Medical specialists’ lack of pricing transparency leading to bill shock for patients

<span>Photograph: Maskot/Getty Images</span>
Photograph: Maskot/Getty Images

A lack of transparency in pricing from medical specialists is leading to bill shock, while a higher proportion of specialist visits among the wealthy undermines the principle of equitable Medicare, according to research in the latest issue of the Australian Health Review.

The journal highlights issues of healthcare access and equity through research from a range of institutions.

An evaluation of Medicare Benefits Schedule data led by the University of Technology Sydney found the distribution of specialist visits favours people living in wealthy, highly educated areas. The researchers found substantial income-related inequality in costs of bariatric surgery, and that Medicare-subsidised psychiatry services also favoured wealthy areas.

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Meanwhile, researchers led by the University of NSW studied the costs of more than 2,000 out-of-hospital initial consultations with cardiologists, ophthalmologists and oncologists and examined cost differences by location, creating the first national dataset for those specialities.

Most specialists have a discrete tiered “fee list”that can vary across locations, they found. This type of data might be more useful for pricing transparency than the government’s Medical Cost Finder website, the authors wrote, which only lists the median out-of-pocket cost for a specialty. This may “mask substantial variation in costs and lead to bill shock for individual patients”.

But the authors added that the location and fee data they interrogated still does not provide concrete information on how much a patient can expect to be charged.

“Providers with the highest fees within their specialty may still bulk bill many of their patients, and providers with relatively low fees within their specialty may occasionally charge a very high fee.”

This is because other studies have found some specialists price-discriminate and adjust fees based on whether they perceive a patient as being more able to afford it. “If and when providers charge different fees depending on patient factors, they will choose one of potentially several fees,” the authors wrote.

The journal, from the Australian Healthcare and Hospital Association, highlights that with rising cost of living and the poverty divide growing, more people are finding it difficult to cover medical expenses that come with out-of-pocket and unexpected fees.

The journal’s editor and adjunct professor at the Queensland University of Technology’s school of public health, Dr Sonĵ Hall, said while individual providers may lower fees or bulk bill for patients with lower or no incomes, “this does not make up for the overall disadvantage to those who can’t afford services that are not 100% bulk-billed through Medicare”.

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“This means that patients are more likely to delay or avoid care and treatment altogether,” Hall said.

It follows data released by the Australian Institute of Health and Welfare on Wednesday that showed bulk billing rates are continuing to decline. The latest quarterly data shows bulk billing dropped from 87% to 83.4%. A growing number of GPs are ditching bulk billing, citing rising costs and inadequate Medicare rebates for patient consultations.

The president of the Royal Australian College of General Practitioners, Dr Nicole Higgins, said the 83.4% figure “is probably a lot worse than initially appears”.

“There is an important distinction between the proportion of GP services that are bulk billed and the proportion of patients who had all their GP consults bulk billed,” she said. “So, for example, we know in the previous term of government there were claims that bulk billing was sitting at a healthy 88%, but a more critical look at the data revealed that the percentage of patients who had all their GP care bulk billed was sitting at just two-thirds nationally in 2020 and 2021.”

For some jurisdictions, the figure was much lower.

“Patients who see their GP regularly with complex conditions that require careful management, such as asthma and diabetes, inflate the proportion of GP services that are bulk billed,” Higgins said. “What all this means is that the statistics are even more alarming than you would initially assume.”