Official figures hiding true cost of private health gap charges

Many privately insured patients face high out-of-pocket medical costs.

Gap charges causing hip-pocket pain

Privately insured patients face out-of-pocket medical costs amounting to thousands of dollars much more frequently than official figures indicate, according to the Consumers Health Forum (CHF).

While the official figure on medical gaps from the Government regulator APRA states that on average 88 per cent of private hospital medical services have “no gap”, industry figures show that, for many surgical procedures, the rate of gap charges is actually much higher.

That reality is being borne out in early responses to CHF’s Out of Pocket Pain survey, which after a week and over 600 responses is showing that significant numbers of respondents are paying gap costs, often more than $1000 and ranging up to $20,000.

Data collected by Australia’s biggest health fund, BUPA, shows that for common operations such as knee replacement, fewer than 40 per cent of operations are performed where no gap is charged and 39 per cent of the operations drew out-of-pocket costs averaging $2001-$5000. 

For some prostate operations, only 17 per cent had no gaps, while more than a quarter of patients had out-of-pocket bills of more than $5000.

Research by the Breast Cancer Network Australia shows that many women with breast cancer face similarly high costs.

The official no-gap figures published by APRA count all in-hospital medical services. CHF suggests the figures are skewed by the numerous low-cost procedures that count towards a person’s overall ‘basket’ of services that do not have a gap charge, such as pathology tests and radiology.

“The confusing nature of these figures highlights the need for much simpler, clearer private health care and insurance arrangements,” CHF CEO Leanne Wells said.

 “Many private patients are questioning the value of health insurance when they have to pay so much more in out-of-pocket costs for services they expected to be covered by insurance.

“It is clear that a Productivity Commission inquiry is necessary to investigate the nature and reasons for this state of affairs.

“Our political leaders must address this issue effectively if we are to retain decent access to health care for all,” Ms Wells said.

Have you ever been caught out having to pay high out-of-pocket medical costs? Has having private health insurance saved you gap costs? Should health insurers be obliged to pay the full cost of procedures they cover, as car insurers do?



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    30th Jan 2018
    For me the out of pocket expenses are the anaesthetist fees and numerous tests I am lucky because I have a health care card which covers blood tests and x- rays, Medicare does cover medical expenses. Major expense is the hospital charge which should be dropped. I would not consider dropping health insurance .Receive quality care .The older you get he more health problems you experience. Having access to health insurance us peace of mind
    30th Jan 2018
    Husband's prostate and misdiagnosed by the GP heart problems have cost us a bomb. Our health fund lists those specialists who do not charge a gap fee, but there is no choice in an emergency situation. I do not begrudge medicos being paid for the lifesaving work they do. We are so fortunate to have such a well trained cohort of lifesavers. What does make me cranky is that my private fund which I have been paying into for 52 years at top level cover does not cover everything. I dare not do the maths. Then I see folk go through the public system with the same results. The health system in this country is on the edge of collapse should more folk go public. Surely it lies at the feet of government to fix this problem before it is too late. Judging by their present performance, any optimists out there? Any ideas? Deprivatising health insurance? Power? Telecommunications?
    30th Jan 2018
    Health insurance C .Link and many more government departments are all in big trouble and most of this has happened in the last few years perhaps you can work it out for your self.Are they being set up to fail any thing is possible with this Government.
    30th Jan 2018
    Well We are one of the 540000 people who lost our part pension due to Hockey's draconian changes for anyone who worked and saved for their retirement, but we believed Turnbull's lie that the PCC would be reinstated. But this was a LIE, anyone who lost it after 1/1/2017 did not have it reinstated. We are now finding that many medical clinics do not accept the Commonwealth concession card, another lie by Turnbull, so seniors and retirees medical expenses will go through the roof. As well as rates, car rego, electricity bills , telephone etc. I cant believe I actually voted for the lying Liberals
    30th Jan 2018
    Can't believe you voted for them either!

    Next time, make sure to vote them and Labor or Greens (whoever holds the seat) last in preferences - maybe then good Independents will come up and the system will be shaken up - as it needs to be.

    30th Jan 2018
    I don't know if there is a fix for this. The government has had an inquiry into the exorbitant cost of prosthetics and we are told that the prices have been reduced. The problem of excess costs in the private sector is directly due to the amount charged by doctors, surgeons and specialists. There is no set, agreed fee for any of these services and, in most cases, these people won't accept what the health funds are prepared to pay which is not insubstantial.

    Some doctors, (thankfully ours) will allow bulk billing but there are others who will not. The AMA should be buying into this a lot more than it does and setting a standard fee for both doctor's consultations and those performing operations. As regards specialists, I have no idea how to get around that problem. I had to be seen by a specialist because of an increase in an area shown up by annual tests. He told me to get the test done again to be sure ($140 for 10 minutes) and when the results came back negative nothing more was done ($120 for 6 minutes)

    There has been a mention of anaesthetists and these people are a total mystery. I have a neighbour who was scheduled for a hernia operation and asked his doctor if he could do a vasectomy at the same time. The doctor agreed and said that he was working in that area anyway, no problem. The anaesthetist, however, said that it was two operations so my neighbour had to pay an amount, in cash, to make it all happen.
    31st Jan 2018
    The AMA acts like a union and so is holding us all t ransom. They need the same treatments as the workers's unions to curb their power.

    The government should be able to set standard fees and employ medical personnel with appropriate salary scales.

    Having two systems, public and private, is excessively expensive and encourages gouging.
    30th Jan 2018
    Mike I think a lot of people lost faith in the Liberal Government at that time I for one will not forget.

    30th Jan 2018
    "APRA states that on average 88 per cent of private hospital medical services have “no gap” - Statistics are known to justify any lies the Govt wishes to propagate. The Dollar amounts in Gaps are more important than the number of Services which as noted in the article includes many low-cost services with no gaps. APRA should do better than this - after all, it's a taxpayer funded Govt organisation.

    Both Doctors' fees and Gap coverage by Insurers need to be firmly controlled by the Govt - I know not this one (can't touch their mates), and can't see Labor (without "U") having the guts either.

    1st Feb 2018
    (Private Health) Insurance = SCAM. A Royal Commission is needed into the entire sector.

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