An increasing number of GPs are abandoning bulk billing due to the rising costs of doing business. Could optometry – as one of the highest bulk billing professions – face a similar fate? The answer is nuanced, as Insight discovers.
Optometry faces an interesting conundrum when it comes to Medicare. On the one hand the gap between what an optometrist receives for providing bulk billed services and the actual cost of providing clinical care sustainably is vast. Yet, the profession boasts one of the highest bulk billing rates among all health disciplines (around 94%).
So, when the sector tries to convince the government that Medicare rebates need to rise to better match the cost of providing contemporary optometric care, policymakers struggle to see a system under strain. Adding to the situation is the ingenuity of optometrists to cross-subsidise the retail and imaging components of their business to cover the rising cost of clinical care.
It’s a situation Optometry Australia CEO Ms Skye Cappuccio is familiar with. She’s long rallied against the erosion of optometric Medicare including through various indexation freezes and a 5% cut in the infamous ‘Hockey Budget’. Thankfully indexation has resumed from 2019, following extensive advocacy from Optometry Australia.
“Medicare rebates are insufficient to cover clinical care,” she says. “A lot of optometry practices are making their money in the retail space, so glasses and lenses, and a lot of them are loss leading in the clinical care space.
“It’s extremely difficult to get better fees under Medicare. Even larger, and hence politically powerful, professions like GPs continue to struggle with this. The particular challenge for optometry is that whilst we have incredibly high Medicare bulk billing rates, it is close-to-impossible to convince the government that the fees are insufficient and that they need to invest further.”
As alluded to, bulk billing rates have declined significantly among Australian GPs. A survey from the Royal Australian College of General Practitioners’ (RACGP) annual health of the nation report, published late 2023, found only 12% of GPs bulk billed all of their patients in 2023, compared with the 24% who reported doing so in 2022. Among the 2,048 GPs surveyed, this represented a halving of the bulk billing rate.
The Australian Medical Association said the Medicare rebate for a usual consult used to cover costs of providing that care, but this now covers less than half of the cost of running a consultation. Now, about two thirds of patients are bulk billed all of the time, the organisation’s figures showed.
Optometry Australia has recently stated estimates drawn from comprehensive analysis of practice costs indicate the actual cost of providing a comprehensive consultation in a sustainable business model is over $50 more than the Medicare scheduled fee.
Cappuccio expects fewer optometrists to provide bulk billed care over the next decade, but she says there are several factors underpinning the relatively high bulk billing rate.
Around 94% of optometry services have been bulk billed back to around 2015. Prior to this, there was a condition on optometry that capped the service fee they could charge on Medicare-subsidised care. Because this was only slightly higher than the bulk billing rate , most didn’t charge a service fee.
“For a very long time, almost 100% of optometry services were bulk billed because of the fee cap. But after 2015, thanks to lobbying from Optometry Australia the fee cap was removed, which changed the conditions that should have been driving bulk billing,” Cappuccio says.
“We did see a drop in bulk billing rates to about 94%. We were expecting many more practices to reduce bulk billing. Undoubtedly, a lot of it comes down to the competition and the perception of competition in the industry. There’s often a perception from practices that they can’t compete if they aren’t predominantly bulk billing.
“I think we’re likely to see gradual reduction in bulk billing rates in coming years, particularly as we see more practices performing chronic disease management and more complex care that isn’t easily cross-subsidised with retail sales and often requires longer appointments.”
Aside from retail, Cappuccio says optometrists are finding other ways to offset the losses from their clinical care, such as charging for OCT, retinal imaging and other services outside Medicare.
A small number of practices have ceased bulk billing altogether by adopting a private billing model where the patient is charged upfront the actual cost of their care, and will receive a Medicare rebate if eligible for the service.
“Sometimes there’s more fear about moving to this type of model than reality might suggest is necessary. We regularly hear from optometry members who were worried about making this billing change, but when they did it turned out to be extremely positive. It’s also important for optometrists to remember it doesn’t have to be all or nothing, many practices charge private fees but will bulk bill concession card holders to ensure they can still access healthcare,” she says.
“You need a considered change management process to introduce billing changes, taking your patients on the journey with you and being clear about who you’re billing and when, so all of your staff, as well as all patients, have an understanding of who’s going to be billed and in what contexts.”
