Take the bill shock out of surgery

Outrage after a Four Corners exposé revealed that some medical specialists pocketed exorbitant fees not covered by Medicare or private health insurance has turned into action.

The report elicited swift criticism from key medical bodies with calls for a royal commission, greater transparency of fees and a limit on doctors’ current freedom to set whatever prices they want. Now, for the first time, patients have some degree of control – they can check how often a surgeon or specialist has used a private health insurer’s gap cover scheme and gauge any out-of-pocket costs.

Online medical directory Healthshare has published gap scheme participation data on the profile pages of more than 14,000 specialists across Australia, Fairfax is reporting.

“For example, a Teachers Health Fund member referred to a particular orthopaedic shoulder surgeon in Sydney would be able to see that four per cent of 124 patients who received in-hospital treatment in the past 19 months paid no gap, 26 per cent paid a known gap, and 70 per cent paid an out-of-pocket cost of more than $400,” the report says.

Thirty health funds that are members of the Australian Health Service Alliance or Australian Regional Health Group, as well as Medibank and HCF, contributed to this information on Healthshare.

Three funds – Bupa, HBF and nib – opted not to make their data available.

A Bupa spokesman told Fairfax it had “led the way on providing transparency of out-of-pocket costs to our customers through our online tools [and] have partnered with a number of providers”.

Patients needing specialist medical treatment have traditionally accepted their GP’s referral. But given there are sometimes huge variations in specialists’ fees, questions are being asked more regularly.

Healthshare CEO Rami Weiss said: “GPs don’t have a lot of this [pricing] information and it’s not realistic for them to search around fund by fund, so we’re putting it at their fingertips.

“We want patients to have better discussions with their GPs and specialists, to take the information, understand their situation and know what questions to ask.

“We’ve also seen specialists say they’ve been tainted by a few outliers [who charge too much], so we’re also allowing specialists to provide information themselves on fees on their profile.”

The Australian Medical Association (AMA) tweeted after the Four Corners program: “No Australian should need a GoFundMe page to afford their medical care. It may only be a small number of doctors charging egregious fees, but it needs to stop.”

AMA president Dr Tony Bartone said: “We’re concerned about egregious billing, but prices can vary depending on what state you’re in, whether it’s CBD or rural, and on the patients – there’s undercurrent illness, intercurrent conditions, complicating factors.”

“The out-of-pocket committee is looking at the issues and whatever the solution is, it must be tested and evaluated to make sure it gives meaningful, informed and reliable outcomes, and that there are no unintended consequences.”

Royal Australasian College of Surgeons (RACS) president John Batten said the majority of Australian surgeons aimed to deliver affordable quality care, but that a small number of ‘rogue operators’ were charging excessive fees in breach of the RACS Code of Conduct.

Grattan Institute health economist Stephen Duckett said Healthshare, in which Fairfax has a minority holding, was responding to consumer need.

“It’s good the consumer can look at what the out-of-pockets are likely to be and then talk to the GP again and say, ‘Hang on, this person seems to have high out-of-pockets, is there someone else?'” he said.

“But one critical risk is that people will think out-of-pockets is the only criterion, when quality of care [and] complication rates are important factors.”

Have you had experience with unexpected out-of-pocket medical expenses? Would you ask the question and shop around? 

Related articles:
Medical bodies slam rogue surgeons
Risks to elderly after surgery
Bupa softens stance on exclusions

Written by Janelle Ward

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