tag:theconversation.com,2011:/id/topics/specialist-fees-25723/articlesSpecialist fees – The Conversation2022-04-28T20:02:15Ztag:theconversation.com,2011:article/1815952022-04-28T20:02:15Z2022-04-28T20:02:15ZRising out-of-pocket health costs are a worry. But the major parties have barely mentioned it<figure><img src="https://images.theconversation.com/files/459931/original/file-20220427-18-i0jg5g.jpg?ixlib=rb-1.1.0&rect=2%2C1%2C995%2C664&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/sad-black-woman-near-window-reading-1314448082">Shutterstock</a></span></figcaption></figure><p>Rising out-of-pocket costs for health care is an important issue the major parties have not yet substantially addressed during the election campaign.</p>
<p>We heard just this week how health-care costs are rising <a href="https://theconversation.com/inflation-hits-an-extraordinary-5-1-how-long-until-mortgage-rates-climb-181832">faster than</a> other costs of living pressures.
<a href="https://www.abs.gov.au/statistics/economy/price-indexes-and-inflation/consumer-price-index-australia/latest-release#key-statistics">Health-care costs</a> are also rising faster than <a href="https://www.abs.gov.au/statistics/economy/price-indexes-and-inflation/wage-price-index-australia/dec-2021">wages</a>. The rising cost of specialists’ fees, in particular, are a concern. So, many Australian families are finding it increasingly difficult to keep up. </p>
<p>Earlier this year, a major consumer survey <a href="https://healthsystemsustainability.com.au/the-voice-of-australian-health-consumers/">found</a> 30% of people with chronic conditions were not confident they could afford needed health care if they became seriously ill; 14% could not pay for health care or medicine because of a shortage of money.</p>
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<h2>Out-of-pocket costs are rising</h2>
<p>Out-of-pocket health-care costs cover a range of expenses not covered by Medicare or private health insurance, such as doctors’ fees for consultations and surgery.</p>
<p>Only 35.1% of specialist consultations were <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/Medicare%20Statistics-1">bulk billed in 2020-21</a> compared with 88.8% of GP services.</p>
<p>For private (multi-day) hospital care in 2019-20, <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/health-casemix-data-collections-publications-HCPAnnualReports">43.7% of separations</a> (hospital admissions that include procedures and operations) had no hospital or medical out-of-pocket cost.</p>
<p>Out-of-pocket costs are rising, <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/Medicare%20Statistics-1">Medicare statistics show</a>.</p>
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<p>There is ample <a href="https://link.springer.com/article/10.1007/s10198-013-0526-8">evidence</a> out-of-pocket costs reduce access to, and use of, health care. This more strongly affects people who need health care the most.</p>
<p>For instance, access to timely specialist care in Australia depends on your income and ability to pay.</p>
<p>Although richer people <a href="https://www.sciencedirect.com/science/article/pii/S0277953618302041">use more specialist care</a>, on average, it is less-affluent people who have higher need for <a href="https://www.sciencedirect.com/science/article/pii/S0168851020302244?casa_token=UO9uqqBMiDgAAAAA:esi0pxqJkXVpBeI2qB2HwxiCBgTcL7VRMlcMDyp_Y0TaQo81MNugRrPRkGpbtsSR5ubUA5Kx_TA">health care</a>. Yet it is less-affluent people who have to wait to see a specialist in a public hospital. </p>
<p>High doctors’ fees have other consequences. They may provide skewed incentives to doctors, leading to <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)30947-3/fulltext">overdiagnosis and overtreatment</a>. Doctors may also flock to high-earning specialties while we have a shortage of GPs (who are paid <a href="https://melbourneinstitute.unimelb.edu.au/__data/assets/pdf_file/0011/3809963/ANZ-Health-Sector-Report-2021.pdf">half as much</a> as specialists).</p>
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Read more:
<a href="https://theconversation.com/specialists-are-free-to-set-their-fees-but-there-are-ways-to-ensure-patients-dont-get-ripped-off-97372">Specialists are free to set their fees, but there are ways to ensure patients don't get ripped off</a>
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<h2>What do the major parties promise?</h2>
<p>Health policies <a href="https://www.abc.net.au/news/2022-04-20/federal-election-liberal-labor-nationals-greens-policy-positions/100482298">announced</a> by the major parties ahead of the federal election do not necessarily translate into lower out-of-pocket health costs, or focus on the most pressing issue.</p>
<p>The Coalition has promised to <a href="https://theconversation.com/what-is-the-pbs-safety-net-and-is-it-really-the-best-way-to-cut-the-cost-of-medicines-180315">lower the safety net threshold</a> for the Pharmaceutical Benefits Scheme. This announcement, made in this year’s federal budget, would make medicines cheaper or free for people who need multiple scripts a year.</p>
<p>But this is an area where out-of-pocket costs have been falling for <a href="https://www.abs.gov.au/statistics/economy/price-indexes-and-inflation/consumer-price-index-australia/mar-2022/640105.xlsx">some time</a> compared with other areas of spending. So any announcement may have been better targeted at areas where out-of-pocket costs are growing more quickly.</p>
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<a href="https://images.theconversation.com/files/459940/original/file-20220427-18-rzq6w3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Person using EFTPOS machine in pharmacy or clinic" src="https://images.theconversation.com/files/459940/original/file-20220427-18-rzq6w3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/459940/original/file-20220427-18-rzq6w3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/459940/original/file-20220427-18-rzq6w3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/459940/original/file-20220427-18-rzq6w3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/459940/original/file-20220427-18-rzq6w3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/459940/original/file-20220427-18-rzq6w3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/459940/original/file-20220427-18-rzq6w3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Election policies announced so far don’t always address the biggest out-of-pocket costs.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/paying-pharmacy-407956288">Shutterstock</a></span>
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<p>In any election there is always a focus on access to GPs and bulk billing. This includes Labor’s proposal for new <a href="https://theconversation.com/labors-urgent-care-centres-are-a-step-in-the-right-direction-but-not-a-panacea-181237">urgent care centres</a>, which would provide bulk billed services to take the pressure off emergency departments.</p>
<p>However, neither of the major parties are doing anything about the continuing and much larger increases in specialists’ out-of-pocket costs. </p>
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Read more:
<a href="https://theconversation.com/labors-urgent-care-centres-are-a-step-in-the-right-direction-but-not-a-panacea-181237">Labor’s urgent care centres are a step in the right direction – but not a panacea</a>
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<h2>Can informed patients make a difference?</h2>
<p>The Coalition introduced a price transparency <a href="https://www.health.gov.au/resources/apps-and-tools/medical-costs-finder">website</a> <a href="https://www.abc.net.au/news/2019-12-30/government-health-website-out-of-pocket-hospital-costs/11832410">in 2019</a> that provides estimates of out-of-pocket costs for private hospital care, with plans for doctors to voluntarily upload their fees. Some <a href="https://www.medibank.com.au/health-support/hospital-assist/costs/">private health insurers</a> also have such websites.</p>
<p>However, these websites rely entirely on consumers doing the “leg work” by shopping around to reduce their out-of-pocket costs. The assumption is that by providing consumers with more information, they will make better choices. But this is too simplistic because information can difficult to get and understand, and these websites don’t include data on the quality of care.</p>
<p><a href="https://minerva-access.unimelb.edu.au/items/a0d05155-4781-59fa-bebd-5a5565c3012d">Our review</a> on price transparency websites in health care shows <a href="https://theconversation.com/we-need-more-than-a-website-to-stop-australians-paying-exorbitant-out-of-pocket-health-costs-108740">they may not work</a> for consumers. Not all consumers <a href="https://doi.org/10.1016/j.ijindorg.2021.102716">can or want</a> to use them. There’s also the risk doctors could use these websites to see what other doctors are charging and increase their fees.</p>
<p>It could be better if these websites were used by GPs when referring patients to specialists. Patients can also be encouraged to ask about the out-of-pocket cost when booking an appointment or during the visit. </p>
<p>But this does not help patients who are usually in a vulnerable position, who want care quickly, do not have the information or time to shop around, and might think the care they receive will be affected if they ask about cost. </p>
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Read more:
<a href="https://theconversation.com/doctors-fees-shouldnt-just-be-transparent-they-should-be-fair-and-reasonable-100948">Doctors’ fees shouldn't just be transparent, they should be fair and reasonable</a>
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<h2>Can doctors make a difference?</h2>
<p>Doctors set their own fees and many use the Australian Medical Association fee schedule as guidance. They decide what fee to charge, whether to bulk bill, or whether to use gap cover provided by private health insurers for private hospital care. </p>
