Who is going to take responsibility and act on out-of-control and opaque out-of-pocket specialist fees are becoming? Is legislation the answer?
There are so many elephants in the room when it comes to funding reform that perhaps we can’t see one of the biggest ones – out-of-control specialist gap fees – and we’re missing a huge reform opportunity.
At this week’s Australian Financial Review Healthcare Summit a common theme running across a few different sessions was how rapidly out-of-pocket specialist fees were running out of control, how little oversight and protection there seems to be in terms of protecting patients from what looks like an emerging gouging problem, and who is going to take responsibility for what is an increasingly obvious systemwide problem.
Dr Nick Coatsworth, now working with advocacy group Patients Australia, wasn’t pulling any punches when the AFR moderator asked him to outline some of the big-picture issues in health for the audience.
“Private specialist medical care is, firstly, no longer universal, and secondly, probably has the least amount of consumer protection to the point that a banking Royal Commissioner might actually flush when you open the lid on this,” he said.
If you’ve got a chronic health condition in Australia today, and you try and see a specialist as a public outpatient you’ve usually got months, if not years, on a waitlist, so the only way you can get somewhere is to go and see a private specialist.
Dr Coatsworth is worried about how that is playing out these days for patients in terms of access and equity, pointing out that what is going on at the moment is going on beneath the waterline. No one is bringing any amount of governance or transparency to the process of specialists, most especially procedural specialists, setting their own out-of-pocket fees.
“It is not acceptable that we have a situation at the moment where you’re allowed to split bill [and] there’s no penalty for doing so, where a practitioner can have one bill that is only visible to the patient and another bill that is visible to the two insurers – that is, a private insurer and a government insurer,” Dr Coatsworth argued.
His panel featured a very prominent specialist from the AMA, who was looking appropriately horrified at how blunt Dr Coatsworth was being.
Dr Coatsworth noted that the problem has always existed but seems to have been put on steroids post-covid to the point where government now had to intervene in a manner that was going to be a lot more effective than a multimillion-dollar cost comparison website that had no data on it for patients – Medical Costs Finder.
He noted that so far the problem was only being discussed by the federal health minister as an election “barbecue” type conversation.
Later in the day Private Healthcare Australia CEO Dr Rachel David suggested that post-covid, procedural specialists who had lost a lot of money during covid had put their out-of-pocket fees up by an average of 12% across the board.
She noted that in some regions that had higher incomes and shortages of specialists – she named the Gold Coast, Canberra and the Mornington Peninsula – patients should really think about travelling out of region because gap costs had become so outrageous.
She didn’t say it, but her description was the same as everyone talking about supermarket “gouging”.
Dr Coatsworth thinks the government needs to legislate to make it all one transparent transaction.
That, of course, is a fight with the AMA and the powerful specialist colleges the government does not want have at the moment – hence why it’s probably only a conversation at a barbecue.
“If we are to effectively enact health policy that will result in an increase in rebate for patients, for Medicare and for private health insurance, you must have only a single way to bill a patient in Australia for service, and that needs to be enshrined in legislation,” said Dr Coatsworth.
He was at pains to point out that this wasn’t patients or the government telling specialists what to charge.
“That’s not the idea. But you can’t pull policy levers and then have an unseen burden of out-of-pocket costs in Australia.
“It’s the major area where we’re losing our universality [of Medicare] and we need some consumer protections,” he said.
For obvious reasons the private health insurers represented at the Summit on the day were more or less in furious agreement.
Dr David described post-covid as a period of “hyperinflation” as far as specialist gap fees were concerned.
“We’re hearing anecdotally from our hospital partners that since the pandemic, we’ve had a number of specialists working less and charging more to make up their income,” said David.
“We’re talking about, at the high end, some very high incomes.”
Up to $3 million was mentioned by someone on the panel for some procedural specialist annual incomes.
“I know the MBS hasn’t moved in a long time, but we’re talking about people on seven figure sums, and people who are on the phone [to us} in tears because they can’t even afford the referral,” said Dr David.
She said that member figures indicated that 20% of people who get referred to a specialist today aren’t going because they can’t afford it.
She said that a cost comparison website was a start but a long way short of what was needed to reign in the situation, and like Dr Coatsworth she too mentioned the L word (legislation).
“The government’s move with the Medical Costs Finder website is absolutely the right thing to do.
“It starts the conversation between the patient and the GP, but they’ve got to look at the workforce side, they’ve got to look at the scope of practice review and look at what we’re doing in terms of competition.
“And we’ve got to strengthen the consumer law to ensure that people that are in such a disempowered position when they’re referred have some sort of protections.
“By that, I mean if you get a bill that you don’t expect, you don’t pay.”
