More of the rural and remote Australians who depend on local primary care will bear the cost of a policy failure that could, with the right framework, be avoided.
Australia’s bulk-billing reforms rest on a deceptively simple premise: that practices can offset lower per-patient revenue by lifting throughput.
In metropolitan areas, that logic holds. A city clinic running several full-time GPs, each seeing six to eight patients an hour – supported by practice nurses and allied health staff helping manage chronic disease plans and annual health assessments – can make full bulk billing viable on volume alone.
But transplant that model to a coastal town of roughly 2000 people, or an inland community of 3000, and the arithmetic falls apart entirely.
We are seeing more and more rural practices from Queensland to Western Australian and rural Tasmania close under the weight of increasing wages, administration costs and pressures to bulk bill patients in an unviable business model.
Small-town general practice does not operate on the same economic foundations as a metro clinic. Fixed costs are higher, the patient pool is smaller, the minimum staffing requirements are far more rigid, and the revenue levers that policymakers assume are available simply do not exist.
This article examines why the model breaks down in isolated communities – and why the pressure on these practices is intensifying.
The myth of the solo rural GP
The romantic image of the lone country doctor remains stubbornly persistent. A solo GP practice in an isolated town is among the most fragile arrangements in Australian healthcare.
A single doctor carries the entire clinical, administrative, and on-call load with no redundancy built in. There is no leave cover. There is no second opinion down the corridor. When that doctor takes annual leave, attends mandatory professional development, falls ill, or simply needs a weekend off, the town’s primary care effectively closes. Locum cover is expensive, inconsistent, and increasingly difficult to secure in remote locations.
This is not a theoretical concern – having owned and operated a solo GP clinic in a large regional centre, the reality of being on call around the clock, seven days a week, is acutely familiar. Taking leave is not simply a matter of booking flights; it requires sourcing one or sometimes two locums to cover the gap, at significant cost and with no guarantee of availability.
The human cost compounds the structural one.
Burnout among rural GPs is well documented, and professional isolation accelerates it. A doctor who is permanently on call, clinically isolated, and unable to step away cannot sustain that pattern indefinitely. When they leave, the town frequently loses its only practitioner – and recruiting a replacement willing to accept the same conditions is slow and deeply uncertain.
Solo practice is not a stable model. It is a single point of failure, and one that policy settings continue to underestimate.
Why two doctors still aren’t enough
The intuitive solution is to add a second GP. In practice, having two doctors rarely resolves the problem, and the reason exposes a structural flaw in how rural workforce planning actually functions.
Many small towns depend on registrars and training doctors to fill positions that established GPs are reluctant to take. This is sound workforce development in principle, but it carries an unavoidable condition: a training doctor requires a supervisor.
A registrar cannot operate independently, which means a practice employing one registrar and one supervising GP does not hold two interchangeable clinicians. It holds one fully independent doctor and one whose capacity is partly consumed by supervision obligations, teaching responsibilities, and the administrative requirements of training accreditation.
This is also the appropriate moment to address a common policy response: directing additional training support and funding toward rural registrars and international medical graduates (IMGs) as a solution to the rural workforce shortage.
While more doctors in rural areas is an unambiguously worthy goal, funding that follows the doctor does not solve the practice’s problem. There is already government support directed at individual rural doctors and trainees.
What rural practices critically lack is direct funding support for the infrastructure and operating costs of delivering care in these communities. Training incentives place more people in the pipeline; they do not pay the practice’s fixed costs when the population cannot generate sufficient billable volume to cover them.
To provide genuine leave cover, supervision capacity, and a sustainable on-call roster, a small-town practice realistically needs three doctors by headcount – yet this does not translate into three full-time equivalents of billable clinical work.
Supervision time, administrative load, and on-call recovery all erode the effective FTE. A practice can list three doctors on its books and still struggle to deliver the equivalent of two full-time clinical loads. Headcount and FTE diverge, and the funding model recognises only the FTE.
Related
The part-time problem
In a city, this staffing gap is routinely bridged with part-time GPs. Several clinicians, each working two or three days, assemble into a flexible and resilient roster. In a small isolated town, that solution is frequently not available.
Part-time work assumes a doctor lives close enough to attend for a few days, or that the role is attractive enough to justify the trade-offs. Neither condition holds easily in a remote or regional setting. Consider the practical barriers:
- Higher cost of living. Remote and regional towns often carry elevated costs for housing, food, fuel, and basic services, eroding the financial value of part-time income;
- Travel costs and time. A doctor commuting from a regional centre faces substantial unpaid travel time and fuel costs, rendering a two-day week economically unviable. Fuel costs in rural and remote Australia are considerable and consistently higher than in metro areas — a factor that affects both practitioners and patients alike;
- Limited housing. Many small towns simply lack suitable rental or purchase options, particularly where strong seasonal tourism demand inflates accommodation costs and reduces availability;
- Lifestyle trade-offs. Relocating a family for a part-time role is rarely justifiable, and the professional isolation that deters full-time GPs deters part-timers with equal force.