<p>At the moment it would require a brave politician to directly control doctors’ fees given the constitutional protections they have and the way Medicare and private health insurance were designed to provide subsidies to patients, not to directly pay doctors.</p>
<p>However, something the major parties can address is “bill shock”. Patients don’t always know the doctor’s fee before they visit, and in some circumstances don’t know in advance how much a procedure will cost.</p>
<p>If care involves many tests, visits and procedures over time by different doctors, then there will be a bill for each. This shifts all the financial risk to patients, something private health insurance was designed to handle. </p>
<p>At a minimum, doctors’s fees and out-of-pocket costs need to be bundled together and published as an upfront quote or range for the expected course of care. This is something that could be addressed by one of the major parties. </p>
<h2>What next?</h2>
<p>Addressing rising out-of-pocket health costs is a complex area linked closely to broader reform of the health-care system, which neither major party has promised to do anything about.</p>
<p>Without such reforms we’ll see Australians prioritising spending on food, housing and petrol over health care, in the current climate.</p>
<p>But Australia cannot afford to allow this to happen. As we have witnessed during the pandemic, an unhealthy population is not only bad for individuals, it’s bad for us all.</p><img src="https://counter.theconversation.com/content/181595/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anthony Scott receives funding from a research grant awarded by the Medibank Better Health Foundation on out of pocket costs and price transparency.</span></em></p>Health-care costs are continuing to rise faster than wages, so many Australian families are finding it increasingly difficult to keep up.Anthony Scott, Professor of health economics, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1272272019-11-25T19:13:21Z2019-11-25T19:13:21ZGreedy doctors make private health insurance more painful – here’s a way to end bill shock<figure><img src="https://images.theconversation.com/files/303374/original/file-20191125-74572-hsguwg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">After an operation, patients might receive half a dozen bills from different health providers involved in their care.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/doctors-working-on-laptop-computer-writing-785808469?src=232d6ce3-a624-4842-942f-6faf15333e09-2-63&studio=1">Smolaw/Shutterstock</a></span></figcaption></figure><p>Large bills are one of <a href="https://chf.org.au/sites/default/files/20180404_oop_report.pdf">the main reasons people are dissatisfied</a> with their private health insurance – especially when these bills come as a surprise. </p>
<p>Doctors charge what they like, and patients rarely have any information about what they are getting for their money. Even <a href="https://chf.org.au/publications/out-pocket-pain">patients with top-level cover are left paying large and unexpected out-of-pocket costs</a> when they use their insurance.</p>
<p>Patients have little power to bargain with their doctors about fees and have almost no information about whether their doctor has higher or lower complication rates than other doctors.</p>
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<p>A Grattan Institute <a href="https://grattan.edu.au/home/health/">report released today</a> proposes that patients’ fees should be negotiated between doctors and private hospitals, rather than between the doctor and the patient. </p>
<p>We propose that hospitals issue one “bundled” bill after a patient is treated, rather than the confusing and seemingly ad hoc array of bills patients get at present.</p>
<p>Under the plan, patients would still choose their specialist, and still be treated in the hospital where their specialist practices. </p>
<p>The difference would be that private hospitals would issue a single bill to the patient’s insurer, and the private hospital would pay the specialist, the anaesthetist, the assistant, and any other medical practitioners on the patient’s behalf. </p>
<p>An insured patient would get one bill – from their insurer – which would include their excess and any additional cost the hospital has advised them about in advance. </p>
<p>An uninsured patient would also get a single bundled bill, but from the hospital.</p>
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<img alt="" src="https://images.theconversation.com/files/303377/original/file-20191125-74557-1vaycpb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/303377/original/file-20191125-74557-1vaycpb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/303377/original/file-20191125-74557-1vaycpb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/303377/original/file-20191125-74557-1vaycpb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/303377/original/file-20191125-74557-1vaycpb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/303377/original/file-20191125-74557-1vaycpb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/303377/original/file-20191125-74557-1vaycpb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Bill shock is one of the biggest problems Australians have with private health insurance.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/close-on-girl-female-woman-hands-1526711993">Miljan Zivkovic</a></span>
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<h2>Why it’s needed</h2>
<p>Medical fees are currently partly reimbursed by Medicare (75% of the schedule fee), partly reimbursed by the insurer (25% of the schedule fee), and doctors often charge more on top of this. </p>
<p>The extra is paid by the patient as an out-of-pocket charge. This results in an incoherent shambles of payments. </p>
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Read more:
<a href="https://theconversation.com/specialists-are-free-to-set-their-fees-but-there-are-ways-to-ensure-patients-dont-get-ripped-off-97372">Specialists are free to set their fees, but there are ways to ensure patients don't get ripped off</a>
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<p>Patients are in the worst position to negotiate fees with their specialist. <a href="https://ama.com.au/sites/default/files/documents/Informed-financial-consent-Oct19-ONLINE.pdf">Quaint pamphlets</a> which encourage patients to ask their surgeons about fees shift responsibility from those who can effect change – doctors, private hospitals, insurers, and government – to those who can’t: powerless patients.</p>
<h2>A handful of doctors is causing the problem</h2>
<p>Only about one-quarter of hospital specialists’ services are <a href="https://www.apra.gov.au/quarterly-private-health-insurance-statistics">charged at the Medicare schedule fee or below</a>. </p>
<p>Many doctors feel this government-determined fee is not fair, possibly because it has not been consistently indexed with inflation. </p>
<p>More than two-thirds of services are charged up to 50% above the schedule fee.</p>
<p>But a very small proportion of services (7%) are charged at more than twice the Medicare schedule – and for these services, the average amount charged is more than three times the Medicare fee. </p>
<p>This small number of expensive services account for almost 90% of all medical gaps. The small minority of specialists who charge more than twice the schedule fee should be called out and labelled as greedy.</p>
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Read more:
<a href="https://theconversation.com/doctors-fees-shouldnt-just-be-transparent-they-should-be-fair-and-reasonable-100948">Doctors’ fees shouldn't just be transparent, they should be fair and reasonable</a>
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<p>To some extent it’s fair that specialists with demonstrably better skills than their colleagues in the same specialty should charge more. </p>
<p>But since neither the public nor specialists have information about relative skill, such as complication rates after taking account of the complexity of the patient, it is hard to justify charging higher fees. </p>
<p>What’s more, higher fees are <a href="https://onlinelibrary.wiley.com/doi/abs/10.5694/mja16.00653">more prevalent in some locations than others</a>, suggesting the higher fees have nothing to do with either skill or the adequacy of the Medicare Benefits Schedule, but rather are more about what these doctors think the market can bear.</p>
<h2>A single bill would help</h2>
<p>Bundling medical fees into a single bill would require doctors to negotiate with private hospitals about what the doctor charges. </p>
<p>Hospitals are in a better position than patients to negotiate with doctors about fees. Private hospitals already negotiate about whether to appoint a specialist to the hospital; those negotiations should include consideration of what the doctor will charge patients.</p>
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<span class="caption">If doctors have to negotiate with private hospitals about the fees they charge, they’re likely to be lower.</span>
<span class="attribution"><span class="source">ESB Professional/Shutterstock</span></span>
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<p>Patients would benefit directly. They would still have choice of doctor but would face fewer and lower out-of-pocket costs for these choices. </p>
<p>Importantly, the doctor-patient relationship would continue; the change would be to the doctor-payment relationship.</p>
<p>Of course, some doctors – especially the greedy billers – would oppose this reform, because it would bring accountability into the medical market. Their squeals should be ignored.</p>
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Read more:
<a href="https://theconversation.com/we-need-more-than-a-website-to-stop-australians-paying-exorbitant-out-of-pocket-health-costs-108740">We need more than a website to stop Australians paying exorbitant out-of-pocket health costs</a>
