Increased bulk-billing for general practice consultations in regional and remote areas, 2002–2008

To the Editor: Equitable access to health care in Australia is facilitated by bulk-billing so that patients incur no out-of-pocket costs for medical services. From 1995 to 2001, there was a steady decline in bulk-billing of general practice consultations and rates of bulk-billing were lower for women living in rural areas than for those from urban areas.1 In 2004, Medicare incentives for bulk-billing were introduced — additional rebates for bulk-billed services provided to concession card holders or children under 16 years, and a higher rebate for services provided to eligible patients in rural and remote areas, selected metropolitan areas with a shortage of general practitioners or low bulk-billing rates, or anywhere in Tasmania.2,3 We assessed the bulk-billing rates for participants in the Australian Longitudinal Study on Women’s Health4,5 following the introduction of these items.

We analysed 2002–2008 data on out-of-pocket costs for general practice consultations (services with item numbers 1–98, 601, 602, 697 or 698 in the Medicare Benefits Schedule). Cohorts of older, mid-aged and younger woman (born 1921–1926, 1945–1951 and 1973–1978, respectively) who had consented to the release of Medicare data were included in the analysis. They were classified according to area of residence recorded at Survey 5 (conducted in 2007–2009), using the Accessibility/Remoteness Index of Australia Plus (ARIA+).6 Claims for services, including items charged to the Department of Veterans’ Affairs, were identified from linked Medicare data.7

The study was approved by the Human Research Ethics Committees of the University of Newcastle and University of Queensland.

Medicare data were available for 3631 older women, 6697 mid-aged women and 3546 younger women (Box). In 2002, 61% of older women in major cities had no out-of-pocket costs, and this proportion was lower for older women in regional and remote areas. From 2005, there was a marked increase in the proportion of older women with no out-of-pocket costs across all areas, especially in remote and very remote areas (where 87% had no out-of-pocket costs in 2008). Older women from inner regional areas were most disadvantaged in terms of bulk-billing, even after the introduction of bulk-billing incentives. Mid-aged and younger women were less likely to have no out-of-pocket costs than older women but showed similar, albeit less dramatic, increases in bulk-billing.

Our data show an overall improvement in access to bulk-billing, although some inequity remains for women in inner regional areas. This contrasts with earlier findings of declining rates of bulk-billing and increasing out-of-pocket costs, particularly in rural areas and for older women.1 The large increases in bulk-billing that we observed for older women are likely to be due to increased use of general practice services overall8 and a higher likelihood of having a concession card. The impact of the concession card holder incentive may have been greater than the geographical targeting.

A strength of this study is that the results are based on a large national random sample. A limitation is that women who consented to the release of Medicare data had higher levels of education than non-consenters,9 which may have resulted in underestimation of the proportions of women who had all their consultations bulk-billed. Also, while bulk-billing incentives are aimed at areas defined by Rural, Remote and Metropolitan Areas classification, our data were analysed according to the ARIA+ classification (which is now the standard classification for accessibility and remoteness and is stable over time).

The Medicare incentives scheme for bulk-billing should be evaluated further to assess the potential for reducing inequity for people in inner regional areas and for disadvantaged groups who may have a greater need for services but less access.