The flexible staffing model that metro practices rely upon is therefore largely closed to small towns. They must recruit doctors willing to commit substantially and often permanently, which narrows an already shallow pool of willing candidates.
The core population economics
This is where the numbers become unforgiving.
A high-volume bulk-billing model is, by design, a volume business. It demands a large and steady stream of patients to generate sufficient billable consultations. Small towns cannot supply that volume.
Take Kalbarri, WA, with a resident population of roughly 1270 people. Now consider what a metro-style high-throughput model requires.
A single GP seeing eight patients an hour across a 7.5-hour consulting day delivers 60 appointments daily. Scale that to the minimum staffing level a town actually needs for sustainable cover, and the required throughput rapidly outstrips anything the local population can generate.
A practice needing to fill 150 appointments a day – the load of 2.5 FTE on a city throughput model – would require approximately 36,000 appointments a year. Spread across a town of 1270 residents, that equates to an implausible 28 GP visits per resident per year. Even generous assumptions about catchment draw, seasonal tourism, and aged-care demand cannot close a gap of that magnitude.
Some will argue that chronic disease management plans and annual health assessments can supplement this revenue base. The arithmetic is sobering.
A GP Chronic Condition Management Plan can be prepared once every 12 months and reviewed up to four times a year where clinically relevant. An annual health assessment may add one further item per eligible patient.
Even if a significant proportion of the population qualifies for and accesses these items, the additional revenue cannot bridge the structural shortfall created by low consultation volumes.
And this assumes the practice can employ a practice nurse to assist with these assessments – a resource that is scarce in city practices and virtually impossible to attract to remote areas. In regional Australia, experienced practice nurses are in extremely short supply. Recruiting and retaining one in a small remote town is, for most practices, not a realistic option.
The conclusion is structural, not anecdotal: small towns do not possess the population base to sustain a high-volume bulk-billing model. The throughput simply is not there to be captured.
Why the bulk-billing push disadvantages small towns
The rural bulk-billing loadings are genuinely higher.
Under the current schedule, a standard Level B consultation yielding a total Medicare payment of around $69.56 in a metro practice can reach roughly $84.86 in an MMM 6 location, and higher again in remote settings. On paper, this represents meaningful compensation for rural practice.
But a per-consultation loading cannot overcome a volume deficit. Compare the two models directly:
- Metro clinic: eight patients/hour × $69.56 = $556.48 per hour;
- Small-town clinic: four patients/hour × $84.86 = $339.44 per hour.
The rural loading lifts the per-patient rate by around 22%, yet the small-town clinic still earns barely 61% of the metro clinic’s hourly revenue, because it cannot achieve metro throughput. The model rewards volume, and volume is precisely what a small town cannot produce. The higher loading softens the blow; it does not reverse the disadvantage.
Put another way, a policy designed to make full bulk billing financially attractive works as intended in the locations that least need support, and works least well in the locations that need it most.
A shrinking revenue buffer: chronic disease and mental health items
For years, rural practices managed these thin margins partly by leaning on chronic disease management and mental health item numbers. In ageing rural populations carrying a high chronic disease burden, these longer, higher-value consultations provided a meaningful revenue stream that partially offset low consultation volumes.
That stream has been restructured.
From 1 July 2025, the established chronic disease management framework changed substantially. The familiar GP Management Plan and Team Care Arrangement items – including items 229, 721, 230, and 723, along with their associated review items – ceased, replaced by the new GPCCMP framework.
The new structure carries genuine clinical merit: more streamlined planning, strengthened continuity through MyMedicare registration, and a clearer review cadence every three months where clinically relevant.
But for rural practices, the change materially alters the predictability of a revenue source they had structured their economics around. Patients registered with MyMedicare must now access GPCCMP items through their registered practice, which ties continuity to enrolment – a requirement that may assist practices with a stable registered population, but adds administrative burden in communities with high transience or seasonal churn.
Layer the broader bulk-billing push and the restructuring of mental health item revenue onto these changes simultaneously, and rural practices face strain from multiple directions: reduced per-consultation flexibility, a reshaped chronic disease revenue base, and the near-impossible task of employing the allied health and nursing support that would enable them to maximise these items in the first place.
The buffer that once made small-town economics survivable is thinning, and in many cases it has already gone.
The on-call hospital burden
There is a further dimension that metro bulk-billing models never contend with.
In many small towns, the local GPs are also the local hospital’s primary medical workforce. Communities like Kalbarri depend on their GPs to provide after-hours and on-call coverage for the town’s hospital or emergency facility – covering presentations that, in a city, would be managed by a dedicated emergency or hospital medical team.
This obligation cannot be met by one doctor, or even two. Sustainable on-call coverage requires a minimum rotation of three doctors to distribute the after-hours burden, accommodate planned leave and unexpected absences, and prevent the cumulative clinical fatigue that drives burnout and patient safety risk.
A two-doctor town running a one-in-two on-call roster will lose its workforce to exhaustion within a foreseeable and predictable timeframe. This is not conjecture; it is a pattern already playing out across rural Australia.