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<img src="https://counter.theconversation.com/content/127227/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Grattan Institute began with contributions to its endowment of $15 million from each of the Federal and Victorian Governments, $4 million from BHP Billiton, and $1 million from NAB. In order to safeguard its independence, Grattan Institute’s board controls this endowment. The funds are invested and contribute to funding Grattan Institute's activities. Grattan Institute also receives funding from corporates, foundations, and individuals to support its general activities, as disclosed on its website..</span></em></p>Specialists can charge patients what they want, and some doctors charge exorbitant amounts. A handful of services account for almost 90% of all medical gaps.Stephen Duckett, Director, Health Program, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1087402019-03-06T11:06:32Z2019-03-06T11:06:32ZWe need more than a website to stop Australians paying exorbitant out-of-pocket health costs<figure><img src="https://images.theconversation.com/files/262361/original/file-20190306-48444-hvs3fo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">For some people, high out-of-pocket costs makes it difficult to see a doctor or fill a prescription.</span> <span class="attribution"><span class="source">From shutterstock.com</span></span></figcaption></figure><p>In an attempt to crack down on specialists charging exorbitant fees, the Morrison government <a href="http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel-yr2019-hunt035.htm">has pledged</a> to create a website listing individual specialists’ fees. </p>
<p>The website is voluntary and doctors will post their own fees. Patients will be able to compare doctors whose fees are listed, and the searchable website will have a special focus on the high fees in gynaecology, obstetrics and cancer services. </p>
<p>The announcement, made on Saturday, follows the release of a ministerial advisory committee’s <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/3A14048A458101B0CA258231007767FB/$File/Report%20-%20Ministerial%20Advisory%20Committee%20on%20Out-of-Pocket%20Costs.pdf">report on out-of-pocket costs</a>, which the government has had since November.</p>
<p>But while the website is a good first step, transparency alone is unlikely to be enough to ensure Australians aren’t forgoing care because of high costs. </p>
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<strong>
Read more:
<a href="https://theconversation.com/more-visits-to-the-doctor-doesnt-mean-better-care-its-time-for-a-medicare-shake-up-110884">More visits to the doctor doesn't mean better care – it's time for a Medicare shake-up</a>
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<h2>What’s the problem?</h2>
<p>A central problem is the lack of transparency around out-of-pocket costs. Patients are typically unaware of the full out-of-pocket costs they might incur at the time of referral and admission. </p>
<p>The Consumers Health Forum’s <a href="https://chf.org.au/sites/default/files/20180404_oop_report.pdf">recent report</a> found Australian consumers face higher than average out-of-pocket costs compared to most countries. This translates into people often avoiding visiting a GP or specialist and failing to fill scripts due to cost.</p>
<p>A <a href="https://grattan.edu.au/wp-content/uploads/2014/07/Grattan_Institute_submission_-_inquiry_on_out-of-pocket_costs_-_FINAL.pdf">report from the Grattan Institute</a> using data from the Australian Bureau of Statistics shows many people already miss out on health care because of cost: 5% skip GP visits, 8% don’t go to a specialist, 8% don’t fill their prescription and 18% don’t go to the dentist. This will happen more if fees go up.</p>
<p>Those who avoid care because of cost are often those most in need, leading to concerns about equity of access. Delaying or foregoing care means when people do visit their doctor, their condition may be much worse than if they had presented earlier. This can affect long-term health outcomes and lead to higher costs over time.</p>
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Read more:
<a href="https://theconversation.com/many-australians-pay-too-much-for-health-care-heres-what-the-government-needs-to-do-61859">Many Australians pay too much for health care – here's what the government needs to do</a>
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<p>“Value” is also about providing information on the various options for care, including the evidence base of the treatments offered, waiting times for various providers, and how the quality of care might vary between the options. </p>
<p>Consumers, with the help of GPs where necessary, should be able to assess these trade-offs to arrive at a decision that works best for them. </p>
<p>But patients know little about the quality of care provided when they are offered treatment or even whether they will really get better as a result.</p>
<p>Significant numbers of procedures and treatments performed on patients in Australia are considered “low value care” – when treatments have little effect on health outcomes, and may even cause harm. <a href="https://qualitysafety.bmj.com/content/early/2018/08/06/bmjqs-2018-008338#block-system-main">Recent estimates</a> for New South Wales public hospitals suggest that between 11% and 20% of treatments involve low-value care.</p>
<p>These issues are being tackled through the <a href="http://www.choosingwisely.org.au/getmedia/042fedfe-6bdd-4a76-ae20-682f051eb791/Choosing-Wisely-in-Australia-2017-Report.aspx">Choosing Wisely</a> campaign which is increasing awareness of tests and treatments that are of low value and may cause harm. </p>
<p>The Medicare Benefits Schedule Review Taskforce is also reviewing how these procedures are funded through Medicare.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/262362/original/file-20190306-48447-5j0ldc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/262362/original/file-20190306-48447-5j0ldc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/262362/original/file-20190306-48447-5j0ldc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/262362/original/file-20190306-48447-5j0ldc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/262362/original/file-20190306-48447-5j0ldc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/262362/original/file-20190306-48447-5j0ldc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/262362/original/file-20190306-48447-5j0ldc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">This website will make specialist fees publicly available to consumers – but only if the specialists choose to list their fees.</span>
<span class="attribution"><span class="source">From shutterstock.com</span></span>
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</figure>
<h2>Your right to know the costs of care</h2>
<p>What are your rights as a patient in relation to the costs of medical treatment?
At present, it seems consumers have very few. </p>
<p>There are no consistent enforceable guidelines on health-care providers to provide information on costs. <a href="https://protect-au.mimecast.com/s/Gb85CzvOL5hQ0lYKs4dl75?domain=urldefense.proofpoint.com">Voluntary codes of practice</a> are in place to encourage fee transparency but cannot be enforced.</p>
<p>The <a href="http://www.ombudsman.gov.au/making-a-complaint/private-health-insurance/informed-financial-consent">Commonwealth Ombudsman’s website</a> provides guidelines on informed financial consent in health care. Unfortunately these place the onus to gather the relevant information on the costs of care on consumers:</p>
<blockquote>
<p>You should ask your doctor, your health fund, and your hospital about any extra money you may have to pay out of your own pocket, commonly known as a “gap” payment. </p>
</blockquote>
<p>Health professionals should be required to provide information that will assist consumers make informed decisions. </p>
<h2>Why we need more than a website</h2>
<p>Gathering information on specialists’ fees and making sense of it is an enormous burden to place on vulnerable patients. This is especially the case for the elderly and those with little education who are reluctant to appear to question their trusted doctor.</p>
<p>We don’t know how effective a website of usually charged fees will be and who will use it. It’s possible it will advantage the rich by increasing their access to information, while not increasing access for poorer consumers. </p>
<p>Published fees may also be used by other doctors to set fees, and could potentially increase fees, if they see their prices are lower than others. </p>
<p>The onus should be on clinicians, and the system, to give patients easily accessible and digestible information as part of the service they provide.</p>
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<strong>
Read more:
<a href="https://theconversation.com/specialists-are-free-to-set-their-fees-but-there-are-ways-to-ensure-patients-dont-get-ripped-off-97372">Specialists are free to set their fees, but there are ways to ensure patients don't get ripped off</a>
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<p>If health professionals cannot provide and interpret these costs to patients, we need to consider other trained workers – health “cost navigators” – who could advise patients as to how to decide on the best treatment for the best price.</p>
<p>The issues of out-of-pocket expenses are serious. They threaten the sustainability of our health system and adversely influence health. We need to ensure patients don’t face prohibitive costs that discourage them from treatment or force them into debilitating financial straits.</p><img src="https://counter.theconversation.com/content/108740/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anthony Scott receives funding from the NHMRC, ARC, ANZ Health, and has previously conducted work for the Medibank Better Health Foundation. He receives funding from the NHMRC Partnership Centre for Health System Sustainability, which receives funding from the BUPA Research Foundation. Anthony Scott attended the workshop that helped form the content of this article.</span></em></p><p class="fine-print"><em><span>Peter Brooks organised the meeting with the Consumer Health Forum that developed a series of issue around out of pocket expenses some of which are the content of this article.
