Life support for primary care – but campaigns silent on deeper health system malaise
Labor’s cash injection is no panacea for our ailing medical system and it could well backfire.
The defining image of this election campaign – leaving aside stage stumbles and errant footballs in the Top End – will be Anthony Albanese brandishing a small plastic rectangular-shaped prop: the Medicare card.
For most Australians, the card that has been dubbed by Labor “a little green piece of green and gold” is a means to an end: the delivery of a Medicare rebate direct to their bank account. For the Labor Party, universal healthcare and the nation’s taxpayer-funded health insurance program is its raison d’etre; one of its most compelling political stories.
But the Prime Minister’s sale of the Medicare story – in the form of a substantial boost to bulk billing with a take-home message that people will be able see a doctor for free – was challenged this week by peak medical groups, general practice academics and some frontline GPs.
The crux of their concern is that the growing difficulties facing Australia’s health system are so enormous that populist policies that sell well in marginal electorates in an election campaign could perversely deepen the nation’s health system crisis. The counterargument is that this huge boost to primary care will take pressure off family budgets and hospitals, keeping people well.
That millions of people cannot always afford to see a doctor when they need to is a reality in modern Australia, as documented for several years post-pandemic by the Productivity Commission and the Australian Institute of Health and Welfare.
It’s an unpalatable situation in a developed nation that prides itself on vital welfare safety nets for the disadvantaged.
The potent political message that a Medicare card – not a credit card – is all you should need to see a doctor for free in Australia harks back to a golden age of universal healthcare. It was a time when the current cataclysmic outlook for health systems around the world with rising chronic disease and an ageing population was not yet envisaged. It’s something Bob Hawke could barely have appreciated when Medicare was born 41 years ago after the Labor Accords in 1984 clinched union support for a skilfully resurrected and recrafted version of Gough Whitlam’s visionary but flawed Medibank policy.
Labor in this election is doing everything it can to link its modern Medicare story to Hawke’s original vision. Buoyed by the lift in bulk-billing rates arising out of its 2023 budget measure to triple incentives for GPs to bulk bill pensioners, concession card holders and children, the Albanese government announced even before the election was called that it would extend the triple bulk-billing incentives to all Australians, with an additional kicker boost for GP practices that bulk billed all patients.
The Liberal Party almost immediately announced it would match the policy with even greater funding but has done little to flesh out or sell the details of its own version. Liberal leader Peter Dutton couldn’t afford to be wedged: the marginal-electorate voters who could swing this election result live in a relatively small array of battleground seats. Voters in these seats, like so many Australians, are smashed by the cost of living; some are avoiding seeing the doctor and many are baffled, stressed and angry as to why they’re no longer bulk billed.
The issue is inherently connected with the other big election swinger: cost of living.
Both parties’ willingness to pour vast amounts of cash into a supercharged bulk-billing incentive program speaks to how significantly the well-documented declines in the general practice sector, from the cities to the bush, are affecting the lives of patients who will soon cast their vote.
Albanese’s antidote is simple and powerful politics. “This is all you should need to see a doctor for free in Australia … not your credit card,” the Prime Minister proclaims in social media ads. Vision pans through B-roll historical shots of the titan Hawke, who is also clutching the “little piece of green and gold”. The next shot is of Albanese in front of a rally protesting against cuts to Medicare, a visual nod to Labor’s story that “you can’t trust the Liberals on Medicare”, especially not Liberal leader Dutton, allegedly the worst health minister in 35 years (a sledge based on a medical press survey that has stuck). This moniker has sparked an array of TikTok and Instagram memes.
Labor’s Bulk Billing Practice Incentives Program promises to lift bulk-billing rates to 90 per cent of appointments. Importantly, that doesn’t mean nine out of 10 people. The number of people always or usually bulk billed is much lower. The triple incentives policy extends the existing incentive to GPs to bulk bill pensioners and concession card holders to all Australians, with an additional 12.5 per cent on top of the base incentive for practices that bulk bill all patients.
The government says the policy will increase the total Medicare payment for a short consultation from $42.85 to $69.56 in urban areas and more in regional and rural locations. That includes a 12.5 per cent boost for practices that bulk bill all patients.
According to a federal Health Department fact sheet, which extends existing modelling derived from the largest dataset of general practice billing in Australia of 6500 general practices enrolled in the practice incentives program, 4800 GP clinics will be financially better off as a result of the incentives policy. The modelling is based on the General Practice Registrars Australia earnings calculator and uses Medicare data across all 140 million GP services delivered throughout metropolitan and rural areas during 2023-24 to calculate national averages and the impact for individual GPs and entire practices.
The earnings calculator assumes a full-time GP delivers an average of four services an hour and retains 70 per cent of billings while passing 30 per cent to the general practice to cover its costs and profits.
“If an individual practice would receive more in additional Medicare payments from bulk billing every patient than it currently receives from charging some patients, then that practice would be in a better financial position from adopting full bulk billing,” the fact sheet says.
