Introduction by Croakey: The Federal Government continues to roll out pre-election health commitments, with the latest being a pledge to open another 50 Medicare Urgent Care Clinics, with more clinics in every state and territory.
The general locations of the new clinics can be seen here (scroll to end of page), with the specific locations and providers to be determined through independent commissioning processes conducted by Primary Health Networks or state and territory governments.
Health and Aged Care MInister Mark Butler said the Albanese Labor Government went to the last election promising to open 50 Medicare Urgent Care Clinics, and had delivered 87 clinics to date. He said once all of the clinics were open, four in five Australians would live within a 20-minute drive of a Medicare Urgent Care Clinic, according to analysis by the Department of Health and Aged Care.
Below, Charles Maskell-Knight provides a detailed overview of responses to a bulkbilling reform package announced recently by Labor and backed by the Coalition.
He also raises two specific concerns: that “it is simply propping up the GP fee-for-service system introduced 41 years ago with more realistic fees”, and that it focusses on GP costs to the exclusion of specialists’ much higher costs.
“The case for moving away from a primary care system based on episodic fee-for-service payment for GPs towards a multidisciplinary team approach based more on capitation has been made over and over again,” he says.
“However, governments have been unwilling to implement any significant change, perhaps because the political conversation around health has been reduced to a debate about a single metric of the GP bulkbilling rate.”
Charles Maskell-Knight writes:
If re-elected, the Albanese Government would extend the GP bulkbilling incentives currently applying to children and concession card holders to everyone, according to an announcement on Sunday 23 February.
The Government also promised an additional payment to general practices that bulkbilled all patients, as well as funding to increase medical school places, expand GP training, remove the disincentives for junior doctors to train as GPs, and establish scholarships for nurses and midwives to extend their skills.
The whole package was costed at $8.5 billion over four years.
Within a few hours of the announcement, the Coalition Opposition promised to match the commitment, but with an additional $500 million to increase the annual cap on the number of Medicare-subsidised psychology session from 10 to 20.
Professor Stephen Duckett AM discussed the changes to bulkbilling in The Conversation, noting that as the new initiatives are for everyone, they will “end the two-tiered incentive the Coalition introduced in 2003 and restores Medicare as a truly universal scheme”.
He suggested that the bonus for practices that bulk bill all patients will “start the necessary transition from a reliance on fee-for-service payments as the main payment type for general practice” and could encourage multi-disciplinary teams of GPs, nurses and allied health professionals such as psychologists and physiotherapists.
Duckett concluded that “the Coalition obviously hopes to negate the impact of a popular announcement by matching it”.
“What will weigh in voters’ minds, though, is whether today’s Coalition announcement will be delivered after the election. The Coalition has a long history – dating back to Malcolm Fraser – of promising one thing about health policy before an election and reversing it after the vote, and this will probably fuel a “Mediscare” campaign by Labor”.
Numerous health sector groups responded to the announcements.
Health workers and providers
The Australian Medical Association (AMA) President Dr Danielle McMullen said “the commitment from the Coalition to match the Government’s $8.5 billion for general practice shows recognition across the major parties that funding for primary care has for too long been in decline, with patients increasingly unable to receive timely and affordable care where and when they need it”.
However, she said that more was needed, including adopting the AMA’s proposed “seven-tier general practice consultation item structure, which will fund GPs to spend more time providing more care for patients”.
The Royal Australian College of GPs (RACGP) focussed on the “commitment to train 2,000 new GPs every year by 2028 and incentivise more junior doctors to become specialist GPs”.
RACGP President Dr Michael Wright “welcomed the Government’s workforce initiatives to build Australia’s specialist GP workforce into the future”.
He also said the Government’s proposal for bulkbilling “will require careful consideration to ensure patient care is sustainable and funding is targeted at those who need it most”.
(The RACGP’s own policy released several weeks ago proposed extending the bulkbilling incentives to everyone aged under 35.)
Wright also reiterated the RACGP’s calls for a 25 percent increase to patient rebates for mental health and a 40 percent increase to patient rebates for longer consults.
The Australian College of Rural and Remote Medicine (ACCRM) said the package “has the potential to significantly improve healthcare access in rural, remote, and First Nations communities”.
ACRRM President Dr Rod Martin said the College was “particularly excited” by the measures intended to grow the supply of GPs and rural generalists.
The Rural Doctors Association of Australia (RDAA) said that the increased bulkbilling incentives would be particularly helpful to practices that already bulkbilled, particularly Aboriginal Medical Services.
However, President Dr RT Lewandowski cautioned that “the additional 12.5 percent incentive for practices that only bulk bill will likely be out of the reach of many rural practices [because] the cost of providing the advanced level of care needed within rural communities, the shortage of health professionals, and the smaller patient cohorts are limiting factors that result in most rural practices having to mixed bill in order to survive”.
Lewandowski said that the RDAA had long advocated for a move away from an exclusive fee-for-service payment model.
He said the RDAA was “worried that the current suite of reform recommendations already on the table will be overshadowed by the bulk billing changes and will result in a missed opportunity for longer lasting and more effective reform”.
The RDAA welcomed the training elements of the package.
ForHealth Group, describing itself as Australia’s largest bulk-billing general practice provider, welcomed the announcement and the Coalition’s support, saying “bulkbilling will now be financially sustainable for both the GP practitioners and for the healthcare clinic”.
It would be “a vital change to the vulnerable outer metropolitan and regional communities we operate in, where cost-of-living pressures and private fees are impacting essential visits to the GP”.
The Australian Primary Health Care Nurses Association described the announcement as “a big investment in the status quo”.