The authors would like to acknowledge the contribution of the Consumer Health Forum to the content of this article and in particular Ms Leanne Wells CEO of the CHF </span></em></p>Seeking and making sense of specialist fees is an unfair burden to place on vulnerable patients. A website might be helpful for some – but health professionals need to be held to higher account.Anthony Scott, Professor, The University of MelbournePeter Brooks, Professor, Centre for Health Policy, Melbourne School of Population and Global Health, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/973722018-05-30T20:01:26Z2018-05-30T20:01:26ZSpecialists are free to set their fees, but there are ways to ensure patients don’t get ripped off<figure><img src="https://images.theconversation.com/files/220904/original/file-20180530-120514-ekemsu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Specialists making their fees publicly available is one way to rein in rogue practices.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>Monday’s <a href="http://www.abc.net.au/4corners/mind-the-gap/9809314">Four Corners program</a> drew attention to the issue of high fees charged by some specialist doctors, causing large out-of-pocket expenses for Australian patients. The program included examples of patients paying out-of-pocket fees totalling in the tens of thousands for hip replacements, prostate and breast cancer surgery. </p>
<p>While the ABC made the problem of specialist overcharging seem huge, the program did rely mostly on anecdotal evidence for the claims it made.</p>
<p>So, how big is this problem really, and what can we do about it?</p>
<h2>How specialist fees work</h2>
<p>Firstly we have to understand how specialist fees work and why this can lead to large out-of-pocket costs. </p>
<p>The Australian government funds consultations with, and procedures carried out by specialist doctors – outside public hospitals – through the <a href="http://www.mbsonline.gov.au/internet/mbsonline/publishing.nsf/Content/Home">Medicare Benefits Schedule</a>. Medicare sets a schedule fee for such consultations and procedures. The fee is indexed to rise each year, apart from <a href="http://www.abc.net.au/news/2016-05-30/medicare-rebate-freeze-what-you-need-to-know/7458796">the past five years</a> where these fees have been frozen. </p>
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<a href="https://images.theconversation.com/files/220909/original/file-20180530-120511-1eqqg1f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/220909/original/file-20180530-120511-1eqqg1f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/220909/original/file-20180530-120511-1eqqg1f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/220909/original/file-20180530-120511-1eqqg1f.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/220909/original/file-20180530-120511-1eqqg1f.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/220909/original/file-20180530-120511-1eqqg1f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1130&fit=crop&dpr=1 754w, https://images.theconversation.com/files/220909/original/file-20180530-120511-1eqqg1f.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1130&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/220909/original/file-20180530-120511-1eqqg1f.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1130&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Medicare subsidises specialist doctor’s fees up to a point, but the gap the patient pays depends on what fee the doctor sets.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
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<p>The Medicare rebate is a percentage of the schedule fee; for instance 75% for specialist items, 100% for certain GP items. But the schedule fee doesn’t restrict doctors from charging a higher fee (the gap), which may or may not be covered by health insurance for in-hospital items. </p>
<p>Health insurance in Australia can’t cover doctors’ fees for out-of-hospital consultations. Doctors are free to charge whatever fee they like; there is no restriction on their pricing.</p>
<p>Medicare <a href="http://www.health.gov.au/internet/main/publishing.nsf/content/annual-medicare-statistics">publishes some data</a> about bulk-billing rates and out-of-pocket costs. From this, we know only around 35% of specialists observe the schedule fee with an average out-of-pocket of A$75 in 2016/17. Worryingly, this average fee grew by nearly 6% from the previous financial year. But, these figures are nowhere near the extreme cases highlighted on Four Corners.</p>
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<strong>
Read more:
<a href="https://theconversation.com/why-do-specialists-get-paid-so-much-and-does-something-need-to-be-done-about-it-74066">Why do specialists get paid so much and does something need to be done about it?</a>
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<p>Relatively little is published about the highest fees. One <a href="https://www.mja.com.au/system/files/issues/206_04/10.5694mja16.00653.pdf">recent study</a> with access to data on the distribution of fees for specialist consultations showed that at the 90th percentile, out-of-pocket costs were between A$85-$212, across all specialties. This is just for initial consultations – total costs for operations (which may include anaesthetist’s fees and other costs) are substantially higher. </p>
<p>So while we know the cases highlighted on Four Corners are not representative of the average specialist, or even of the some of the higher-charging doctors, out-of-pocket costs for private specialists are still high and rising at twice the rate of inflation. </p>
<p>So, what can be done to keep a lid on these price rises?</p>
<h2>Transparency and incentives</h2>
<p>The first potential solution is price transparency. Hopefully the government is seriously contemplating a system that would mandate all doctors publish their fees on a publicly accessible website. </p>
<p>On Four Corners, the Chief Medical Officer, Brendan Murphy, indicated this step is seriously being considered by the <a href="http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel-yr2018-hunt002.htm">advisory committee on out-of-pocket costs</a> that he is leading. It would be reassuring to see statements from ministers and the Australian Medical Association (AMA) to give this idea some real traction.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/many-australians-pay-too-much-for-health-care-heres-what-the-government-needs-to-do-61859">Many Australians pay too much for health care – here's what the government needs to do</a>
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<p>And while transparency would be a good step, it still ignores the fact Australia is an outlier in allowing doctors such unfettered freedom to set prices as they see fit. </p>
<p>Other comparable systems where doctors receive fee-for-service payments such as France and Canada, don’t allow their doctors freedom to charge as they like. In 2010, Australia was <a href="https://www.oecd-ilibrary.org/docserver/5kmfxfq9qbnr-en.pdf?expires=1527645664&id=id&accname=guest&checksum=DBD13F453B4AB88AAC0D90081B5A1D93">identified as the only country</a> in the OECD that allowed doctors complete price freedom. </p>
<p>While a complete overhaul of our health system is unlikely in the short-term, we could still make progress in the existing system. A radical solution could use some of the power of the Medicare Benefits Schedule to give specialists financial incentives to keep their prices low. </p>
<p>This might seem like a tricky concept to implement, but it’s actually been done before, and successfully, with the so-called “bulk-billing incentives” for GP consultations. Introduced in the mid 2000s, these incentives pay an extra rebate of A$6-$9 to GPs for each bulk-billed consultation where patients pay no out-of-pocket fee. </p>
<p>These incentives seem to be at least partly responsible for a large increase in the bulk-billing rate <a href="https://theconversation.com/factcheck-were-just-67-of-gp-visits-bulk-billed-when-tony-abbott-was-health-minister-17652">over the past 15 years</a>. </p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/factcheck-are-bulk-billing-rates-falling-or-at-record-levels-72278">FactCheck: are bulk-billing rates falling, or at record levels?</a>
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<p>Similar “schedule fee incentives” could be introduced for specialists, which pay an extra Medicare rebate if the total fee is within some acceptable range. For example, specialists could be paid an extra incentive of A$10 if their total fee is no more than 10% higher than the schedule fee.</p>
<p>The amounts and conditions could be changed over time in response to how the market reacts to these changes. As shown by the impact of the bulk-billing incentives, the incentive amount might not have to be high to have a substantial impact in keeping prices low.</p>
<p>While not a silver bullet, radical reforms should be considered to mitigate the rise in specialist out-of-pocket fees before a full-blown crisis emerges.</p><img src="https://counter.theconversation.com/content/97372/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter Sivey receives funding from the Australian Research Council.</span></em></p>Australia is the only country in the OECD that allows specialists complete freedom to set their own fees. This puts patients at risk – but the government can help protect them.Peter Sivey, Associate Professor, School of Economics, Finance and Marketing, RMIT UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/970772018-05-25T01:30:57Z2018-05-25T01:30:57ZMore Medicare funding goes to wealthy kids: why, and what can we do about it?<figure><img src="https://images.theconversation.com/files/220251/original/file-20180524-51091-17vh31o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Medicare exists to ensure all Australians have fair access to health care. </span> <span class="attribution"><span class="source">from www.shutterstock.com</span></span></figcaption></figure><p>When Medicare was in <a href="http://parlinfo.aph.gov.au/parlInfo/search/display/display.w3p;query=Id%3A%22chamber%2Fhansardr%2F1983-09-06%2F0071%22">early development</a>, the goal was to provide affordable, basic health care to all Australians. But a <a href="https://authors.elsevier.com/a/1X1p7-CmUhjHP">new study</a> has found Medicare spending is higher for children from high socioeconomic backgrounds than their poorer counterparts.</p>