The department modelling says 4800 practices will receive an average of $344,000 in additional funding a year depending on the number and type of services delivered.
At present a bulk-billing GP earns less than their mixed billing or privately billing colleagues for providing the same number of services, according to the department, which says this policy will close that gap. The difference from November 1 to annual GP earnings if all patients are bulk-billed is relatively modest in a metropolitan area, according to this fact sheet. GPs at a full bulk-billing practice would earn $5357 more than at an average bulk-billing practice, the fact sheet says. In a rural practice, because of a bigger incentive loading, it’s much larger: $23,964 a year.
But the modelling now made public has been picked apart by doctors who have important questions about some of its assumptions, expressing disbelief that it predicts city-based doctors who bulk bill patients for every visit would collect earnings of $403,805 annually if the policy is implemented after November 1. This assumes a full-time GP delivers four services an hour and works for 3.8 hours a session, for 10 sessions a week, with four weeks of annual leave a year, retaining 70 per cent of billings and passing 30 per cent to the general practice to cover its costs and profits.
While welcoming the historic funding injection that few doubt will increase bulk billing rates, the Australian Medical Association and GP groups insist the policy rewards “fast medicine” and shorter consultations, when most of the patients they now see have chronic disease or mental health issues that take time to examine in a consultation.
These groups feel an opportunity for desperately needed structural reform to health systems has been lost in this election.
The question no political party seems to be asking itself is whether incentivising bulk billing for all Australians including the privileged is a smart use of money.
There’s an argument that the era of fully subsidised healthcare amid rising costs driven by chronic disease is not only fiscal folly that privileges those who can and should pay, it also will make it ever harder to shift the dial to focus on structural reform and a serious commitment to gear the system towards the prevention of disease – a reform project that Labor promised to progress four years ago.
Many of the people whose votes may swing the election result know from experience that it’s not only primary care suffering system breakdown. They may, at times, need to go to hospital, where emergency departments are buckling, ambulances are ramping and where getting access to an inpatient bed is challenging. Tens of thousands are stuck on public elective-surgery waiting lists. Countless patients need emergency care for diabetes complications, one of the most common and potentially life-threatening reasons for being admitted to hospital nationwide.
Labor is offering these people an expanding national network of urgent care clinics, open for long hours and designed to avoid people having to go to emergency departments. Urgent care clinics subsidise healthcare at no expense to the patient but are a very expensive model of care in which the ultimate bill is footed by the taxpayer at a rate about five times higher than a standard GP visit. These clinics are criticised by many doctors who say they fragment and duplicate care, but they’re highly popular with voters – and so the money flows.
Not much has been said in this election campaign about tackling the dire state of public and private hospitals. The former are critically overloaded with enormous workforce shortages and dysfunction, and the latter are in a state of near collapse, with maternity units shutting down at an alarming rate, tolling the bell on a looming private sector catastrophe.
Yet these seismic issues have been almost totally neglected in this election campaign in favour of easily digestible slogans that tap into what political parties know is a hot-button issue at their most common interface with medicine: primary care.
And so it is bulk billing that gets $8.5bn in cash as part of the Bulk Billing Practice Incentives Program. This is on the table for all, even people who are sending their kids to private school at $45,000 a year per child.
The politics of whether GPs will or should bulk bill is red-hot. Doctors proclaim that “medicine is not a shop” but a service. It’s clear that the top end of town doesn’t need bulk billing, but some doctors argue that almost everyone should pay a gap, just as they do for any other medical specialist. Those specialists also have been subject to rebate freezes for years and have not seen one iota of extra Medicare support.
Labor began a temporary freeze on Medicare rebates in 2013 that was continued by successive Liberal governments for about seven years. During that time a proliferation of incentive programs poured billions into GP clinics.
Offering incentives to drive billing practices and health service delivery are now firmly the preferred vehicle for funding GP clinics by all governments. Peak GP bodies prefer Medicare rebate lifts, but the dilemma for the government is it cannot control what GPs charge, meaning many would not bulk bill at a greater rate regardless and would bank greater income and profits rather than resolving the access and cost problems for patients.
Election campaigns and their lead-up are arguably terrible environments in which to craft health policy. Labor in fact has been advancing a Strengthening Medicine program of reforms including moving away from episodic care and getting more nurses into GP clinics, but that’s virtually unknown to voters. For the sake of votes, people are now being told they’ll be able to see a doctor for free. The policy risks shifting the dial back towards episodic care and cost, not quality. Many in the health sector are concerned that it sets up a transactional way of thinking about healthcare in primary practice.
After many years of neglect of primary care sector, what’s being delivered in the biggest investment in Medicare since its inception will please voters and will almost certainly significantly raise bulk-billing rates but at what cost to the system?
What is needed most is not only that deeper reform of outdated systems but a 180-degree turn in thinking to fund and incentivise the policies that take pressure off GPs and health systems in the first place: preventive care. It’s the game changer that families really need, yet preventive care makes up a tiny proportion of the health budget and is utterly neglected, including in this campaign.
