pressure declining bulkbilling is having on public hospital emergency departments.
The states are arguing that because people are unable to access bulkbilled GP services, they are instead attending an emergency department where they will receive free care.
While it is true that two percent of patients were no longer “always bulkbilled” in 2021-22 compared with 2018-19, it is also true that the rate of patients “always bulkbilled” in 2021-22 was higher than at any point between 2009-10 (the first year in the data) and 2014-15.
While emergency departments are always under pressure, they were apparently able to cope with a rate of only 57.7 percent “always bulkbilled” patients in 2009-10 without buckling. Why is a rate of 64.3 percent of patients “always bulkbilled” causing such problems now?
I suspect there are a number of factors at play, which are not captured in the Medicare data.
The first is the alleged behaviour of some general practices of bulkbilling Medicare while still requiring a separate co-payment by the patient. The Medicare system would not be aware of the co-payment, and would record the service as bulkbilled. This was supposed to be a key part of the $8 billion in Medicare rorts which gained a lot of media attention in October last year.
Unfortunately, it is not possible from existing data to make any estimate of how many patients recorded as “always bulkbilled” are also making a co-payment. The Department thinks the claims are not “backed by any evidence that we’ve seen that the issue is that large”. However, it could be having some impact in inflating the number of patients who are recorded as “always bulkbilled” when they are not.
The second factor is that bulkbilling is only a factor for patients who are able to see a GP in a timely way. In many areas across Australia doctors are managing their workloads by “closing the books” to new patients (for examples, see websites and media reports at Newcastle, South West Rocks, Wyong, and Derwent Valley). In such circumstances the local emergency department may become a de facto general practice for some patients.
Even if a general practice is accepting all comers, it is not uncommon for the first available appointment to be a few days or even a week or more away. For many patients (or parents of patients) with discomfiting or alarming symptoms, a wait like that is unacceptable, and they will resort to the emergency department.
And finally – and quite unrelated to Medicare – it is quite likely that the pandemic has affected the supply of emergency department services.
Dr Stephen Parnis wrote eloquently about the problem of staff burn-out in The Guardian, and a study by Emma Dixon et al highlighted the impact of COVID on already vulnerable emergency department staff. It would not be surprising if emergency departments’ capacity to deliver services has reduced, but unfortunately there are no available data to confirm this.
In an ideal world the Commonwealth and state governments would cooperate on a project to collect robust data from people attending emergency departments on the factors that led them to present there, rather than at a general practice.
Such a study would allow policy-makers to understand the relative impacts of cost and supply of general practice services, as well as factors such as GP referrals to EDs. Governments should also develop a methodology to report on hospitals’ capacity to deliver services.
In the absence of good information about the problem, policy solutions may well be poorly targeted.
The other surprising result (as shown in the next chart) is that the proportion of patients “never bulkbilled” has declined nationally from 15.7 percent in 2009-10 to 7.1 percent in 2021-22. (In the ACT, the proportion of “never bulkbilled” has halved from over 40 percent to a little over 20 percent.)
While patterns of service provision during the period of COVID lockdowns may have affected the data for 2019-20 and 2020-21, the level for 2021-22 is in line with the long-term trend.
If doctor groups are right in arguing that the level of MBS rebates is such that doctors cannot afford to bulkbill, it is remarkable that more and more patients are being bulkbilled for at least some services.
While the false bulkbilling issue mentioned above may have affected these figures at the margin, it is implausible that it has been the only factor driving the change.
Raising more questions
In many respects the data released by the Department raise as many questions as they answer.
Some of these can only be answered by further disaggregation of the data: cross-tabs of frequency of bulkbilling by patient age, and by total number of services, as well as information on patient co-payments
However, the Government deserves credit for making more data about the operations of Medicare available.
As well as providing more detail on GP services, it should make available data on out-of-hospital specialist services by specialty and by area, to cast some light on another area where anecdote suggests Medicare is failing to deliver on its promise of universal affordable access.
See here for Croakey’s previous archive of stories on Medicare
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