‘Almost impossible to get bulk billed’: patients avoid seeing doctors due to out-of-pocket costs

Ella Elliott was "outraged" when she heard the prime minister, Scott Morrison claim there are currently "record levels of Medicare bulk billing", with the government saying GP bulk-billing rates at 88%.

"Where I live in northern Tasmania, it is almost impossible to get bulk billed for a doctor's appointment, even with a healthcare card," Elliott said.

"If you find a doctor in Launceston who bulk bills, please let me know. There are many, many people, including working people in this area, going without basic health care because they cannot afford the high co-payments."

The 88% statistic refers to the number of services provided by a GP that are bulk-billed, and not the number of patients that are bulk-billed. In one appointment, some patients may have some of their services bulk-billed while they are charged for others. Certain patients are more likely to be bulk-billed, such as concession card holders.

The latest annual Health of the Nation report from the Royal Australian College of General Practitioners (RACGP), published in October, said the median percentage of patients who had all of their general practice services bulk billed in 2018-19 was 64%.

"Patients who receive many services each year - such as older patients with chronic diseases - are more likely to hold concession cards and to have those services bulk billed," the report said. "This inflates the levels of bulk billing each year. One in five (22%) GPs works at a practice that bulk bills all their patients, and 64% of GPs reported bulk billing the majority of their patients."

Some experts have questioned the accuracy of the bulk billing data, saying incorrect billing is artificially inflating the data. The RACGP has long predicted growth in bulk billing of GP services will halt or reverse.

"While overall bulk-billing of GP services has increased by 1.3%, when new Medicare Benefit Schedule items for Covid vaccinations and telehealth are removed (just over 42m services) the remaining 129m services were bulk billed at lower rates than seen since 2016-17," the health of the nation report said.

The latest Australian Health Consumer Sentiment survey, published by the Consumers Health Forum [CHF] in March, found 14% of Australians with chronic conditions could not pay for healthcare or medicine because of the cost. CHF president, Leanne Wells, wants Medicare rebates for general practice consultations to substantially increase.

"Closing the gap between what a patient pays for a GP service and the rebate they receive will help tackle this problem," she said.

Despite increasing out-of-pocket health costs affecting 86-year-old Susan Randall and her peers - "my friends and I all talk about it," she said - Randall can not think of anything politicians have said during the election campaign that gives her confidence the issue will be addressed.

"I've heard nothing about affordable health care," she said, though she added the more important election issues for her are "more affordable housing for young people and action on climate change".

Neither Labor nor the Coalition has announced plans to increase GP Medicare rebates.

Like Elliott, Randall lives in Launceston, and said she pays roughly $300 each year out-of-pocket to see her GP. "It's an awful lot of money, but I don't want to change my GP because I have been seeing them for 25 years, they know my history and they are excellent," Randall says. "Getting to the doctor is also a consideration when you're older, and even if I were to look for a bulk-billing doctor, I wouldn't be able to find one. So I try to keep the gap between doctor visits as long as possible, I try to stretch it out."

GP bulk-billing rates also vary between regions, from 32.9% of patients in the Australian Capital Territory electorate of Canberra and 36.9% in the WA electorate of Curtin, to more than 96% of patients in the New South Wales electorates of Chifley and Fowler.

In Canberra, Emma Connell lives with three chronic health conditions - anxiety, depression and a degenerative back problem - and sees a GP multiple times every year.

"None of my visits are bulk billed," she said.

"Unsurprisingly, none of my specialist visits are bulk billed either. The only completely bulk billing GP service that I am aware of in the entire Territory is the after hours service."

"There are only three people in my circle who have bulk-billed GP appointments - my mother, aged 80, my partner, aged 65, and my terminally ill daughter who has a health care card."

Martin Taylor lives in Manly West in Brisbane, and said after living in the US he is grateful for the health system in Australia, but when it comes to GP visits, "I tend to ration visits because of cost".

"I am a retired senior with less than $26,000 regular income [each year]," he said. 

"I usually pay $35 a visit after Medicare rebate. But I also had to pay $300 for a PET scan for cancer recently as it is not covered by Medicare.

"I would prefer to move to the bulk-billing clinic up the road, but it's hard to have a regular GP there as they turn over so much."

In 2011, Taylor spent $248 on out-of-pocket health costs after Medicare rebates. This rose to $3,277 last year.

"Costs have increased both because fees have gone up, but also because I am getting older and more things are breaking down," he said.

Sarah Bonnor is close to retirement and says in Perth, Western Australia, "bulk-billing is a rarity". She is worried about the cost of GP appointments and dental care.

"I Googled bulk-billing doctors in Perth metro and so few came up," she said.

"This means I have to travel to attend a bulk-billing GP. I refuse to pay the $85 out-of-pocket expense which is standard in Perth when attending a non bulk-billing GP. If bulk-billing were not available to me, it would be a struggle especially with rising costs of living expenses, fuel prices, local government rates, and utility bills."

Bonner has a chronic illness which requires reasonably regular GP visits. Unable to wait in the hope that one day dental treatment might be included in Medicare, she has opted for tooth extractions, rather than pay for the cost of implants.

"This means my chewing is compromised and I have to steer clear of some foods," she said. "I have lived and worked previously in the UK through dual citizenship, and there I received all my dental care for minuscule amounts. I pay my taxes and feel strongly about such unnecessary, out-of-pocket expenses in Australia."

*All names have been changed to protect medical records and privacy