When Mary’s* heart began beating irregularly one evening in 2016, she was taken by ambulance to a major public hospital in Melbourne and treated by a cardiologist.
She was surprised when her required follow-up appointments were in the cardiologist’s private consulting rooms rather than also through the public system.
Mary’s out-of-pocket costs for these appointments grew to more than $100 per appointment by November 2023. On a disability pension due to myalgic encephalomyelitis/chronic fatigue syndrome, it meant by January 2024 Mary’s savings were “well and truly gone”.
When she told her specialist she was struggling to pay and asked if she could move to the public system, he said: “I don’t want you to fall through the gaps.”
He offered to bulk-bill every second appointment, an arrangement which worked well until March, when Mary says another staff member accused her of not respecting the doctor, loudly and in front of other patients .
When Mary said she could not pay for the appointment – believing it was to be bulk-billed – she says the staff member “threw the Eftpos machine down on the desk”, recalling how “embarrassed” she felt.
At her next appointment Mary’s cardiologist said a change in practice ownership meant their payment arrangement could not continue.
A system without protections for patients
Dr Elizabeth Deveny, the chief executive of the Consumer Health Forum of Australia (CHF), says Mary’s story is not isolated and reveals “how fragile affordability can be for many people”.
“When costs fluctuate or communication breaks down, people are forced into impossible choices. These stories highlight the need for stronger protections and better transparency. It’s not about individual specialists being ‘good’ or ‘bad’ – it’s about a system without effective guardrails,” Deveny says.
“We also see very positive examples where specialists work with patients to keep care affordable, and those examples matter. But they’re not guaranteed. That inconsistency is exactly the problem.”
She says the CHF has long been lobbying the government to improve specialist affordability and fee consistency.
“Frankly, Australians can’t wait any longer.”
The former chief medical officer and health department secretary Prof Brendan Murphy wrote an article in the Medical Journal of Australia (MJA) in November calling for “ethical reflection” among specialists.
“I’m not so worried about people who can afford to pay, but for low-income people with chronic disease, it really is presenting a problem with access to care,” Murphy told Guardian Australia.
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He says many specialists have “kneejerk reactions” to the issue. But Murphy wrote in the MJA that when Medicare was introduced in 1984, there were fewer specialists than general practitioners, so the limited numbers were in high demand and often worked more than 65-hour weeks.
With more non-GP specialists today, they work fewer hours but “still feel the same entitlement to maintaining the relative income that the previous specialist colleagues had”, Murphy says.
He acknowledged specialists today often enter private practice with significant Hecs debts, and at a later age due to the increasing competitiveness of specialty training positions and longer training pathways.
It means experienced older specialists often have some of the lowest fees, while younger doctors charge more, Murphy says.
Many doctors do have a concessional rate for people on healthcare cards and pensioners, but often that’s “still quite a substantial gap and I do think there should be some more nuanced charging practices”, Murphy says.
Forced towards unaffordable care
Without reforms, experts say patients will keep being pushed towards the private system – even when they can’t afford it.
Sam, a retiree seeing nine specialists in Sydney for several conditions affecting his heart, eyes, lungs and nose, says it’s not possible to get public care “unless you arrive in an ambulance”.
Respiratory issues were the beginning of Sam’s “health crisis”, and led to the diagnosis of several other unrelated conditions within a six-month period.
After months of not hearing back about a referral to a Sydney public hospital’s ear, nose and throat unit, Sam’s GP “hassled” enough to secure him an appointment in six months’ time.
But as the appointment approached, the hospital told Sam he needed to see the surgeon for an initial consultation in their private rooms. He ended up finding a different private specialist who charged him the Medicare scheduled fee, the government-set baseline, lowering the appointment cost.
While Sam, whose retirement income is “not far” above the pension, is grateful that some specialists have done this, he says accessing affordable care is too hard.
Prof Owen Ung, the president of the Royal Australasian College of Surgeons, says it is common for doctors, especially in New South Wales, not to be allocated a public outpatient clinic, so the only option to see patients outside of a hospital admission is in private rooms.
Ung acknowledges there is a “very small minority” of doctors who need to be called out for charging egregiously.
But he says some fees are justified even when they far exceed Medicare rebates because indexation has “fallen so far behind that the country could never afford to put it to where it needs to be”.
“In reality, there are some schedules that need to be 300% of the schedule fee,” Ung says. “My rooms would cost me about 150 to $200 per hour just to keep the doors open.”
He highlights a problem GPs have also raised with Medicare: “We have a system problem in that it’s remuneration by occasions of service, not quality of service.”
He says similarly hospitals are funded by activity, not quality of care. Ung said surgeons receive very little remuneration for consultations with patients; instead, they get remunerated for operating, which may not always be the best solution for the patient.
“What the government needs to work towards is better outcome-based policy settings and fair remuneration for fair services,” he says.
Murphy says government’s have an “obligation” to ensure access to care.
“I suspect that governments, over the years, have considered fee regulation, but have shied away from it, probably because nobody wants to fight with the doctor group,” he says.
The federal health minister, Mark Butler, said tackling soaring specialist fees will be a priority in the government’s second term, after its first term focused on strengthening GP access and bulk-billing.
Speaking to ABC Radio Melbourne on Friday, Butler said laws addressing the issue may be considered, but he acknowledged constitutional limits on what governments can force doctors to charge. But he said specialists fees had gone “well beyond” charging a modest amount on top of the Medicare rebate, describing some fees as “out-of-control,” and “completely a rip-off”.
As a first step, Butler said the government would force specialists to publicly disclose their fees on the Medical Costs Finder website, after asking specialists to disclose their fees failed.
Ung says Australia has one of the best health systems in the world, because there is a symbiotic relationship between the public and the private, with most of his colleagues working across both sectors. “But that is all at peril if we don’t do something about the system.
“The pressure on the system now, so many people now can’t afford private health insurance. They can’t afford private care. And if that keeps moving in that direction, that puts more pressure on our public hospitals. We’ve got to make sure that we provide healthcare for everybody,” Ung says.
*Names changed to protect privacy
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