Life after bulk billing

7 minute read

From the big smoke to the bush, GPs are breaking up with bulk billing. Here’s two stories of why and how they did it.

Last year, the RACGP president made a bold move: she encouraged her peers to move away from bulk billing.  

The Medical Republic has published countless articles on whether and why bulk billing is dying, how long it is taking to die and speculation on whether it can be resuscitated. 

Ongoing post-mortem aside, it’s not easy to introduce new billing methods.  

If it was, the government statistics wouldn’t claim that 89.1% of GP non-referred attendances were bulk billed over the past 12 months – though finally the new Health Minister Mark Butler has challenged this spurious figure.  

Here’s how two female GPs – Dr Sarah McLay in country Queensland and Adjunct Professor Karen Price in metropolitan Melbourne – increased private billing.  

Dr McLay, who founded Clermont Country Practice in 2019, never intended to run a high bulk billing practice.  

“When the government mandated bulk billing for phone calls with the introduction of covid telehealth, we went from doing a fairly average amount of bulk billing to doing extreme amounts of bulk billing,” she tells TMR.  

“It was near impossible to pull that back, because the expectation had then been set.” 

Clermont, in central Queensland, has a population of around 3500 people.  

While surrounding towns like Emerald and Moranbah rely heavily on the resources sector, Clermont itself is primarily an agricultural town; it was there long before the mining boom, Dr McLay says, and will continue to be there after the mines are exhausted. 

“Because it is a multigenerational community, there’s a lot of complex medicine,” she says.  

“We’ve had shortages of doctors for such a long time … that we haven’t had good preventative care.” 

Problems like kidney disease, heart disease, lung disease and diabetes have gradually built up in the town, according to Dr McLay, to the point where presentations in general practice are quite extreme. 

The nearest tertiary hospital is a 3.5-hour drive away, and for some time there wasn’t even a transport service for the people who couldn’t make that drive.  

Given that more complex presentations invariably require more time to treat and trying to get patients into hospital can be tricky even under the best circumstances, appointments tend to run long. 

Medicare, quite famously, does not reward GPs like Dr McLay for these long appointments.  

Something had to give.  

“I knew there would be problems with the public interpreting the challenge [of bulk billing] because it is so multifactorial,” she tells TMR.  

“I thought it would be better if I put it out there and gave them an opportunity to understand what was happening, than just simply change my billing structure and have no explanation. 

“Our environment is very isolated out here, so it’s also very easy for me to make a change and for the community not to understand that it’s actually happening in the broader community, in the broader Australian system, on a widespread scale.” 

In May, Dr McLay posted a 15-minute video presentation breaking down all the reasons why Clermont Country Practice could no longer bulk bill.  

“I was really anxious and delayed making the decision [to stop bulk billing] for so long out of a sense of obligation to the community, but there was just no alternative by the time I did it,” she says. 

The video has since been viewed well over 6000 times, almost double the entire population of Clermont.  

“I was prepared for a lot of really cranky people, but instead what I’ve seen is a lot of people coming forward and saying ‘look, you provide really good quality care,’” Dr McLay says.  

“‘We don’t want to see you go and we understand that if we don’t step up and help you, that you are going to leave.’”  

One of the driving factors behind her decision to move away from bulk billing was the fact that general practice has a culture of sacrifice. There’s an underlying feeling that GPs are there for the common good, not to earn anything.  

“It was almost taboo, when I was training – you just don’t discuss money,” says Dr McLay.  

“There’s a persistent expectation in [this area of] medicine that you’ll give and give and give and give, and that it’s not okay to expect payment. That you’ll do overtime, and that you should just expect that it’s for free.  

“You’ll turn up early, you’ll give up your weekends, you’ll do seven years of university and if you’re lucky you can earn $15,000 to $20,000 a year, and that’s okay. 

“You just keep copping this relentless sacrifice on the chin because that’s the job you chose.” 

The shift to private billing is, for Dr McLay, just as much about running a viable practice as it was about changing the public perception of GP care.  

She’s also noticed a change in how her GP peers see their work. 

“I’ve seen GPs, instead of having that sense of hopelessness, identifying that this is the opportunity to start the narrative around what general practice really is,” says Dr McLay.  

“This is what we do, it is really important and it costs money.” 

She encourages her colleagues to follow suit and move away from bulk billing.  

“Now is the time to not be afraid to offend people,” Dr McLay says. “Just like me, you might be surprised – your community might turn around and really fight for you.” 

A few years earlier, a GP at the other end of the country also made the decision to move away from bulk billing.  

Professor Price, current RACGP president, was working in a low socio-economic area on the outskirts of Melbourne when she hit breaking point.  

It was a location with a high level of need and complex presentations were common. 

“As one of the only full-time females – and this is a while ago now – I became heavily involved in all of the long, complex consultations and got less and less procedures, so my income plummeted while I was doing this really hard work, compared to other people in the practice,” she tells TMR.  

Female doctors being saddled with more than their fair share of complex patients is an all-too-common issue.  

“We’ve got to fix Medicare, which is heavily biased towards procedures and heavily biased towards short consultations,” she says.  

“The cohort of women who have come through since I’ve started are now in senior positions, a lot of us, in terms of our careers… and I think we’ve all had enough.” 

Eventually, Professor Price elected to move to a practice in a middle-class suburb which already had mixed billing set up.  

This wasn’t an easy decision. 

“I had a large cohort of patients who relied on me, that I hoped I was providing a high quality service to,” says Professor Price. 

“I had to walk away from that [because of] the failures of government to keep pace with CPI in the Medicare benefits schedule.” 

Moving away from bulk billing, the RACGP president has come to believe, is the only way to deliver quality care to the patients who can least afford it.  

“Mixed billing allows you to help those people who really are unable to manage any co-payment, but also subsidise the practice,” she says.  

“It allows you to do what we call cross-subsidisation, and the only way you can see those patients is by having a cohort of patients who are privately billed.” 

Professor Price has a stern warning for the people and groups who put her concerns about the viability of general practice down to GP whinging or greed.  

“For people who might criticise that politically, I’ll just say two words: aged care,” she says.  

“There was a lot of whinging about aged care for several decades, and then it broke.” 

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