<p><a href="https://doi.org/10.1016/j.healthpol.2007.09.018">Previous studies</a> looking at the distribution of funding of Medicare have focused on adults. They show poorer adults are more likely to consult GPs and richer adults more likely to consult specialists. </p>
<p>The overall funding provided by the government <a href="https://www.mja.com.au/journal/2012/197/11/how-fair-medicare-income-related-distribution-medicare-benefits-special-focus">favours those with low income</a> once you control for health-care needs.</p>
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<strong>
Read more:
<a href="https://theconversation.com/factcheck-has-medicare-spending-more-than-doubled-in-the-last-decade-38374">FactCheck: has Medicare spending more than doubled in the last decade?</a>
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<p>For our new study, we used the <a href="https://growingupinaustralia.gov.au/">Longitudinal Study of Australian Children</a>, a large study assessing over 10,000 Australian children over time, and linked this to the children’s Medicare data. </p>
<p>From this, we assessed the amount of Medicare spending on children according to five family income groups, from poorest to richest. We made adjustments to the analysis to make sure we were comparing children with equal health needs. </p>
<p><a href="https://doi.org/10.1016/j.socscimed.2018.04.037">The results of our study</a> show Medicare is fair for government spending on GP consultations for children, but it’s not fair for spending on specialists and testing. Overall, Medicare spending was also not evenly distributed, particularly in the first year of life. </p>
<p>The blue line on the graph indicates equal or fair Medicare spending, with a curve below the blue meaning more is spent on richer children. </p>
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<img alt="" src="https://images.theconversation.com/files/220157/original/file-20180523-117628-1n2ul79.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/220157/original/file-20180523-117628-1n2ul79.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=440&fit=crop&dpr=1 600w, https://images.theconversation.com/files/220157/original/file-20180523-117628-1n2ul79.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=440&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/220157/original/file-20180523-117628-1n2ul79.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=440&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/220157/original/file-20180523-117628-1n2ul79.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=553&fit=crop&dpr=1 754w, https://images.theconversation.com/files/220157/original/file-20180523-117628-1n2ul79.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=553&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/220157/original/file-20180523-117628-1n2ul79.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=553&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<p>Children from higher income households gained a greater share of Medicare resources over the <a href="https://www.unicef-irc.org/article/958-the-first-1000-days-of-life-the-brains-window-of-opportunity.html">first 1,000 days</a> of their lives. For children aged zero to one year, the richest 20% used 30% of specialist resources, and the poorest 20% of children used only 12%. As the children grew older, the payments became more even. </p>
<p>This is a worrying finding, as we know the first 1,000 days of a child’s life are <a href="https://doi.org/10.1126/science.1128898">critical for future health, education and well-being</a>. Children need more health services early in life, and a healthy early childhood is increasingly recognised as <a href="http://pedsinreview.aappublications.org/content/33/2/51?sso=1&sso_redirect_count=1&nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3a+No+local+token">protecting against chronic disease in older life</a>. For example, low birth weight is related to increasing rates of heart disease, diabetes and bone disease <a href="https://www.nejm.org/doi/full/10.1056/NEJMra0708473">in adult life</a>. </p>
<h2>Possible explanations</h2>
<p>There are many efforts in Australia to ensure all children receive fair health care such as vaccinations, child health nurse visits, bulk billed GP visits and additional school services. </p>
<p>Part of the problem could be the patient payment that is often required when seeing a specialist. <a href="https://doi.org/10.1071/AH15218">A recent study</a> found an average co-payment of A$127 to see a paediatrician in Australia, with some costing much more. </p>
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Read more:
<a href="https://theconversation.com/essays-on-health-australia-is-failing-new-parents-with-conflicting-advice-its-urgent-we-get-it-right-77943">Essays on health: Australia is failing new parents with conflicting advice – it's urgent we get it right</a>
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<p>This may be a barrier to poorer families using specialists for their children’s care. According to the <a href="http://www.abs.gov.au/ausstats/abs@.nsf/mf/4839.0">Australian Bureau of Statistics</a>, around 8% of people in Australia who need health care report delaying or not seeking care because of cost. </p>
<p>Another explanation could be getting specialist health care to children in rural areas, away from large children’s hospitals. </p>
<h2>What can be done?</h2>
<p>One solution could be to have salaried paediatricians whose services are low or no-cost available in the community, including rural areas. Preferential visits would then be given to lower income children and those with greater health needs.</p>
<p>Seeking solutions to these problems, particularly for poorer children and rural children in the early years of life, is critical to the health of our nation. Work is still required to achieve the vision that Medicare be simple, fair and affordable for all Australians.</p><img src="https://counter.theconversation.com/content/97077/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Philip Clarke receives funding from the NHMRC and ARC.</span></em></p><p class="fine-print"><em><span>Harriet Hiscock, Kim Dalziel, and Li Huang do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Poorer children in Australia are less likely to receive their share of Medicare funding, particularly in the first years of life.Kim Dalziel, Associate Professor Health Economics, The University of MelbourneHarriet Hiscock, Principal Fellow, Department of Paediatrics, The University of Melbourne, Murdoch Children's Research InstituteLi Huang, Health Economist, The University of MelbournePhilip Clarke, Professor of Health Economics, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/819982017-08-13T21:13:54Z2017-08-13T21:13:54ZWhy it costs you so much to see a specialist – and what the government should do about it<figure><img src="https://images.theconversation.com/files/180834/original/file-20170803-6254-1focqf6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Some specialists charge a premium because they claim to be exceptional in their field. But how are patients to know if that's true?</span> <span class="attribution"><span class="source">from www.shutterstock.com</span></span></figcaption></figure><p>Australians <a href="https://theconversation.com/how-much-seeing-private-specialists-often-costs-more-than-you-bargained-for-53445">pay too much</a> when they go to medical specialists. The government can and should do more to drive prices down. A current <a href="http://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/Privatehealthinsurance">Senate Inquiry on out-of-pocket costs</a> will hopefully lead to some policy action.</p>
<p>The problem is clear to anyone who has had to see a specialist recently. About <a href="http://health.gov.au/internet/main/publishing.nsf/Content/Quarterly-Medicare-Statistics">85% of GP visits are bulk billed</a>, but the rate of bulk billing for visits to a specialist is much lower, at around 30%. The out-of-pocket costs can be very high, <a href="https://www.mja.com.au/journal/2017/206/4/variation-outpatient-consultant-physician-fees-australia-specialty-and-state-and">hurting patients</a>.</p>
<p>To work out how to reduce the out-of-pocket costs for specialist care, we first need to identify why they are so high. There are four potential reasons.</p>
<h2>1. Government rebates?</h2>
<p>It may be that rebates for some procedures or for attendances are set too low. Rebates are set by government and may bear no relation to the actual cost of providing a service. Unlike in <a href="http://laws-lois.justice.gc.ca/eng/acts/c-6/page-2.html#h-6">Canada</a>, there is no obligation in Australia for government to consult with medical practitioners before setting fees.</p>
<p>But this explanation cannot account for the very high variation in fees. If high levels of billing above the nominated fee were due to inadequacies in the fee paid by government, then this would apply to all specialists equally. But in fact, some specialists charge more than others.</p>
<h2>2. Supply and demand?</h2>
<p>It may be that a specialist’s ability to charge a substantial out-of-pocket premium is simply the result of high demand for a particular service in a particular location.</p>
<p>Certainly, if the market for specialist care was functioning perfectly, supply would adjust to meet demand. But the reality is that specialist care is not a perfect market. Even with the increase in the number of medical graduates in Australia over recent years, there are still shortages of specialists in rural and remote parts of the country.</p>
