title: Strengthening Medicare: will increasing the bulk-billing rate and supply of general practitioners increase access to Medicare-funded general practitioner services and does rurality matter?
abstract: BACKGROUND
  Recent increases in the bulk-billing rate have been taken as an indication that the Federal government's Strengthening Medicare initiative, and particularly the bulk-billing incentives, are 'working'. Given the enduring geographic differences in the supply of general practitioners (GPs) it is timely to reconsider the impact that this increase in the provision of 'free care' will have on access to Medicare-funded GP services in rural and urban areas of Australia. Utilisation has been modelled as two different stochastic processes: the decision to consult and the frequency of consultation.
  
  
  RESULTS
  In the decision to consult model the supply of FFS GPs is a more important predictor of utilisation than the bulk-billing rate. Paradoxically the modelling predicts that ceteris paribus increases in either GP supply or the bulk-billing rate appear to have perverse effects in some areas by decreasing utilisation. In the frequency of consultation model, GP density is not a predictor and increasing the bulk-billing rate will unambiguously increase the frequency of consultation across all areas. In both models, the positive impacts associated with changes in supply and cost are constrained outside the inner metropolitan area by reduced geographic accessibility to Medicare-funded GP services. The modelling also shows that people are more likely to consult a GP in areas of high socioeconomic disadvantage, although socioeconomic status is not a predictor of frequency of consultation.
  
  
  CONCLUSIONS
  Bulk-billing rates and the supply of FFS GPs are important features of the Australian health care system that are, potentially, amenable to policy manipulation. The implications of this research are that government policies designed to achieve similarity in these characteristics across geographic areas will not result in equity of access because they fail to address problems caused by geographic inaccessibility in rural and remote areas. Attempting to increase bulk-billing rates in some of these areas may, in fact, reduce access to FFS GP services.
authors.affiliation: Centre for Health and Society, School of Population Health, University of Melbourne, Australia.
authors.forename: Susan E
authors.initials: SE
authors.lastname: Day
authors.affiliation: Centre for Health and Society, School of Population Health, University of Melbourne, Australia.
authors.forename: Katrina
authors.initials: K
authors.lastname: Alford
authors.affiliation: Program Evaluation Unit, School of Population Health, University of Melbourne, Australia.
authors.forename: David
authors.initials: D
authors.lastname: Dunt
authors.affiliation: Cancer Control Research Program, British Columbia Cancer Research Centre, Canada.
authors.forename: Stuart
authors.initials: S
authors.lastname: Peacock
authors.affiliation: Centre for Molecular, Environmental, Genetic and Analytic Epidemiology, School of Population Health, University of Melbourne, Australia.
authors.forename: Lyle
authors.initials: L
authors.lastname: Gurrin
authors.affiliation: Department of Public Health Sciences, University of Alberta, Canada.
authors.forename: Don
authors.initials: D
authors.lastname: Voaklander