Safety nets and other offsets
Approximately 80% of general practice consultations are bulk
billed. Yet of specialists’ appointments for clinic care, this figure
is less than 30%.26 Although gap payments (i.e. the difference
between the private fee charged by a specialist and the Medicare
benefit received by a patient) are, on average, approximately
$60, gaps in excess of $100 or more are not uncommonly
incurred.
Most private specialists do not bulk bill. With gap fees being
unaffordable for the poor in the first place, less than 4% of
Extended Medicare Safety Net benefits are distributed to 20%
of the most socioeconomically disadvantaged members of our
population. By comparison, more than half of the benefits are
distributed to the 20% most advantaged.27 Some of these may
present for treatment later as public hospital outpatients but this
is nevertheless a failure in policy – those least likely to benefit make the safety net system more accessible, the concomitant
reduction in the maximum amount of out-of-pocket costs that
will be reimbursed through Medicare and the increased limits
on the type of expenses that count towards the safety net do
nothing to protect those most vulnerable from the economic
burden that occurs as a result of high out-of-pocket healthcare
costs.
Bulk billing incentives
Unlike GPs, specialists do not receive incentive payments
for bulk billing consultations. A Medicare incentive for specialists
to bulk bill consultations and other services for
concession card holders and children, which is what GPs currently
receive, would help to address the financial barrier faced
by many patients. Furthermore, as relatively few specialists
work outside metropolitan regions nor within less affluent
metropolitan areas,27 this type of incentive could redress the
potential revenue difference for specialist practices between
affluent and deprived communities. A bulk billing incentive
would be more socially fair than the Extended Medicare
Safety Net.28
Conclusions
A compulsory co-payment for bulk billed GP consultations will
exacerbate already high financial barriers that Australians face
when accessing health care and essential medications, and
further undermine any claims that our current health system has
to equity and fairness.
The key to a financially sustainable healthcare system is a
primary healthcare system that is accessible to all and which
enables individuals to obtain early diagnosis and treatment, thus
averting higher downstream healthcare costs that inevitably
arise through delayed access to care. Instead of creating a barrier
to access primary health care through the introduction of compulsory
co-payments, the Federal Government should do more
to curb unsustainable spending by addressing current inadequacies
within the health system.
Given the burden of out-of-pocket costs found in the general
population, and in people with chronic disease in particular, there
is an urgent need to review the impact of out-of-pocket expenditure
in the current system. We therefore endorse the recommendation
made by the Consumer’s Health Forum to improve
the current system by developing a national policy on co-payments,
informed by community consultation and the growing
body of Australian research.22 Our concern with the recent
Budget announcement is the serious erosion to the principle of
universalism that has underpinned Medicare for the past three
from the Extended Medicare Safety Net are the poor who have
the lowest discretionary income and are most likely to experience
ill-health.
Nine per cent of adults delay or fail to fill prescriptions because
of cost; this rises to more than 12% in the most socioeconomically
disadvantaged fifth of the population.18 Despite concession card
holders incurring a reduced lower prescription co-payment, many
patients with chronic illness who are economically disadvantaged
cannot afford the co-payments on earlier prescriptions and will
not reach the PBS safety net. Furthermore, the Medicare and PBS
safety net programs are not easy to use, with patients reporting
problems understanding safety net requirements and being unaware
of their eligibility.7,22 Other challenges cited include:
program timing (the need to re-qualify each calendar year);
complex administrative requirements (inconsistent processes, a
need to record personal spending, eligibility differences for
families compared with individuals); and program inequities
(couples qualify before singles in elderly households).
Although simplification of the present safety net system
proposed by the Australian Government in the 2014 Budget may