She says Optometry Australia has developed comprehensive resources to assist members making the transition away from bulk billing, including videos and webinar, a glaucoma billing and fee calculator tool, recommended private fee list and staff training resources.
So, what does the future hold for bulk billed optometry?
Cappuccio expects to see change, albeit slow. A reduction in bulk billing might result in alternate funding methods, including optometrists positioning themselves to work at a broader scope.
“To be able to provide full-scope care for patients, we need to be able to fund it. We either need to see a change in the way optometrists are billing to fund enhanced levels of chronic condition management or a change in the funding systems ,” she says.
“With the MBS review now finalised for optometry we have commenced planning for our next round of advocacy in this space including new optometry MBS items to try and obtain fairer renumeration for many of the key services members provide.
“It’s clear the government has some appetite for changing primary healthcare funding models, but these changes have been talked about for the last 15 years and are only now being incrementally implemented in general practice. There’s hope that we might see some change in the optometry space in years to come.”
A fundamental problem is that Medicare items don’t provide enough coverage to support that kind of care. For example, the scheme hasn’t covered as many visual fields services as an optometrist would like for high-quality care for a newly diagnosed glaucoma patient in the first year. Interestingly, shortly after this interview, the Federal Budget announced in May 2024 allowed for a new item from March 2025 for a third visual field test in a 12-month period for patients with a high risk of glaucoma progression. It’s progress, but indicative of how long change takes.
Independent weighs up private billing switch
As an independent optometrist, Dr Jonathan Ucinek sees few ways he or his colleagues can run a successful business based purely on bulk billed clinical services.
“To me, it appears the only way to make bulk billing viable is by having two or three optometrists fully booked and you’re seeing one patient every 15 to 20 minutes,” he says.
“In the private, independent setting we’re often spending more time with patients, it’s difficult to provide the level of optometry I provide within that timeframe.”
Dr Ucinek took over a defunct practice in Adelaide in December 2021, inheriting the patient base and store fit out and renaming it Northgate Eye Care. One of the biggest things he has been grappling with is his billing structure.
Currently, the practice adopts a mixed billing approach, where the patient is bulk billed, then charged a service fee. For example, for a comprehensive initial consultation patients are charged $20-30 above the 85% Medicare rebate of $62.45 (10910).
“But this is still putting us behind the eight ball,” he says.
“We charge for our imaging to also help fund the practice. Individually, it could be $84 for an OCT, $60 for a retinal image, $60 for a corneal topography but we bundle these up for pensioners to be $84 and for non-pensioners $104. Everybody at our practice, also receives a Rodenstock DNEye scan at no charge, which is one of Adelaide’s most advanced pre-tests because it includes a scan for cataract, corneal topography, anterior chamber OCT and checks the thickness of the cornea in addition to the standard autorefraction and non-contact tonometry.”
Dr Ucinek wants to move to a private billing model, where the patient is charged for the clinical services in full, upfront and on the day, before receiving a rebate in their account shortly after. For a small enterprise like Northgate Eye Care, this will help generate better cashflow, rather than having to wait two weeks for the bulk billed income to reach the business account.
“The main hurdle to implementing private billing is the administrative aspect of overhauling my systems. It might start by the beginning of the upcoming financial year. We are just trying to get training and notifications up and running first,” he says.
Dr Ucinek has accessed Optometry Australia resources that advise he should be charging $130 for comprehensive initial consults, but he’s worried that patients used to receiving the perceived “free” bulk billed care won’t understand the rationale for this.
After such a heavy investment in imaging technology, he wants to avoid the need to cross-subsidise his care, and charge a rate that places value on the equipment suite and the professional service delivered.
“We are concerned we will lose patients in this move to private billing, but even at a loss of 10%, we still stand to be better off with such a move. The benefits of the move will improve patient outcomes by enabling us to practise sustainable optometry and continue to provide the rare but amazing eyecare services to the community at our practice.”
For the future of Medicare, Dr Ucinek says he would love to see extra codes that reward optometrists for specific tests they perform, that aren’t outsourced to ancillary staff.
“For example, a code for the corneal pachymetry, corneal topography, contact tonometry and gonioscopy as well as OCT and retinal photography. We would also benefit for an assessment code for meibomian gland dysfunction, so that we get rewarded for the extra services and care we are providing our patients,” he says.