CEO Ken Griffin said “only pumping money into general practice won’t stop the bleed in our health system and won’t keep more patients out of our overstretched hospitals”.
“Once again, nurses – the largest, most trusted, reliable workforce in primary health care – are not being recognised as the solution”.
Griffin again called for the Government to “act without further delay on the recommendations of Professor Cormack’s three-year Scope of Practice Review… to allow nurses to provide broader care to patients who are waiting for support”.
The Australian Collage of Nursing (ACN) struck a similar note, with CEO Adjunct Professor Kathryn Zeitz saying “immediate solutions to make a GP visit more affordable are welcome, but we cannot lose sight of the long-term reform that is needed to fix the sector”.
She said that short-term measures to improve struggling bulk billing rates were welcome, but the Government should “continue to focus on its reform agenda and implement the recommendations of reviews including the Scope of Practice Review”.
The Australian Physiotherapy Association (APA) said that while it supported any measure that reduced out-of-pocket costs for patients, the announcement “places pressure on an already depleted GP workforce and fails to empower multidisciplinary team-based care as advised in the government’s own scope of practice review”.
APA President Dr Rik Dawson said that “after years of ‘listening’ and ‘reviewing,’ this $8.5 billion pledge results from an extremely narrow reform lens…. that ignores so many of the complex challenges of the Australian healthcare system and neglects the reform that physiotherapy can deliver to a health system in desperate need of real change”.
The Australian Nursing and Midwifery Federation (ANMF) supported the package, with Federal Secretary Annie Butler saying “if people can access affordable care when they need it they will be less likely to end up in already overstretched emergency departments, helping to taking pressure off our hospital system”.
Butler said the commitment to 400 scholarships for nurses and midwives was also “great news”, adding that the ANMF “continued to call on the Government to support the work of nurses and midwives, allowing them to work to their full scope of practice and delivering best health outcomes across the community”.
The Health Services Union strongly endorsed the package, with National Secretary Lloyd Williams saying the union particularly welcomed the increased support for regional and remote healthcare, which “will help address critical workforce shortages across the country”.
Consumers and others
The Consumers Health Forum (CHF) welcomed the package and the Coalition’s support.
CEO Dr Elizabeth Deveny said “we have been consistently hearing from consumers for some time now that they struggle to find providers that will bulk bill them, and they simply cannot afford to see a doctor”.
“This investment, if taken up by GPs, will significantly reduce out-of-pocket costs when consumers see a GP.”
COTA CEO Pat Sparrow described the announcement as “a common-sense reform that will hopefully improve the wellbeing of older Australians while also helping to ease some of the cost of living pressures people are facing.”
She added that the next step in Medicare reform should be the introduction of a Seniors Dental Benefit Scheme.
The National Rural Health Alliance (NRHA) welcomed the announcement, but said it was still “deeply concerned by the ongoing challenges faced by rural and remote GP or primary care practices that cannot afford to bulk bill services for communities”.
NRHA Chief Executive Susi Tegen said “many rural practices are already experiencing a thin or failed market, making it difficult to cover costs. The newly announced Government measures will do little to change that reality”.
Tegen said the workforce measures would take years to deliver practical benefits, but rural Australia needed flexible solutions to improve health access now.
The Australian Healthcare and Hospitals Association welcomed the announcement, but said for the spending “to provide the greatest benefit for Australians, the focus must be on delivering value over volume”.
CEO Kylie Woolcock said Australians should be asking:
- How will this investment ensure a more timely, accurate diagnosis when I present with symptoms?
- How will it ensure I am informed about the treatment options available to me?
- How will it ensure I have access to and can navigate the range of supports I need to monitor and manage my condition?
- How will it keep me from needing to go to the hospital?
Analysis
A number of issues arise from the Government’s announcement and the sector’s response.
First, the package does not amount to reform in any way, shape or form – it is simply propping up the GP fee-for-service system introduced 41 years ago with more realistic fees.
The case for moving away from a primary care system based on episodic fee-for-service payment for GPs towards a multidisciplinary team approach based more on capitation has been made over and over again.
However, Governments have been unwilling to implement any significant change, perhaps because the political conversation around health has been reduced to a debate about a single metric of the GP bulkbilling rate.
While the bonus paid to practices bulkbilling all patients for all services will technically represent a transition away from fee-for-service, I don’t share Professor Stephen Duckett’s optimism that it will encourage multidisciplinary teams. It is far more likely to be disbursed as additional GP remuneration.
Second, the package focusses on GP costs to the exclusion of specialists’ much higher costs.
Several days after the announcement, the Australian Institute of Health and Welfare (AIHW) released MBS billing data for January, showing that on average Medicare paid 83 percent of GP fees, but only 49 percent of much higher specialist attendance fees.
Where I live on Yuin country in regional NSW the standard out-of-pocket cost for a specialist attendance appears to be around $150, and it is much the same in Canberra.
People attending a specialist quarterly may be facing out-of-pocket costs just as high if not higher than people visiting a GP monthly, yet their circumstances have not attracted any policy response.
Finally, Leader of the Opposition Peter Dutton has indicated that the Coalition will pay for its commitment to the package by cutting 36,000 public servants.
Is an improvement in the affordability of GP services worth degrading the time taken for assessing veterans’ entitlements, determining eligibility for the NDIS, or simply answering the telephone at Services Australia?
• 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. He is a member of Croakey Health Media and writes The Zap, a weekly column. Follow on X/Twitter at @CharlesAndrewMK, and on Bluesky at: @charlesmk.bsky.social.
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