Australia is at risk of developing a two-tier health system where only those with money will have access to healthcare, says one of the country's leading general practitioners.
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President of the Royal Australia College of General Practice Harry Nespolon, said bulk-billing services were becoming less financially viable, and as a result the health system was reaching a crisis point.
On the Border major bulk-billing company Tristar, which runs operations in Wodonga and Albury, has admitted it has had to undergo a complete restructure after a period of "significant financial stress" which resulted in delayed payments to staff.
And alarmingly, Tristar isn't alone.
In fact, Tristar's struggles appear to be emblematic of the financial strain all general practices, who fully or partially bulk bill, have been experiencing for years.
What freeze?
In 2013, the then-federal Labor government temporarily froze the amount of money they would pay doctors for various services listed in the Medicare Benefits Schedule. Successive governments kept the freeze in place until 2017.
Doctors who bulk bill agree to provide a service for the amount listed in the MBS, they are then directly reimbursed for that agreed cost by the government.
In private clinics, doctors are able to set their own prices for services, which patients pay. Doctors within private and mixed clinics can choose to bulk bill at their, and the practice's, discretion.
"We tried to hold our fees back for a number of years... It's just not viable at the amount Medicare are paying."
- Jodie Dennis, The Doctors practice manager
When a patient pays fees upfront they receive a rebate, or refund, from Medicare - but generally there is a gap or out-of-pocket expense.
Before Medicare was 'frozen', the government increased the amount of money given to doctors under the MBS annually, to keep up with the rising costs to businesses. But from 2013 until 2017, the price paid to doctors for services stagnated despite their costs rising.
Since 2017, the government has gradually begun to reintroduce indexation of incentives. This April, the government announced indexation would resume, in phases, on 119 general practice items in the next four years.
So the freeze may be thawing, but can practices - and the health system - recover?
Income flatlines
In recent years Border GPs have struggled to stay afloat with a stagnant income and growing costs.
To stay viable, some have introduced additional fees, others have stopped bulk billing or reduced its frequency and others have done their best to find savings elsewhere.
Practice manager for The Doctors in Lavington and Thurgoona, Jodie Dennis, said both clinics have had to start charging all patients a fee for service, just to keep their doors open. From July 1, both practices introduced a policy that they do not bulk bill clients.
Mrs Dennis said the decision was a direct result of the four-year Medicare freeze and ongoing low indexation.
"We tried to hold our fees back for a number of years," Mrs Dennis said.
"It's just not maintainable and feasible to bulk bill patients. When you consider the increase in wages over that time and the increase in patients' expectations - patients want more, they want to be able to book appointments online, they want to be able get reminders of their appointments - all of these things require extra costs... but it's not something we have provided to us for free.
"It's just not viable at the amount Medicare are paying."
"It's real and we're going to have a two tiered health care system where there will be those who can afford it and those who can't."
- Dr Nespolon
Owner of bulk-billing clinic Elmwood Medical Centre Craig Ford said the past few years had been hard.
"We're fully bulk billing, we're still totally committed to bulk billing," he said.
"It has been a very tough period of course, when your income flat-lines and all your other costs increase around you, it does put a massive squeeze on the business.
"We feel we've fought our way through it and come away on the other side [of the freeze].
"I know some other clinics have either gone mixed billing, a mix of private or bulk billing, or gone entirely private....it's not to say we haven't considered doing the same thing, but we were the first bulk-billing clinic in Wodonga when we opened 12 years ago and we are determined to continue that way.
"So we're just trying to cut our costs as much as we can so we can still provide bulk-billing services."
Dr Nespolon said although the Medicare freeze had lifted, the payment increases were still not keeping up with the rising cost of running a business.
"The freeze went on for about five years and took about a billion dollars out of general practice and there's been no catch up," he said.
"What's happening now is that general practice is covering the government's lack of investment in general practice.
"The [struggles] of Tristar should really be a salutary message to the government that if you keep cutting the costs and failing to invest in GP... you're going to find more and more practices are going to charge.
"So in answer to the question is bulk billing a viable model going forward? For a lot of general practitioners going forward it won't be."
Over-servicing
Mrs Dennis believes bulk-billing services have not been viable for many years and to get by some have been focusing on getting as many patients through the door as quickly as possible.
