When I explained to the GPs that bulk billing for the insertion of an IUD and charging $ 150 separately for the same service was illegal, they were horrified. It had been their business model for years. Then when I explained to a patient that his GP had spent more than 20 minutes undertaking complex work, he was equally horrified, but for different reasons – the GP had apparently taken less than five minutes to write a prescription and order a blood test. That was last week.
I have been administering medical bills since Medicare began in 1984. The place where I work is best described as Medicare’s underbelly. It is a dark and disturbingly secret part of the health system where patient journeys, treatments and procedures are converted to claims for payment. I basically shuffle the money around the health system, in an environment where no one trusts anyone, and consumers are just plain confused and bewildered.
Even before I commenced a PhD on Medicare claiming and compliance in 2012, it was obvious to me that Australian health regulation had become an omnishambles, and bulk billing was broken.
When the government announces that 90% of Australians are not paying out-of-pocket costs at the GP, I am certain that most consumers would be scratching their heads wondering where all the bulk billing GPs are hiding.
GP bulk-billing statistics are an important metric in measuring the health of our health system, which is why the government often holds them up as proof that Medicare is in good shape.
However, high rates of bulk billing do not necessarily indicate that Medicare is functioning well, and within the statistics are many complex, and poorly understood phenomena.
Firstly, the GP statistics count services rather than patients, and patients can have more than one service at one GP visit. When a GP provides more than one service, they do not have to bulk bill both, and can chose which service is charged. A common example is bulk billing a consultation, and charging a private fee to remove a skin lesion. There is no illegality, but this type of mixed billing skews the data because the bulk billed consultation drops into the statistics, but the procedure doesn’t. So, this patient will fall within the 90% group, even though they paid on the day. A study undertaken by the RACGP in 2016 suggests this phenomenon reduces the statistics to below 69%. But it doesn’t end there.
There is also what I would describe as ethically questionable billing, caused by system dysfunction. The most common example is repeatedly returning patients for additional appointments, with the sole purpose of enabling more bulk billing. An example might be a patient presenting for a pap smear, back pain, and needing a repeat prescription. All of this could, and should, be dealt with at one appointment, but if the GP brings the patient back multiple times, their revenue increases.
Then we come to non-compliant billing, which is a spectrum of behaviors with criminal fraud at one end and unintentional errors at the other. The most common type of fraud in Australia occurs when a doctor knowingly bulk bills for a service they did not provide. It is devilishly difficult to find and therefore prosecute. Moving along the spectrum of illegality, away from fraud, we have what is called “up-coding”, where a doctor bills for a longer or more complex service than that provided. That is what the patient I previously mentioned experienced – a five-minute consult bulk billed as having taken more than 20 minutes.
Moving still further along we are now in non-compliant, but not fraudulent territory. A good example is found in this 2020 defamation case between two GPs. It is a sobering read about GPs teaching their colleagues to bill incorrectly to maximize Medicare revenue. One of the GPs in the case described teaching her GP colleagues to “pack and stack” as many Medicare items as possible onto every patient.
Medicare only reimburses services that patients need, so even if all services are provided, “packing and stacking” unnecessary services is non-compliant.
All of these non-compliant behaviors end up in the bulk billing statistics. They artificially inflate our health expenditure, and are signs of system failure, not success.
The final, major problem, that skews the data, is bulk billing and charging gaps as separate Eftpos transactions. Once upon a time GPs were charged with criminal fraud for doing this, but an ill-conceived policy change many years ago has changed all that, and the practice has now become so common that it is like a co-payment by stealth, that is hidden in plain sight.
As to the impact of this phenomenon on the bulk-billing statistics, well it’s actually very easy to quantify if we want to. But rather than do that, we could just start believing consumers who are telling us loud and clear that they cannot find bulk-billing GPs, and are struggling to pay for primary health care. Continuing to gaslight them by repeatedly trumpeting completely meaningless bulk billing statistics is worsening our out-of-pocket medical cost crisis and needs to stop.
My doctoral research concluded that Medicare is unfortunately in trouble. It is haemorrhaging to the tune of about $ 7bn per annum and urgent action is required to stem the flow.
It is not too late, but without evidence-based, structural reform encompassing regulation, education, and digitization, consumer OOPs will continue to rise.