Australia has lost more than 400 dedicated bulk-billing GP clinics in the past year, with some electorates experiencing an almost 30% decline, according to an analysis of a government health services register.
Guardian Australia analysed clinics listed as “bulk billing only” on the Healthdirect service finder GP database between 2023 and 2024.
Patients who are bulk billed do not pay anything for their consultation, with GPs billing the government directly through Medicare instead. Mixed billing clinics bulk bill some services, often just to concession card holders, while other patients pay an out-of-pocket fee.
The analysis found 455 GP clinics switched from fully bulk billing to a mix of bulk billing and out-of-pocket fees in the year to February. Meanwhile, 114 bulk-billing clinics are no longer on the register, having either closed or been removed for other reasons.
However, 124 clinics switched from mixed billing to fully bulk billing, while 35 new dedicated bulk-billing clinics were added to the register.
In the same time period there was a net increase of 301 GP clinics listed as charging out-of-pocket fees.
Changes mapped by area
Guardian Australia’s analysis also shows the change in billing practices aggregated to electorates. Each clinic is responsible for updating their register entry and some clinics may not have updated their billing information. While many GP clinics are listed in the service finder, it is also not an exhaustive list.
For example, in the Queensland electorate of Fisher, the Caloundra health services minor injury clinic does continue to bulk bill despite not being listed in the directory.
Nonetheless, the data does give a general overview of where dedicated bulk-billing services are most scarce.
Pearce, in Western Australia, had 36% of GP clinics listed as bulk billing only in 2023, which dropped to 8% in 2024. Dickson, in Queensland, experienced a similar drop, from 29% to 8.2%.
At least one region in Tasmania, the electorate of Franklin – covering the towns of Dover and Cygnet – has no bulk billing-only GP clinics listed in 2024. Franklin still has at least 11 GP clinics listed that offer discretionary bulk billing.
Tasmania is historically the jurisdiction with the second-lowest proportion of visits to the GP that are bulk billed, behind the ACT. Both had the lowest percentage of bulk billing-only GP clinics in 2024, when the service finder data was aggregated by state.
The electorate of Adelaide has lost the most dedicated bulk-billing clinics overall, with 13 fewer over the year. Among those, two clinics closed and one general practitioner died after more than 60 years working as a doctor in the area, but the remaining 10 transitioned to a mix of charging fees and bulk billing.
A difficult adjustment
Dr Stephanie Ng is a general practitioner at City Medical Centre in Adelaide, which in December 2023 switched from a bulk billing-only practice to mixed billing. Ng said the practice still bulk bills about half of its patients who are under 16 and concession card holders but other patients have found it difficult to adjust.
“In the first two months we have aggressive patients all the time, yelling and screaming at our front desk staff,” Ng said.
Their patients are largely vulnerable groups, including retirees, pensioners and migrants, she said. However, the choice to have to move away from universal bulk billing was needed due to the cost of rent; the wages of front desk staff, a practice manager and nurses; the software needed to run the practice; equipment such as needles, gloves and disinfectant; and utilities – which Ng said is “the killer”.
“In the past few years, the inflation rate has gone crazy. All the staff’s wages have gone up at least 15%, and all the consumables have gone up pretty much 15-30%, so we can’t actually afford that.”
In November the government increased the rebate paid to GPs for bulk billing concession card holders and children under 16 for most standard consultations.
The federal health minister, Mark Butler, said the government’s increased incentives had resulted in a rise in bulk billing numbers.
“The boost to bulk billing backs up the reports that we’ve been getting from doctors everywhere, with more GPs offering bulk billing to the patients that need it most, even in clinics that aren’t exclusively bulk billing,” he said.
“In Queensland’s Magnetic Island, near Townsville, Dr Michael Clements told us his clinic has ‘actually returned from private billing children and pensioners to bulk billing them, because it is a significant difference’.”
Bulk-billing rates trail pre-Covid levels
Newly released government data shows an increase nationally in the percentage of services bulk billed by GPs from October (before the incentive increase was introduced) to December. However, the rate of bulk-billed services is still below the pre-pandemic level.
The October-December increase is greater in some areas. In Franklin, where there are no dedicated bulk-billing clinics listed in 2024, 61.3% of trips to the GP were bulk billed in December after the incentive increase, up from 53.7% in October.
Other areas have also had large increases in bulk-billing rates, such as Clark in Tasmania (up 9.3 percentage points), Mayo in South Australia (8.9 percentage points) and Bendigo in Victoria (eight percentage points).
Medicare ‘undermined’
Sue is a 72-year-old pensioner from Sippy Downs in the electorate of Fisher. Her local general practice switched back to bulk billing after the government tripled the incentive, only for her GP to leave the practice and the new doctor she was allocated to charge her a $20 out-of-pocket fee once more.
After major abdominal surgery in November for a giant hernia that ripped open her abdominal wall, Sue has had to manage the sack that drains her stomach’s fluids herself because she says she cannot afford to pay the out-of-pocket fee. “Over a year, that is hundreds of dollars out of my pension.”
Dr Lesley Russell, an adjunct associate professor at the University of Sydney’s Menzies Centre for Health Policy and Economics, said: “The way Medicare is currently operating and what this data highlights perfectly is how the universality of Medicare has been undermined.”
While the cost of operating a general practice has gone up, there is no publicly available data to show by how much, Russell said.
“But it’s pretty clear that the doctors themselves now feel dramatically less constrained about what they charge now than they used to,” she said.
“It seems that clinics reflect what other clinics in the area are doing … and that’s perhaps why you see that area around Newcastle and Adelaide with decreasing bulk billing [clinics].”
Russell said there was a possibility that more corporations moving into the ownership of private practices could be part of why there are decreasing rates of universal bulk billing.
She also noted that the government data that measures the proportion of bulk-billed services “only measures the out-of-pocket costs for people who actually get care. They don’t measure the fact that a lot of people don’t even get to care because they can’t afford it in the first place.”
A database of GP clinics in Australia was collated from the National Health Services Directory site in February 2023 and February 2024.
Listings provide name of clinic, address, latitude and longitude, and some details about the practice including billing options.
Practices were aggregated to state and territories, electorates, and primary health networks using latitude and longitude provided in the data.
Each clinic can self-classify their billing category from the following options: Bulk Billing Only, Fees Apply, Fees and Bulk Billing, No Fee, Other Option.
We combined two categories which only appeared several times - No Fee (Means Tested) with No Fee, and Co-Payment with Fees and Bulk Billing.
The No Fee category is used almost exclusively by Aboriginal health services, so it was excluded from the main analysis of bulk billing.
We calculated the proportion of each billing category (Bulk Billing Only, Fees Apply, Fees and Bulk Billing) nationally, at the state and territory level, per electorate, and by primary health network (PHN), as well as the total national change from 2023 to 2024.
We looked at the correlation between the percentage of Bulk Billing Only, Fees Apply, Fees and Bulk Billing in a PHN as at February 2024 with % of services bulk billed (“Total GP Non-Referred Attendances”) in the September 2023 quarter.
We also looked at the correlation between the percentage of Bulk Billing Only, Fees Apply, Fees and Bulk Billing in an electorate as at February 2023 with 2021-22 data showing the percentage of patients with all GP visits bulk billed.
It’s not clear what the difference between Fees Apply and Fees and Bulk Billing categories are, as some clinics categorised as Fees Apply seem to still bulk bill on a discretionary basis. However, the % of Fees Apply in an electorate has a strong negative correlation with the % of services bulk billed, so the assumption is it is practices which tend to charge fees rather than bulk bill.