<p>Here, the government needs to do more. It should consider whether specialists’ productivity can be improved, or whether other health professionals could perform roles in areas of short supply. The Grattan Institute’s 2014 report, <a href="https://grattan.edu.au/report/unlocking-skills-in-hospitals-better-jobs-more-care/">Unlocking skills in hospitals: better jobs, more care</a> outlined some options such as <a href="https://www.health.qld.gov.au/ocnmo/nursing/nurse-endoscopy">nurses performing endoscopies</a> or <a href="http://www.australiancriticalcare.com/article/S1036-7314(13)00129-X/abstract">providing sedation</a>, work mostly now done by medical specialists such as gastro-enterologists.</p>
<p>Left to their own devices, specialists tend to establish their practices in more salubrious, city locations. There’s no guarantee newly accredited specialists will set up shop where their services are needed most. So the government should offer some carrots and wield some sticks to encourage new specialists to practice in rural and remote areas.</p>
<hr>
<p><em><strong>Read more:</strong></em></p>
<p><em><strong>- <a href="https://theconversation.com/why-do-specialists-get-paid-so-much-and-does-something-need-to-be-done-about-it-74066">Why do specialists get paid so much and does something need to be done about it?</a></strong></em></p>
<p><em><strong>- <a href="https://theconversation.com/how-much-seeing-private-specialists-often-costs-more-than-you-bargained-for-53445">How much?! Seeing private specialists often costs more than you bargained for</a></strong></em></p>
<p><em><strong>- <a href="https://theconversation.com/for-real-health-reform-turn-the-spotlight-on-specialists-fees-37111">For real health reform, turn the spotlight on specialists’ fees</a></strong></em></p>
<hr>
<p>Carrots could include subsidies and other support for the first few years in rural or remote practice. Sticks might include restrictions on access to Medicare billing in areas of existing over-supply in particular specialties. This would not preclude specialists establishing practices in over-supplied areas, but rather would limit public subsidies in those areas and thus provide an incentive for newly-minted specialists to go where the need is greatest. </p>
<p>Medicare already provides differential rebates for general practice in different parts of the country (rural and regional compared to inner city). Why not do the same for specialist practice?</p>
<h2>3. Market power?</h2>
<p>High specialist charges and consequent high out-of-pocket costs may simply be the <a href="http://onlinelibrary.wiley.com/doi/10.1002/hec.3317/abstract">result of specialists using their market power to maximise their income</a>. Even in areas of reasonable supply, specialists may be able to charge high fees because they benefit from established referral patterns. That is, local GPs, clinics and hospitals may refer patients to particular specialists almost by habit, without paying heed to the fees they change. Patients may not be aware of these fees until they’re committed to being treated by that specialist.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/180835/original/file-20170803-9082-1owb69.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/180835/original/file-20170803-9082-1owb69.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/180835/original/file-20170803-9082-1owb69.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/180835/original/file-20170803-9082-1owb69.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/180835/original/file-20170803-9082-1owb69.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/180835/original/file-20170803-9082-1owb69.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/180835/original/file-20170803-9082-1owb69.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/180835/original/file-20170803-9082-1owb69.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">The government could limit rebates in built-up areas already serviced by other specialists.</span>
<span class="attribution"><span class="source">from www.shutterstock.com</span></span>
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<p>A good way to respond to market power is to strengthen the market, to use competition between specialists to drive prices down. And the first step to improving competition is to increase transparency about prices charged.</p>
<p>The government – and perhaps private health insurers too – should publish information on specialists’ fees: the proportion of visits that are bulk billed, how each specialist’s fees compare to the average of specialists in, say, a 10-kilometre radius, and so on.</p>
<p>The government should further discourage higher fees by eliminating a rebate when fees are significantly above the standard rebate. For example, rebates might be paid only if the specialist fee is less than twice the standard rebate.</p>
<h2>4. Skill-based premiums?</h2>
<p>The fourth reason there may be high out-of-pocket charges is that some specialists are able to charge a premium for skill – or at least they might claim that is the basis for their high fees. Unfortunately, patients have no way of knowing whether this skill-based premium is warranted.</p>
<p>Again, transparency can help here. Governments and private health insurers should publish information which would help patients and their GPs assess whether a specialist’s outcome-based premium is warranted.</p>
<p>There are, of course, challenges associated with publicly reporting indicators of specialists’ quality of care. Agreement would need to be reached on what the key quality indicators for a range of procedures are in each specialty. Imperfect measures can be gamed, or discourage specialists from treating high-risk patients. And not all differences in performance metrics reflect actual differences in performance.</p>
<p>But opportunities for gaming or over-interpreting performance metrics could largely be removed by reporting performance within broad bands – for example: the bottom 25%, the central half, and the top 25% of performers. In the first instance, reporting should simply state whether, based on the specialist’s record, future performance is likely to be of a high standard.</p>
<p>Excessive costs for specialist care hit patients in the hip pocket and can discourage some from seeking appropriate treatment. Driving these costs down would make Australia a fairer and healthier nation.</p><img src="https://counter.theconversation.com/content/81998/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Grattan Institute began with contributions to its endowment of $15 million from each of the Federal and Victorian Governments, $4 million from BHP Billiton, and $1 million from NAB. In order to safeguard its independence, Grattan Institute’s board controls this endowment. The funds are invested and Grattan uses the income to pursue its activities. </span></em></p>To work out how to reduce the out-of-pocket costs for specialist care, we first need to identify why they are so high.Stephen Duckett, Director, Health Program, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/740662017-03-07T03:12:28Z2017-03-07T03:12:28ZWhy do specialists get paid so much and does something need to be done about it?<figure><img src="https://images.theconversation.com/files/159476/original/image-20170306-919-1i4qbsr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The pay gap between specialists (including surgeons) and GPs in Australia is the largest in the world. </span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/clement127/11354819183/">Clement127/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>This week the <a href="https://www.mja.com.au/journal/2017/206/4/variation-outpatient-consultant-physician-fees-australia-specialty-and-state-and">Medical Journal of Australia</a> published a <a href="https://www.mja.com.au/journal/2017/206/4/variation-outpatient-consultant-physician-fees-australia-specialty-and-state-and">paper</a> and <a href="https://www.mja.com.au/journal/2017/206/4/variation-fees-medical-specialists-problems-causes-solutions">commentary</a> that highlighted the huge variation in specialists’ fees and the associated out-of-pocket costs for patients. High specialist fees in this country, and what they mean for Australians’ access to healthcare, <a href="http://apo.org.au/node/52434">have been of concern for some time</a>.</p>
<p>The inevitable questions about what can and could be done to address this can only be answered by looking at what fees are reasonable and why they have been allowed to grow at such disproportionately high rates.</p>
<h2>The pay gap between specialists and GPs</h2>
<p>Australia is not the only country with these problems. A <a href="http://www.oecd.org/els/health-systems/41925333.pdf">working paper</a> produced by the Organisation for Economic Co-operation and Development (OECD) in 2008 found the remuneration of specialists was greater than that of general practitioners (GPs) by more than 50% in half of the 14 countries studied (Australia was not included). </p>
<p>But other countries have done more to investigate and understand the factors that underpin what doctors charge for their services and whether these charges are appropriate given the skills involved. These involve both technical skills (such as surgical) and cognitive skills (such as diagnosis and patient communication).</p>
<p>A <a href="https://economix.blogs.nytimes.com/2009/07/15/how-much-do-doctors-in-other-countries-make/">2007 US study</a> attempted to compare the compensation for specialists and GPs across a number of countries. The average compensation for specialists was 3.7 times the average national income, and for GPs it was 2.8 times greater. </p>
<p>For Australia, specialist compensation was a shocking 7.6 times the average national income, higher than any other country, including the US (5.7) Canada (5.1) and the United Kingdom (4.9). In contrast, Australian GP compensation was 2.8 times the average national income, lower than the US (4.1), Canada (3.4) and the United Kingdom (3.9).</p>
