Plan to address specialist fees 'conflates excessive charging and affordability'

The AMA has warned broader affordability problems could only be resolved through greater investment in Medicare rebates and insurer fee schedules, creating more specialist training places, and expanding specialist services in public hospitals

In its submission to the government’s consultation on specialist affordability, it noted the department has raised limitations in its own analysis of the plan yet failed to correct them.

It went as far as saying one of the ideas should be “consigned to the dustbin”.

With out-of-pocket costs for healthcare having increased by more than 75% between 2019 and 2025 a growing number of Australians are delaying or putting off seeing a specialist doctor because of cost.

AMA National Vice President Associate Professor Julian Rait said there was a mismatch between solutions proposed in the department’s paper and the complex causes of access and affordability issues.

He said patient out-of-pocket costs were influenced by many factors including Medicare rebates, private health insurer benefits, the complexity of cases, geography and workforce supply.

“The government must rule out several options in this paper, including the idea that Medicare rebates can be used as a benchmark given how far these have fallen behind the costs of delivering care,” A/Prof Rait said.

“Several years of Medicare freezes and years of below Consumer Price Index indexation should see this idea consigned to the dustbin.

“There’s been no top-up funding after years of rebate freezes, no investment plans, and no signs of reform, with our Medicare Gap campaign highlighting just how far behind reality Medicare specialist consultation funding has fallen.”

A/Prof Rait said the department’s paper detailed limitations in its analysis but then failed to address those limitations when considering policy.

“The department acknowledges the Medicare Benefits Schedule fee may not reflect contemporary costs and has a different relationship to charged fees across items.

“Despite this concession, the same benchmarks, distributions and specialty rankings continue to support the paper’s proposed options.

“The government must rebuild its analysis to compare genuinely comparable services and practitioners, excluding bulk-billed services when establishing benchmarks for privately billed care.”

In its submission, the AMA argued that including bulk-billed claims depresses the median and may make ordinary privately billed fees appear to be outliers.

It also wants to see the proposal to remove a patient’s Medicare rebate dropped, with A/Prof Rait saying it would leave patients worse off without reducing provider’s fees.

The government has looked at whether caps for excessive fees might act as a deterrent but raised concerns that regulatory enforcement of caps would need to occur after a fee has been charged.

One option to avoid this considered making excessive fees ineligible for Medicare rebates, but it risked the MBS benefit being withheld from the patient, placing further financial burden on them while the provider retained the full fee.

The AMA has proposed a statistical threshold to identify cases for further examination, with serious, repeated and unexplained cases proceeding to specialist peer review, with appropriate procedural fairness and appeal rights.

A/Prof Rait said the profession was keen to work with the government to tackle excessive fees and hopes the government consider its constructive ideas put forward for consideration.

Submissions on the Specialist Affordability paper are now closed with the Department of Health saying findings of the consultation would contribute to broader consultation on specialist affordability and access.

The AMA’s full submission is available online.