Industry’s largest bulk biller
As Australia’s largest provider of optometry services, Specsavers has struck the balance of offering affordable, quality patient care while ensuring its clinical services are bulk billed at no out-of-pocket cost to the patient.
Director of clinical services, Dr Ben Ashby, says bulk billing is a cornerstone of the business – and would remain so.
“We see more than four million Australians a year for their eyecare, and it is a great honour and responsibility that so many people trust us with their vision, which is why we believe in offering accessible and affordable bulk billed eyecare to all Australians,” he says.
“The contribution that optometry provides in early diagnosis and treatment of avoidable causes of blindness could be placed at risk if there is a move away from bulk billing. It is equally important that as a sector we demonstrate continuous improvement in the value we provide for all Australians through Medicare services and also that government funding for eyecare keeps pace with the growing costs of providing these services.”
Dr Ashby says Specsavers is focused on accessibility and affordability. Anything that made it financially harder for patients would restrict access to regular eyecare. By offering bulk billed eye tests, the network provides a place for Australians to access professional clinicians providing comprehensive eye examinations and a range of affordable eyewear.
“We know that with an ageing population and an increasing prevalence in eye conditions, anything that creates a barrier for Australians to access regular eyecare will result in poorer health outcomes for patients. Particularly with economic conditions putting a strain on everyone’s spending choices, introducing any financial barriers to attending a regular eye test will only result in more undetected eye conditions and an increasing cost to the public health system. Investing in preventative care now ensures equitable access to quality eyecare for all Australians,” he says.
“By removing barriers, we’re able to focus on helping to detect sight-threatening eye conditions that left undiagnosed can cost the Australian economy billions of dollars every year.”
As for the future of Medicare, Dr Ashby believes there could be potential to cover remote optometry consultations – where rural and remote patients can connect with an optometrist virtually for a comprehensive eye exam.
The model also pioneers a potential new way of working for optometrists, Dr Ashby notes, providing flexibility into a workforce that traditionally has never been available, providing models of care that help make the profession sustainable and well distributed across the country.
“While we’re currently piloting this model, we’ve been collaborating with the industry on how a model like this can provide safe and sensible eyecare to Australians, and with funding support could be sustainably rolled out across the country,” he says.
“As reported in the Deloitte Access Economics insights into the optometry workforce report released this year, there is an urgency for the industry to look at ways to enhance the delivery of eyecare in the face of a workforce shortage and increasing demand. We know the health landscape shifted owing to the impact of COVID-19, highlighting the opportunity of the value and potential of new and alternative health models to meet local needs.”
System imperfect, but Australia is fortunate
Bulk billing is also fundamental to much of the work the Australian College of Optometry (ACO) performs, at its Carlton headquarters in Melbourne and seven satellite clinics. Traditionally, bulk billed eyecare has been offered to those with a concession card, those who identify as an Aboriginal or Torres Strait Islander person, or are a refugee or asylum seeker.
Many of these patients are also eligible to receive subsidised glasses, contact lenses and visual aids under the Victorian Eyecare Service, a Victorian Government program administered by the ACO.
In October 2023, ACO expanded its bulk billing eligibility to cover all children under the age of 18 regardless of their socio-economic status, in a major move to combat rising myopia rates.
Dr Nellie Deen, general manager of city clinics, says as a not-for-profit that receives government funding, the ACO had different objectives to private optometry businesses, but still needed to be prudent when it came to covering its operational costs and bulk billing of patients.
For those who fall outside the eligibility listed above, a modest $38 out-of-pocket fee is charged, which covers all imaging and any other diagnostic work-ups.
After moving to Australia from the US, Dr Deen says Australia is fortunate to have a system where bulk billing is still available, even though it’s imperfect.
“In the US insurance companies play a significant role, and many people avoid regular check-ups with their GP or getting their eyes examined simply because they lack insurance coverage for those specific services,” she says.
“It’s important to realise how fortunate we are in Australia. When we decided to bulk bill all children under 18, we recognised it as a crucial step since they need frequent check-ups, and preventable eye diseases can easily be missed. It’s vital for bulk billing to continue, especially for more vulnerable patient groups.”
More reading
Changes to optometry Medicare coverage revealed
Medicare turns 40 – but Optometry Australia asks whether it’s time for a check up?
What to do about Medicare – Skye Cappuccio
