The recent ABC 4 Corners film about gap charges for private surgery raises many important questions. There are many surgeons in Australia who think that ethical behaviour is all about following rules on advertising, but there is a great deal more to “doing the right thing” than that. The programme presented a more or less balanced view, although it did focus on some extreme examples to make its point.
In the film it was pointed out that while we might consider private healthcare to be a free market, it rarely is because patients do not have all of the information required to make informed choices. Asymmetric relationships generally put the surgeon in full control and patients at a disadvantage as they do not know their options.
The idea of “you get what you pay for” does not always hold in healthcare, and surgeons can play upon this to extract the highest possible fee that the market will stand. The 4 Corners film focused upon a patient charged an out-of-pocket surgery fee of $7500 for his hip replacement, but there is more to high fee-structures than a minority of surgeons charging that far over the odds. The Australian Medical Association (AMA) has a recommended surgeon fee schedule that would leave even the best-insured patient out of pocket by $1000 for a hip replacement.
The value proposition of private health care balances coverage and faster access with price. If the private system is perceived as being unfair, with excessive out of pocket fees, then patients will drop out and turn to the public system. For the balanced system of public/private provision current in Australia to be sustained, confidence in the private system is critical.
So, what can I do as a surgeon?
- Reasonable fees– my standard fees are those paid by BUPA. If a patient has BUPA insurance, no gap. Where other insurance companies pay less than that rate, then there will be a gap, generally under $450 for a major surgery such as joint replacement. I do not think currently that the AMA fee schedule is justified in a regional setting where median incomes are lower than those in metro areas.
- Charge only the gap – where there is a gap, that will be discussed. The remainder of the fee will be billed to the Insurance Provider, rather than the patient paying the whole fee up front and claiming for themselves from their fund.
- Informed financial consent– I discuss fees with patients directly; it is not passed over to a practice manager.
- Predictable anaesthetic fees – I work regularly with two anaesthetists, and don’t take part in a roster, so I always know who my patients will meet in the anaesthetic room. In that way, I am able to advise patients (in advance) what fees they will face from the anaesthetist (currently no gaps from either anaesthetist). We are also able to develop sound co-operative care for patients.
- No booking fees or hidden charges – policy excess charges differ between funds, but I will be completely transparent in what I charge. No nasty surprises.
- High quality, local, personal care – daily visits while patients in hospital, co-ordination with physios etc, easy access to out-patient review, patient-centred care including shared surgeon/independent physio review of joint replacements over the long term. All while trying to take a balanced view on reasonable remuneration for that service.
What can GPs do?
- Find out what surgeons you refer to charge – not just for outpatient clinics, but what are their surgery gaps? And if you think it is excessive, tell them and tell your patient. If it is not easy to find out from the surgeon, then ask why and ask why you should refer to them.
- Think local – surgery in the city will generally be more expensive for the patient, but is it better? And what are the secondary costs for patients being far away from their surgeon and aftercare when they come home? We value and support the GPs who choose to live in the region, and hope that surgeons who make the same choice will be valued by you.
- Support local services - Currently, at least 40% of insured patients from south-west Victoria get their orthopaedic care outside the region, often in Melbourne, placing greater pressure on St John of God Warrnambool, which is under financial pressure. The surgeons providing local private orthopaedic services are the same surgeons providing local public services, including trauma care, and for the system to remain viable, both sides have to function effectively.
What can patients do?
- Ask questions – find out your costs and options, shop around.
- Think local –local services can be cheaper and more convenient for you than metro services, without necessarily compromising care.
- Support local services – so that they are there when you need them.
Alasdair Sutherland
June 2018
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