Triple next to nothing is nowhere near enough

6 minute read

Why was the BBI tripled and not the patient rebate? It’s a clever play and it’s not good for GPs.

The response to the health budget, especially the tripling of the bulk billing incentives for eligible groups, has me fearful all over again.

The decision to triple the incentive but barely touch the rebate – 4% is nothing – is worth looking at closely.

The past year and a half I’ve watched peers who were committed to universal bulk billing slowly realise that socialist values don’t mean much when you can’t pay your own bills, or when you’re paying more for childcare than you’re earning from a day of consulting.

I’ve personally helped talk friends into making the jump; they got cold feet at the last minute, only to find once they did it, nothing bad happened – their lives actually improved and they were able to give the kind of care they wanted to while earning enough to pay bills.

Then came the 2023 federal budget and now it feels fraught again.

Many who had planned to move to private billing everyone are now hesitating because of the BBI, especially in metro areas, which is the only kind of area I can speak for.

In rural and remote areas, it seems almost a given that eligible groups will be bulk billed; but in cities, where many reluctantly moved to gap fees, peers are afraid.

Those who have continued with universal bulk billing are elated, since the triple BBI for eligible groups will still put them ahead of the current status quo. Others who were charging small gaps may return to bulk billing those eligible groups.

But some colleagues who’ve moved to privately billing everyone tell me they won’t be changing, that the media and government spin has made them angry enough to double down. It remains to be seen if this remains true come November.

Some of those in eligible groups who have been paying gaps may move to the clinics that will now bulk bill them as the cost of living continues to bite.

Will those who charge everyone have the courage to hold strong instead of caving in, given the current shortage of GPs anyway? Will they remain busy enough to hold firm?

The system is in flux and we won’t know for perhaps a few years who will ultimately hold out and who will capitulate.

It reminds me of the time I decided to start charging gap fees in 2013, against the advice of the clinic owners and other bulk billing doctors.

Like a toddler tantrum where you only have to outlast them by one second, I used to remind myself during those quiet weeks and months that I could change my mind and give in – but at what cost?

There is now a clear divide between GPs who have disengaged from their total reliance on the government for their livelihood by charging their own fees and making their own rules, and those who feel duty-bound to continue to serve those who cannot or do not wish to pay a gap fee.

The latter will likely experience a boom initially. But the gap will widen.

Why has the government tripled the BBI and not the rebate? The targeting of only vulnerable groups seems to be a clear acknowledgment by the government that universal bulk billing is now unsustainable. But the decline in bulk-billing rates looks bad for Canberra, and without doing something about the funding it couldn’t plausibly keep blaming GPs. This move puts it back into GPs’ court to justify not bulk billing and allows it to reinstate the #greedygps narrative with the implied line: “We are giving them triple the money, but if they choose not to pass on the savings …”

Triple sounds like a lot, and maybe they’re hoping enough people will have confused the incentive with the rebate.

And why stop at bulk billing eligible groups – with all that extra incentive money, why not bulk bill everyone?

The government won’t even be paying anything extra on the incentives until November.

Over time, my suspicion is that this will widen the gap between those who become (almost) entirely private billing and those who continue to bulk bill some/all of their demographic, along with VPE. The latter will become like contracted public outpatient departments for accessing GPs, but at a fraction of the cost of urgent care clinics and hiring GPs as salaried employees with pay parity to hospital specialists.

Encouraging clinics to continue to bulk bill is a way for the government to continue to control general practice, and those of us who disengage end up saving the government money, since the rebate for all practical intents and purposes continues to be frozen. Win-win for the government.

At times in 2013, when it seemed easier to capitulate and return to bulk billing, I used to remind myself of why I was choosing to charge gaps, the kind of care I provide, and whether the money on offer by the government would be reliable going forward given history.

It’s the same story again as I watch from the outside this time around.

The people who have the most to lose are not the ones who’ve moved to gap fees for most patients.

For those who’ve not done it, it’s still a no-brainer.

It’s the group that’s managed to move away recently, that’s uncomfortably charging gaps, that’ll struggle the most and possibly be tempted to go back to an unknown deal that has yet to take effect, with pressure already to pass on the “savings” to ineligible groups.

Whatever choice you make, I hope you consider what’s best for you and your loved ones not only now, but also two, five and and 10 years in the future. We don’t know what the government will do, but historically it has not been kind to general practice at all.

For many, salaried roles also seem like a boon, which may happen eventually with VPE in place. But again, the devil is in the detail and it remains to be seen whether, as in the UK and Canada, this is a carrot that eventually will turn into a stick.

Dr Imaan Joshi is a Sydney GP; she tweets @imaanjoshi.

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