This requirement stacks directly atop the clinical staffing pressures already described. The town does not need three doctors for daytime consulting alone; it needs at least three to sustain a humane on-call rotation, in addition to the supervision and leave-cover demands of a training-reliant workforce.
The staffing floor for a genuinely viable small-town service is therefore far higher than the resident population – and the bulk-billing revenue that population can generate – can ever justify on a metro funding model.
When the doctor only comes once a week
The endpoint of this economic pressure is already visible in parts of remote and rural Australia. Unable to sustain a resident medical workforce, some small communities have already fallen back to visiting-doctor services – a GP who attends once or twice a week, often flying in from a regional centre.
For some very small and geographically isolated communities, a visiting model may be the only realistic option. But it is a fundamentally inadequate response to the full scope of what rural communities need from primary care.
A doctor attending on Tuesday and Thursday cannot provide continuity of care for complex chronic disease management. They cannot respond to an acute presentation on a Wednesday afternoon. And critically, they cannot staff a local hospital’s on-call roster. When the regional hospital needs a doctor at 2am, the visiting GP is not in the town.
The visiting model solves the problem of access on the days the doctor is present; it abandons the community on every other day.
Reducing communities to visiting-doctor services is not a sustainable solution to the rural GP crisis. It is a managed retreat that leaves some of Australia’s most geographically isolated residents with profoundly inequitable access to care.
The cost borne by patients
When local primary care becomes unavailable or severely constrained, patients do not simply go without. They travel – often far, and always at their own expense.
This cost is substantial and widely underappreciated in urban policy settings. Fuel prices in remote and regional Australia are consistently and significantly higher than in metropolitan areas. A patient in Kalbarri who cannot access a GP locally may need to travel to Geraldton, some 150km to the south – a journey of roughly 300km return.
For a low-income earner, a pensioner, or a person managing a chronic condition requiring frequent review, this is not a minor inconvenience. It is a material and recurring financial burden.
Critically, GP services are not eligible under the Patient Assisted Travel Scheme. PATS supports travel for specialist and certain diagnostic services, but general practice consultations fall outside its scope. Patients who must travel to access GP care do so entirely at their own expense, without subsidy.
This is an equity issue that rarely features in the policy debate about bulk-billing expansion, yet it sits at the heart of what it means to provide genuine access to primary care in rural Australia.
The case for a different policy lens
The economics of small-town general practice are not a scaled-down version of metro economics. They are structurally different. Higher fixed costs, rigid minimum staffing requirements, limited part-time flexibility, a hospital on-call obligation, inadequate support infrastructure, and a population too small to generate metro-level throughput combine to make the volume-based bulk-billing model fundamentally unsuited to these communities.
Per-consultation loadings, however generous, cannot resolve a problem rooted in volume and fixed cost rather than unit price. Directing more training incentives and workforce grants toward rural registrars and IMGs may increase the number of doctors interested in rural work, but it does not address the structural economics of the practices they would join.
The funding follows the individual doctor; the practice still cannot cover its costs from the consultations its small population can generate. These are two distinct problems, and conflating them produces policy that partially addresses one while ignoring the other.
What rural and remote practices need is direct, practice-level funding – funding that supports the delivery of healthcare services regardless of consultation volume, and that reflects the true cost of maintaining a viable, continuous medical service in an isolated community.
Several mechanisms would engage with these economics as they genuinely are:
- Block funding directed to the practice, guaranteeing a baseline level of operational income independent of consultation volume, and recognising the practice as essential community infrastructure rather than a commercial enterprise expected to be self-sustaining on Medicare revenue alone;
- Guaranteed minimum practice payments that acknowledge the fixed cost of maintaining a resident medical workforce, including housing, clinical equipment, and administrative capacity;
- On-call and hospital service loadings that recognise the additional obligation rural GPs carry in providing after-hours and inpatient coverage that in any metropolitan context would be funded through a separate hospital budget;
- Infrastructure and housing support at the practice and community level, to directly address the recruitment and retention barriers that prevent both full-time and part-time clinicians from making a sustainable life in these towns;
- Patient travel support for primary care, including either an extension of PATS eligibility to cover GP services or the introduction of a dedicated rural primary care travel subsidy, so that the cost of distance is not borne entirely by the patients least able to afford it.
The current policy framework asks small-town practices to do more with less, in harder conditions, while applying a funding model designed for a different scale of operation entirely. That is not a sustainable ask.
Until the funding framework acknowledges that the numbers in a town of 1270 will never resemble those in a metropolitan suburb – and that this difference is a reason for greater investment, not less – small towns will keep feeling the pinch.
More of them will fall back to visiting-doctor models that serve only some of the need, some of the time. And more of the rural and remote Australians who depend on local primary care will bear the cost of a policy failure that could, with the right framework, be avoided.
Dr April Armstrong is the owner of Grow Medical Group, is principal CEO and managing director of Business For Doctors, and company director of April Armstrong Enterprises.
This article was first published on Dr Armstrong’s LinkedIn feed. Read the original article here.