<h2>Why such high pay?</h2>
<p>Doctors are valued and highly trained: they are deserving of an income that reflects this. And arguably, as a country’s health and wealth rises, so should doctors’ pay. But Australian doctors are paid at thousands of dollars more than <a href="https://economix.blogs.nytimes.com/2009/07/15/how-much-do-doctors-in-other-countries-make/">would be predicted</a> on the basis of the national Gross Domestic Product (GDP).</p>
<p>Regrettably, much of the data is not current, but the trends are likely to have worsened rather than improved over time. This is supported by recent (2016) <a href="http://www.doctorportal.com.au/male-neurosurgeons-highest-ato-earners-gps-in-top-50/">data from the Australian Taxation Office</a> showing medical specialists are the highest paid professionals in Australia, and a neurosurgeon can earn over three times more than a GP.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/159477/original/image-20170306-893-11asl85.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/159477/original/image-20170306-893-11asl85.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/159477/original/image-20170306-893-11asl85.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/159477/original/image-20170306-893-11asl85.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/159477/original/image-20170306-893-11asl85.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/159477/original/image-20170306-893-11asl85.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/159477/original/image-20170306-893-11asl85.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/159477/original/image-20170306-893-11asl85.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Doctors are important and go through years of training, so they deserve to be highly paid.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/zivkovic/7559803292/">Zdenko Zivkovic/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
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</figure>
<p>So what are the likely causes of variations in doctors’ incomes? </p>
<p>The OECD paper found the variations seen were not completely explained by roles in the healthcare system (such as the “gatekeeper role” for GPs), supply factors such as doctor/population ratios, or differences in the length of training for GPs and specialists. It did find self-employed specialists and GPs earn substantially more than those on salary, even where they work side by side.</p>
<p>In Australia the situation has been aggravated by government policies. General practitioners’ income growth has been restricted because practice incentive payments (where doctors were paid for meeting specific patient care targets - for example with immunisation) <a href="https://ama.com.au/media/cuts-practice-incentive-payments-pip-penalise-gps-and-pose-public-health-risks">have been cut</a>, because of the recent impact of the <a href="https://ama.com.au/media/ongoing-medicare-rebate-freeze-sends-shiver-through-patients-and-medical-practices">Medicare reimbursement freeze</a> and because there is a continual focus on their bulk billing rates.</p>
<p>Specialists, on the other hand, have faced little government or public scrutiny over their charging practices except where these have been truly outrageous. This was the case with the inflationary impact of the <a href="https://www.uts.edu.au/research-and-teaching/our-research/health-economics-research-and-evaluation/our-research/resear-2">Extended Medicare Safety Net</a>, which attempted to limit out-of-pocket costs once an annual expenditure threshold was reached. And many specialists have simply moved the majority of their work into the private sector where it is <a href="http://johnmenadue.com/?p=5050">easier to charge large fees</a>.</p>
<h2>What are the consequences?</h2>
<p>If potential income influences the career choices of those interested in medicine, then recruitment to general practice (which is rightly viewed as a central component of the health-care system) will be negatively affected. So too will the salaried positions in community health and public hospitals (where the skill levels required are the same as for the private sector), with serious consequences for the delivery of health-care services. </p>
<p>The growing costs of medical education will aggravate this as newly qualified doctors <a href="https://theconversation.com/rising-university-fees-threaten-to-skew-public-health-services-32829">look to quickly pay off their education debts</a>. That is certainly <a href="http://www.macyfoundation.org/docs/macy_pubs/pub_grahamcenterstudy.pdf">the case</a> in the US.</p>
<p>The exorbitant fees of the highest charging specialists stand in contrast to the public spiritedness of their colleagues who bulk bill and charge more modestly. </p>
<p>It is often overlooked that significant numbers of specialists <a href="https://www.mja.com.au/journal/2017/206/4/variation-outpatient-consultant-physician-fees-australia-specialty-and-state-and">do bulk bill</a> for both outpatient and inpatient services. And there is <a href="https://www.mja.com.au/journal/2017/206/4/variation-fees-medical-specialists-problems-causes-solutions">no evidence</a> those specialists who charge higher fees deliver better care. </p>
<p>But simply condemning geriatricians for only bulk billing 17% of services when haematologists bulk bill 60% may be simplistic. It’s possible the Medicare reimbursement rates are seen as inadequate for the work geriatricians do.</p>
<h2>What’s the solution?</h2>
<p>It’s clear that how doctors are paid is a major factor for how medicine is practised. Everyone knows about the perverse incentives of fee-for-service medicine, but there has been little interest from Medicare policymakers to change that in the face of some <a href="https://ama.com.au/ausmed/fee-service-should-be-part-new-pay-blend-doctors">stiff opposition</a> from doctors’ groups. </p>
<p>The current system arguably warps the way medicine is practised and devalues essential components of coordinated, patient-centred care. But the solution is not straightforward. </p>
<p>The perception is that fee-for-service pays for doing as much as possible, capitation (where doctors are paid for the number of patients they service regardless of how often they see them) pays for doing as little as possible, and pay-for-performance skews medical services to what can be measured. </p>
<p>The goal is to pay for the “best care possible”. This involves finding that “sweet spot” where Medicare (or the private insurer) is paying for the right utilisation and the right quality.</p>
<p>Doctors worry about being appropriately rewarded for their skills and meeting their expenses and overheads. They need to learn to understand and pay attention to the costs of their services and to their patients instead. Self-regulation is unlikely to change this, so the Australian government needs to pay attention to these issues which undermine the equity of the health-care system. </p>
<p>There should be mechanisms to encourage and reward those specialists who bulk bill - and some teeth should be given to <a href="http://www.news.com.au/lifestyle/health/the-surgeons-charging-ten-times-the-medicare-fee/news-story/cab846d96f31648da0cf998c2df768de">proposed efforts</a> to name and shame the price-gouging outliers.</p><img src="https://counter.theconversation.com/content/74066/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lesley Russell does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>High specialist fees in this country, and what they mean for Australians’ access to health care, have been of concern for some time.Lesley Russell, Adjunct Associate Professor, Menzies Centre for Health Policy, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/534452016-03-15T19:08:19Z2016-03-15T19:08:19ZHow much?! Seeing private specialists often costs more than you bargained for<figure><img src="https://images.theconversation.com/files/114567/original/image-20160310-31852-g4aqx6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Patients often rely on their GP to make the choice of specialist for them through the referral process with little or no discussion of prices.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-226271230/stock-photo-surgeon-operating-live-shot.html?src=Jqcav0q_HU6g5J0V1JyTqQ-2-26">gtfour/Shutterstock</a></span></figcaption></figure><p>Around <a href="http://www.apra.gov.au/Pages/phiac-redirect.aspx">half of Australians have</a> private health insurance. Most of us know that if we need to see a private specialist, we may face some out-of-pocket fees between what the doctor charges and the rebate we receive from Medicare and, if we’re having a procedure or operation, our private health fund. </p>
<p>But why is it so difficult to find out exactly how much it’s going to cost to have that suspicious mole removed or to be admitted to hospital for that colonoscopy or hip replacement? </p>
<p>Outside of public hospitals, most clinical health services are essentially private markets. The Commonwealth government, through Medicare, provides a variety of subsidies to reduce the cost burden on patients but does not regulate prices. Doctors can charge what they like – or what the market will bear. </p>
<p>Patients can learn their local GP’s fees relatively quickly and make informed choices about whether to switch practices. Our <a href="https://www.melbourneinstitute.com/downloads/working_paper_series/wp2013n23.pdf">recent research</a> suggests GP practices facing strong local competition were more likely to keep their prices low.</p>
<p>But specialist prices are more obscure. Patients often rely on their GP to make the choice of specialist for them through the referral process, with little or no discussion of prices. And patients see specialists less frequently than GPs, so they don’t have the opportunity to learn about prices through repeated use. </p>
