The demise of bulk billing — Howard's two-tier Medicare

by Dr Con Costa*

She came in complaining of nausea. She said she had been to the 24-hour 
Medical Centre on the Sunday and "had waited with a hundred other people". 
At the end of a two-hour wait she was given a prescription for Stemetil — 
a tablet used for symptoms of nausea.

Not much history taking, no examination and not even a pregnancy test 
which, in this 30 year old woman, would have quickly revealed the diagnosis 
of pregnancy and led to more appropriate treatment for both mother and 
baby. (Fortunately, most family GPs are a lot better than that!)

There is a crisis in general practice. People want their bulk billing but 
they are having to wait longer and longer for medical attention only to end 
up with rapidly-revolving-door type of medicine. Waiting even longer are 
those at home, too sick to come to the doctor, or those in nursing homes.

And it is not just a shrinking Medicare rebate that is driving the medical 
sausage machine faster. Four years of restrictions on Provider Numbers 
means there is now a shortage of doctors.

GPs are tired of facing over-crowded waiting rooms every day and the fact 
that there is no one to replace them even for a short holiday — much less 
find a long term assistant or another doctor to join a medical practice.

Waiting rooms are becoming more crowded and many doctors are refusing to 
make house calls or visit nursing homes — or even to give simple test 
results over the phone.

As more GPs stop bulk billing things only get worse. The pressure increases 
on the remainder and the log-jam has now spilled over into the Accident & 
Emergency rooms of the Public Hospitals.

The Federal Government continues to deny widespread GP shortages across 
Australia but the Federal Health Department's most recent Better Health 
Outcomes quarterly publication admits that, of the 150 outer metropolitan 
areas of the six capital cities "70 percent would be classified as 
experiencing workforce shortages in 2003 and would consequently be eligible 
for the new workforce strategy" commencing in January.

The situation has become particularly parlous for those at the end of the 
bulk billing queue — nursing home residents and people needing care in the 
home.

Elderly frail people with chronic pain or suffering from poor circulation 
and worn out joints — most on a cocktail of medications which can prove 
toxic without thoughtful and regular medical supervision — wait for a GP 
who may never come or who turns up only to write up the repeat 
prescriptions".

Most of these elderly patients can end up in expensive hospital beds — 
very quickly and fairly often. Senseless cutbacks to Medicare are causing 
the health system mind boggling expense. And they may be the lucky ones.

Bulk billing is important for patients and no less for the middle classes. 
People value it. For most Australians bulk billing is Medicare. If bulk 
billing goes — even if it remains only for pensioners and card holders — 
then Medicare is finished and it will quickly be followed by the loss of 
the Pharmaceutical Benefits System (PBS).

But even before the demise of Medicare the federal government has created a 
two-tier health system. The rich who are willing to pay a bonus to the 
doctor become first class patients in Howard's Medicare — they get 
appointments and time with the doctor. Those who insist on their right to 
bulk billing are regarded as second class and may end up with "turnstile 
medicine".

Bulk billing for everyone

The leader of the AMA, Kerryn Phelps is a talented and capable performer 
and one of the best representatives doctors have had for a long while. But 
I find it difficult to comprehend her description of bulk billing as 
"middle class welfare". It is a wrong notion and it must be challenged.

Corporate Medical Centres also view bulk billing as a "safety net" for 
patients who cannot afford private care. They are encouraging doctors to 
increase their incomes by moving away from bulk billing. (Surely Corporate 
Centres — with their ability to concentrate profits from Medicare bulk 
billing — should be expected to return some of this money via more 
prevention and health education services provided by nurses and health 
workers in their waiting rooms as well as providing community care).

Even politicians in the Labor Party talk about saving bulk billing "in poor 
areas or for elderly patients and card holders". (They talk about bulk 
billing by postcode.) How high an apartheid type fence will we need to 
build around these bulk billing enclaves to stop the desperate middle 
classes from getting their bulk billing?

Really we have to give it a lot of thought. Medicare and bulk billing, just 
as the PBS, has always been about universal cover. Take out the middle 
class (and the wealthy) and funding for the whole system collapses. The 
beauty of Medicare and the PBS, is that they are essentially funded by 
everyone — including the middle class — and everyone should benefit.

In the USA, where there is no universal Medicare, the average patient 
suffering from heart disease and diabetes now pays around $1,000 per month 
only for their medications!

While the federal government continues to shilly-shally on a package of 
support for bulk billing, it is the sick and the elderly at the end of 
lengthening bulk billing queues who are paying the price. It makes the 
government's treatment of asylum seekers seem positively humane!

A package of support for bulk billing

Urgent measures are needed to support bulk billing — an increase in the 
Medicare rebate (to match the Schedule fee) and a one off annual payment to 
those practices which continue to bulk bill their patients.

More innovative would be subsidies towards the provision of nurses in bulk 
billing practices.

Why should patients waiting for two hours to see a doctor not have the 
opportunity to have health screening, health promotion or preventive care 
while they wait? Why aren't nurses available to work with doctors and 
patients in general practice — other than in trauma rooms?

The government could also pay the increase in medical indemnity insurance 
premiums for bulk billing doctors and give priority to bulk billing medical 
practices for placement of GP registrars. Higher medical indemnity 
insurance premiums will only be passed on to the patients through less bulk 
billing by even more practices.

If the AMA and the government are really concerned about so called "middle 
class welfare" then they should immediately scrap the $2.8 billion taxpayer 
subsidy to the private health insurance industry. By this means the above 
measures to support bulk billing could be implemented without the need to 
raise taxes or increase the Medicare Levy.

There would still be enough money left over to increase Aged Care funding, 
introduce a proper National Dental Scheme to provide affordable dental care 
for all needy Australians and to improve our aging public hospitals!

Furthermore, there would be tremendous long term savings to the health 
system by re-organising around better funded and team based primary care.

The young woman with the nausea eventually found proper care — but she 
ended up losing her baby. The frail and elderly at the end of the queue are 
often even less fortunate.

* * *

* Dr Costa is the National Vice-President of the Doctor's Reform Society