Opt-in Medicare model ‘would lift bulk billing’

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A proposal to increase bulk-billing rates through a voluntary participation scheme would deny rebates to GP practices that don’t sign up.

As healthcare leaders agonise over whether increasing the MBS rebate is the solution to saving general practice or whether the Medicare system needs a complete rethink, two policy experts have floated a radical proposal to reduce financial barriers to healthcare access.

The scheme would allow GP practices to access MBS items by signing up to a voluntary participant scheme – and practices that chose not to participate would need to go it alone and bill on an entirely out-of-pocket basis.

In a paper published in the Federal Law Review earlier this month, Associate Professor Fiona McDonald, co-director of the Australian Centre for Health Law Research, and Professor Stephen Duckett, former director of the Grattan Institute’s health program, argued the Australian Constitution gave government greater freedom to shape healthcare policy than previously thought.

Plummeting bulk-billing rates could be bolstered to meet the needs of more needy patients, they said.

The proposal floats the idea of a “participating provider” program that could restrict access to some or even all Medicare items to practices that choose to opt in.

The authors believe a policy could be designed that would increase bulk-billing rates without introducing a mandate to use MBS items – avoiding worries about overstepping the restrictions of the Constitution.

“In brief, government might restrict access to some or all Medicare items to those practices which voluntarily decided to opt into participation,” the paper says. “New items – such as telehealth or enrolment payment items – might be candidates for restriction to participating practices. A condition of participation might be that all patients be bulk-billed.”

According to Professor Duckett, patients would benefit from knowing how much they would likely need to spend – or not.

“At the moment, patients have no certainty if they front up at a practice – they don’t know whether they’re going to be bulk billed or not,” Professor Duckett told TMR. “What we’re saying is, we ought to have a system where practices commit to bulk billing, and they also commit to other sorts of things like training other GPs, future generations of general practitioners.

“So, it’s a quite a different way of thinking about Medicare and about what your guarantee to the Australian population is.

“Now, in return, the GPs have to know they’re going to get fair remuneration and they have to, for example, no longer be subject to fee freezes implemented at political whims. So, there’d be a sort of a quid pro quo, that the practices get guarantees and patients get guarantees as well.”

But what about those that decide not to opt in as participating providers?

“Doctors not opting into participation would still be able to practice medicine outside this scheme but would rely solely on patient out-of-pocket payments,” the paper says.

“Demand for doctors charging full out-of-pocket payments would decline marginally because the effective price for patients would increase. Literature suggests that a 10% increase in price leads to only a 2% decrease in demand for GP services.”

The authors appear confident market forces will look after non-participants:

“The fact that about 10% of services are currently not bulk-billed suggests there is a market distinct from bulk-billed practice and that some patients are willing to pay out of their own pockets for GP services,” the paper says. “Some of these people will continue to make out-of-pocket payments to see a non-participating GP of their choice.”

Professor Duckett accepted this would create a two-tier system, but not that it would create a problem for non-participating practices.

“There are lots of practices which don’t buckle at the moment at all, and charge significantly above – twice, or more than twice – the schedule fee,” he said. “So they’d make a commercial decision about whether to sign up or not, and that’s up to them.

“These are private businesses, of course, and they make commercial decisions all the time.

“And so it’s up to the businesses to decide whether they want to be part of that second-tier non-bulk-billing approach.”

The policy proposal follows what the authors say has been a trend in thinking more liberally about how much the Constitution restricts the government’s ability to become involved in healthcare.

The Constitution enables social policies but also appropriately limits how the Commonwealth government can intervene in the medical marketplace,” according to the paper. “Policymaking can be quite problematic if the scope of political power is unclear.”

What’s known as the “civil conscription” provision of the Constitution is still cited as a major barrier to developing health policy and policymakers appear to be cautious about testing whether the Commonwealth has the power to legislate around medical services to pursue a bold agenda about access, quality, and efficiency of medical care.

But legal thinking about the area has been changing gradually since the 1980s.

“A distinction has begun to be drawn between regulation of services and regulation of access to Medicare benefits – and the scope of what would be seen as practical compulsion has begun to be limited,” the paper says.

“It is now clear that the Commonwealth can take reasonable steps to ensure value for taxpayers’ money and that a right to practice medicine is not the same as a right to bill Medicare. This opens up a range of policy possibilities for government to improve the quality, efficiency, and equity of access to health services.”

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