<p>There is a simple way of increasing price transparency so we all know how much services cost at alternative providers: make this a requirement for all specialists and publish the data on a government website such as the <a href="http://www.myhospitals.gov.au/">My Hospitals</a> portal. </p>
<h2>Specialist consultations</h2>
<p>Prices for specialists are high, with only <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/34A89144DB4185EDCA257BF0001AFE29/$File/MBS%20Statistics%20Financial%20Year%202014-15%20external%2020150714.pdf">around 30%</a> of consultations bulk-billed and an average out-of-pocket cost of A$65.73 (for those not bulk-billed).</p>
<p>The size of out-of-pocket costs may be influenced by the <a href="http://www.amawa.com.au/wp-content/uploads/2015/10/AMA-Fees-List-Nov-15.pdf">list of recommended fees</a> published annually by the Australian Medical Association. The AMA-listed fee for initial specialist consultations is A$166, almost twice the Medicare Benefits Schedule (MBS) fee of A$85.55. </p>
<p>For initial consultations with consultants, the listed fee is A$315, more than twice the MBS schedule fee of A$150.90.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/114572/original/image-20160310-31847-sktrj5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/114572/original/image-20160310-31847-sktrj5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/114572/original/image-20160310-31847-sktrj5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/114572/original/image-20160310-31847-sktrj5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/114572/original/image-20160310-31847-sktrj5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/114572/original/image-20160310-31847-sktrj5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/114572/original/image-20160310-31847-sktrj5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The AMA-listed specialist fees are roughly double the MBS fees.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/karolfranks/6957537942/">Karol Franks/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
</figcaption>
</figure>
<p><a href="http://onlinelibrary.wiley.com/doi/10.1002/hec.3317/epdf">Recently published research</a> by health economists at the University of Technology Sydney confirms that many specialists practise “price discrimination” – they charge higher prices to patients who can afford to pay more. This is often seen as an indicator of a lack of competition in an industry.</p>
<p>Specialists are less price-competitive because of the high barriers to entry into these professions. This leads to long waiting lists for consultations as well as high prices. </p>
<p><a href="https://www.hwa.gov.au/sites/uploads/HW2025_V3_FinalReport20121109.pdf">Health Workforce Australia</a> has identified psychiatry, obstetrics and gynaecology among important specialities with a current shortage that are likely to be under-supplied in the future. Causes include a lack of specialist training places, long training programs and falling working hours. </p>
<h2>Procedures and surgery</h2>
<p>Most patients who have private in-hospital elective procedures have health insurance that pays their hospital costs, subject to an excess on the insurance policy. But doctors’ fees are more complicated.</p>
<p>Doctors’ fees for such procedures are funded by Medicare with a “gap” payment, often reimbursed by private health insurance. Medicare will fund 75% of the “schedule fee”, with private health insurance usually funding the other 25%. </p>
<p>But Medicare <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/34A89144DB4185EDCA257BF0001AFE29/$File/MBS%20Statistics%20Financial%20Year%202014-15%20external%2020150714.pdf">data shows</a> only 13% of anaesthetics services and 47% of operations services (mainly the surgeons’ fees) are charged at the schedule fee. </p>
<p>This leads to an average patient contribution of A$76 for operations and A$126 for anaesthetics. This may be funded by private health in some cases, but not all. Often this will depend on the agreements reached between private health insurance companies, doctors and private hospitals. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/114568/original/image-20160310-31852-73un10.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/114568/original/image-20160310-31852-73un10.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/114568/original/image-20160310-31852-73un10.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/114568/original/image-20160310-31852-73un10.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/114568/original/image-20160310-31852-73un10.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/114568/original/image-20160310-31852-73un10.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/114568/original/image-20160310-31852-73un10.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">It’s difficult to know how much your total bill will be.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-265489313/stock-photo-hospital-aisle.html?src=v2IjMRyI9NCppXHuwdet2g-2-43">dailin/Shutterstock</a></span>
</figcaption>
</figure>
<p>Patients may be left in the dark about their final out-of-pocket costs until months after any private hospital procedure. These delays are caused by the fragmentation of the billing process: an operation or procedure often involves several doctors, such as a surgeon, anaesthetist, pathologists and radiologists. </p>
<h2>So what’s the solution?</h2>
<p>Health insurer Bupa has introduced <a href="http://www.independent.co.uk/news/business/news/bupa-offers-fixed-fee-surgery-as-uk-profits-take-turn-for-the-worse-8531854.html">fixed-price surgery</a> in the United Kingdom to reduce the “bill shock” associated with private elective procedures. Such a development would be welcome in Australia. </p>
<p>But the motivation is lower here due to the high take-up of private health insurance. We rely on insurance companies to do the bargaining with hospitals and doctors for us.</p>
<p>Price-transparency regulation has a lot of potential to reduce the hip-pocket impact on Australian patients. Specialists should be forced to publish a list of their fees online, which GPs can use, together with patients, when making referral decisions. This should put pressure on specialists to think twice about increasing their fees.</p>
<p>Liberal MP Angus Taylor, now assistant minister for cities and digital transformation, <a href="http://www.smh.com.au/federal-politics/political-opinion/angus-taylor-time-to-empower-patients-in-healthcare-20151029-gkmiwg.html">has called for</a> a “My Doctor” website to provide comparative quality information about doctors. This is a good idea and a natural extension of existing policies. If it does eventuate, publishing prices should be a key component of the comparative information. </p>
<p>Price transparency is no panacea but should be an important component of ensuring taxpayers and patients get good value for money out of the health system.</p>
<p>In the meantime, if you’re seeing a specialist or undergoing a procedure, ask questions about the cost of your care, especially referrals to specialists and private hospitals. You’re paying for a service from a private company and should be able to weigh the perceived benefits against the price before making an informed purchase.</p>
<hr>
<p><em><strong>This article is part of our series <a href="https://theconversation.com/au/topics/hospitals-in-australia">Hospitals in Australia</a>. Click on the links below to read the other instalments:</strong></em></p>
<ul>
<li><p><strong><a href="http://theconversation.com/the-problems-with-australias-hospitals-and-how-can-they-be-fixed-54248">The problems with Australia’s hospitals – and how can they be fixed</a></strong></p></li>
<li><p><strong><a href="http://theconversation.com/infographic-a-snapshot-of-australias-hospitals-56139">Infographic: a snapshot of Australia’s hospitals</a></strong></p></li>
<li><p><strong><a href="http://theconversation.com/from-triage-to-discharge-a-users-guide-to-navigating-hospitals-54658">From triage to discharge: a user’s guide to navigating hospitals</a></strong></p></li>
<li><p><strong><a href="http://theconversation.com/why-do-we-wait-so-long-in-hospital-emergency-departments-and-for-elective-surgery-54384">Why do we wait so long in hospital emergency departments and for elective surgery?</a></strong></p></li>
<li><p><strong><a href="https://theconversation.com/heres-how-to-boost-hospital-funds-and-end-the-blame-game-54247">Here’s how to boost hospital funds and end the blame game</a></strong></p></li>
<li><p><strong><a href="https://theconversation.com/what-are-better-public-or-private-hospitals-54338">What are better, public or private hospitals?</a></strong></p></li>
<li><p><strong><a href="https://theconversation.com/do-you-really-need-to-go-to-hospital-time-to-recentre-the-health-system-54406">Do you really need to go to hospital? Time to recentre the health system</a></strong></p></li>
<li><p><strong><a href="https://theconversation.com/no-one-should-get-dud-hospital-care-its-time-to-lift-our-game-on-quality-and-safety-54561">No-one should get dud hospital care – it’s time to lift our game on quality and safety</a></strong></p></li>
<li><p><strong><a href="https://theconversation.com/hospitals-dont-need-increased-funding-they-need-to-make-better-use-of-what-theyve-got-54815">Hospitals don’t need increased funding, they need to make better use of what they’ve got</a></strong></p></li>
</ul><img src="https://counter.theconversation.com/content/53445/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter Sivey receives funding from the Australian Research Council and has previously been funded by Health Workforce Australia and the National Health and Medical Research Council.</span></em></p>Why is it so difficult to find out exactly how much it’s going to cost to have that suspicious mole removed or to be admitted to hospital for that colonoscopy or hip replacement?Peter Sivey, Senior Lecturer, Department of Economics and Finance, La Trobe UniversityLicensed as Creative Commons – attribution, no derivatives.