Fri Apr 29

Rising out-of-pocket health costs are a worry. But the major parties have barely mentioned it

Written by: Anthony Scott, Professor of health economics, The University of Melbourne

Rising out-of-pocket costs for health care is an important issue the major parties have not yet substantially addressed during the election campaign.

We heard just this week how health-care costs are rising faster than ^[1] other costs of living pressures. Health-care costs ^[2] are also rising faster than wages ^[3]. The rising cost of specialists’ fees, in particular, are a concern. So, many Australian families are finding it increasingly difficult to keep up.

Earlier this year, a major consumer survey found ^[4] 30% of people with chronic conditions were not confident they could afford needed health care if they became seriously ill; 14% could not pay for health care or medicine because of a shortage of money.

Out-of-pocket costs are rising

Out-of-pocket health-care costs cover a range of expenses not covered by Medicare or private health insurance, such as doctors’ fees for consultations and surgery.

Only 35.1% of specialist consultations were bulk billed in 2020-21 ^[6] compared with 88.8% of GP services.

For private (multi-day) hospital care in 2019-20, 43.7% of separations ^[7] (hospital admissions that include procedures and operations) had no hospital or medical out-of-pocket cost.

Out-of-pocket costs are rising, Medicare statistics show ^[8].

There is ample evidence ^[9] out-of-pocket costs reduce access to, and use of, health care. This more strongly affects people who need health care the most.

For instance, access to timely specialist care in Australia depends on your income and ability to pay.

Although richer people use more specialist care ^[10], on average, it is less-affluent people who have higher need for health care ^[11]. Yet it is less-affluent people who have to wait to see a specialist in a public hospital.

High doctors’ fees have other consequences. They may provide skewed incentives to doctors, leading to overdiagnosis and overtreatment ^[12]. Doctors may also flock to high-earning specialties while we have a shortage of GPs (who are paid half as much ^[13] as specialists).

What do the major parties promise?

Health policies announced ^[15] by the major parties ahead of the federal election do not necessarily translate into lower out-of-pocket health costs, or focus on the most pressing issue.

The Coalition has promised to lower the safety net threshold ^[16] for the Pharmaceutical Benefits Scheme. This announcement, made in this year’s federal budget, would make medicines cheaper or free for people who need multiple scripts a year.

But this is an area where out-of-pocket costs have been falling for some time ^[17] compared with other areas of spending. So any announcement may have been better targeted at areas where out-of-pocket costs are growing more quickly.

Person using EFTPOS machine in pharmacy or clinic

Election policies announced so far don’t always address the biggest out-of-pocket costs. Shutterstock ^[18]

In any election there is always a focus on access to GPs and bulk billing. This includes Labor’s proposal for new urgent care centres ^[19], which would provide bulk billed services to take the pressure off emergency departments.

However, neither of the major parties are doing anything about the continuing and much larger increases in specialists’ out-of-pocket costs.

Can informed patients make a difference?

The Coalition introduced a price transparency website ^[21] in 2019 ^[22] that provides estimates of out-of-pocket costs for private hospital care, with plans for doctors to voluntarily upload their fees. Some private health insurers ^[23] also have such websites.

However, these websites rely entirely on consumers doing the “leg work” by shopping around to reduce their out-of-pocket costs. The assumption is that by providing consumers with more information, they will make better choices. But this is too simplistic because information can difficult to get and understand, and these websites don’t include data on the quality of care.

Our review ^[24] on price transparency websites in health care shows they may not work ^[25] for consumers. Not all consumers can or want ^[26] to use them. There’s also the risk doctors could use these websites to see what other doctors are charging and increase their fees.

It could be better if these websites were used by GPs when referring patients to specialists. Patients can also be encouraged to ask about the out-of-pocket cost when booking an appointment or during the visit.

But this does not help patients who are usually in a vulnerable position, who want care quickly, do not have the information or time to shop around, and might think the care they receive will be affected if they ask about cost.

Can doctors make a difference?

Doctors set their own fees and many use the Australian Medical Association fee schedule as guidance. They decide what fee to charge, whether to bulk bill, or whether to use gap cover provided by private health insurers for private hospital care.

At the moment it would require a brave politician to directly control doctors’ fees given the constitutional protections they have and the way Medicare and private health insurance were designed to provide subsidies to patients, not to directly pay doctors.

However, something the major parties can address is “bill shock”. Patients don’t always know the doctor’s fee before they visit, and in some circumstances don’t know in advance how much a procedure will cost.

If care involves many tests, visits and procedures over time by different doctors, then there will be a bill for each. This shifts all the financial risk to patients, something private health insurance was designed to handle.

At a minimum, doctors’s fees and out-of-pocket costs need to be bundled together and published as an upfront quote or range for the expected course of care. This is something that could be addressed by one of the major parties.

What next?

Addressing rising out-of-pocket health costs is a complex area linked closely to broader reform of the health-care system, which neither major party has promised to do anything about.

Without such reforms we’ll see Australians prioritising spending on food, housing and petrol over health care, in the current climate.

But Australia cannot afford to allow this to happen. As we have witnessed during the pandemic, an unhealthy population is not only bad for individuals, it’s bad for us all.