"I don't think for a long time solely bulk-billing general practitioners have been [viable], what the freeze has done is forced them to over-service," she said.
"There will be a lot of bulk-billing clinics that require patients to come back to obtain results even though they're normal and that's simply because they have to see certain volumes of people to make funds, to keep practices viable."
Mrs Dennis said the Medicare freeze had also resulted in fractured health care for many people, who are happy to pay for a check up with their GP, but opt to go to a bulk-billing clinic when they just want a script repeat. She said this could have serious unintended consequences.
"What can occur then is they're prescribed something at that clinic that their regular GP isn't aware of and there could be an adverse event occurring just through that fractured care," she said.
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Mrs Dennis said she had also seen instances where bulk-billing clinics claimed Medicare refunds for care plans or other services she believes they haven't delivered or that should be delivered, and claimed financially, by someone's primary doctor.
Dr Nespolon said as more clinics begin to charge patients, the country's universal health care system will transform into something a lot less egalitarian.
"The Australian Institute of Health and Welfare did a survey a couple of years ago and found about a million Australians didn't go to GP because couldn't afford to go," he said.
"One of the great things about Australia is we have universal access to healthcare and that's being chipped away at the moment.
"It's real and we're going to have a two tiered health care system where there will be those who can afford it and those who can't," he said.
A 2018 Australian Institute of Health and Welfare report found a million Australians delayed or avoided seeing a GP because of the cost.
"It's real and we're going to have a two tiered health care system where there will be those who can afford it and those who can't," he said.
On the Border there are currently seven entirely bulk-billing clinics, including two Tristar clinics.
Other practices are entirely private and decide their own fees, or are mixed practices who offer bulk billing for health care card holders, children and at the doctor's discretion - but charge others as private patients.
A human cost
Elmwood's Mr Ford knows when people have to pay to see a doctor they often simply won't go.
"When we first opened we had patients coming in that hadn't been to a doctor in 10 years," he said.
"But since we opened and offered bulk billing they came. I know that with some that came, we were able to detect certain things and really help patients a lot .
"People, if they have to pay for their health care, they put it off."
Both Mr Ford and Dr Nespolon agree, without bulk billing, people often don't go to the doctor, instead waiting until they are extremely sick and going to the emergency room. But putting off healthcare until a condition is acute has a very real human, and financial, cost.
"When they rock up to the hospital they're going to be sicker than they need to be," Dr Nespolon said.
"They lurch from acute problem to acute problem.
"It costs the health care system a lot more, the poor patient has a poorer quality of life and is going to be spending more time in hospital. It's not a good outcome for anyone."
Mr Ford said since some Border clinics had asked patients to start paying, Elmwood had seen an increase in new patients, many of whom can't afford the fees at their previous practices.
"It's a real peace of mind for them that they know their health will be taken care of and it's not going to impact their bottom dollar - it's incredibly important to have bulk billing services in the area," he said.
What needs to be done?
Despite concerned raised by GPs bulk billing rates are continuing to increase Federal Health Minister Greg Hunt says, as the commonwealth invest record levels of funding.
"86 per cent of GP services are currently being bulk billed, an all-time high," he said.
"The government is working with our GPs, other specialists and consumers to continuously improve the way Medicare supports quality, affordable health services."
President of the Royal College of General Practice Harry Nespolon said the statistic touted by the government does not actually say how many people were being bulk billed.
"It's 86 per cent of services being bulk billed, not people," he said.
"Actually only about 66 per cent of people that are being bulk billed and about 33 per cent are being asked to pay and that's likely to increase as time goes on."
In 2018, Dr Nespolon said, a Australian Institute of Health and Welfare report found only 23 per cent of doctors in general practice bulk bill all of their patients.
Dr Nespolon said now the Medicare freeze has thawed the government needs to review how items are indexed.
He said the amount of money given to GPs when they perform services on the MBS and bulk bill, should increase in line with the medical inflation index, not the lower consumer price index as it is now.
The Doctors' practice manager Jodie Dennis said the government needs to review the system and should also considering making some payments time-based to ensure patients are being managed adequately and practices are not abusing the system.
While Elmwood's Craig Ford said the government should ensure rebates go up at the same rate as expenses do.
"I don't think that's a big ask," he said.