The decline in bulk-billing and increase in out-of-pocket costs for general practice consultations in rural areas of Australia, 1995–2001

To the Editor: Do the data in Young and Dobson's study of general practice consultation fees1 support their conclusion that women in rural and remote areas lack access to affordable healthcare services?

The declining prevalence of bulk-billing by general practitioners suggests that healthcare may be becoming increasingly unaffordable for people on lower incomes. But affordability is not only income-related — it depends also on choices regarding discretionary expenditure. Considering median levels of disposable weekly income, together with the prices of basic daily commodities such as milk or bread (not to mention a $10 pack of cigarettes!), how "unaffordable" is an occasional $5–$10 out-of-pocket fee for a GP consultation?

As Young and Dobson concede, a further complicating factor in their study was that "the consenters . . . tended to have higher socioeconomic status and so may be less likely to be bulk-billed".

It would have been helpful if the authors had defined affordability of GP care in relation to family income (perhaps analogous to advice that rental or mortgage repayments should not exceed a third of household disposable income) and identified just how much their frequent attenders' GP costs exceeded a specified limit of affordability.

Services free at point of delivery are overused, both by patients and doctors, as evidenced by the Commonwealth's implementation of the Professional Services Review Scheme and the States' legislating to curb the costs of workers compensation and third-party motor vehicle insurance claims. There is probably an optimal price range that would facilitate affordable access without penalising the less affluent or encouraging "inappropriate practice".

Closer attention to the affordability of GP services for individual households would help target resources to people who truly need the services but cannot afford them. This may be a better alternative to the authors' suggestion of simply making policy changes (taxpayer-funded?) to lower the price of GP services for all women in rural and remote Australia.