What Grattan argued
In The Conversation on 8 November, Peter Breadon and Thomas Shortridge of the Grattan Institute argued that specialist fees are "out of control". They wrote that falling Medicare rebates and rising practice costs don't explain them, and that specialists whose fees average more than three times the Schedule Fee should repay the rebates linked to their services. They also call for training targets, with colleges held to account, and $500 million a year for public clinics. Their article ends: "Charging unjustifiable fees is a choice."
Read the original at The Conversation
My view
Grattan is right that patients are struggling, and right that public clinics need serious investment. But its central argument, that this is a problem of specialists' choices, is wrong, and the policy built on it would make access worse.
"Don't blame Medicare."
Grattan says the average specialist rebate has fallen only $9 in real terms since 2012. That figure is an average across every service, and Grattan's own chart notes that it doesn't account for changes in the mix of services. An average can hide what has happened to individual items, and it says nothing about whether the rebate was ever adequate.
The Medicare Schedule Fee is what the government determines it will pay towards a service. It's a government funding benchmark, not a prescribed professional fee or an independent assessment of what care should cost, and decades of rebate freezes and inadequate indexation have only widened that gap.
The government is entitled to decide what taxpayers contribute. That's quite different from deciding what a medical professional's services are worth.
Using the Schedule Fee as the yardstick for "extreme" fees means measuring doctors against a number the government has let fall behind.
"Costs don't explain it."
Aggregate tax data on practice costs can't show what has changed inside the consulting room: longer appointments, more complex patients, and more time spent correcting misinformation. Nor does it count the specialist's own time as a cost. Grattan treats profit as if it were surplus. For a specialist in private practice, it is largely payment for their own clinical work.
"Hold the colleges to account."
This is the claim I can rebut most directly. Colleges accredit training posts. Governments decide how many to fund. In my own college, trainee numbers are limited by the funded positions available in public hospitals, not by the college. Grattan itself notes that the May budget rolled over specialist training funding without adding a single new place. You can't hold colleges to account for training posts governments won't pay for.
What the data leaves out.
Grattan's specialty comparisons are built on initial consultations outside hospital. Anaesthesia, delivered almost entirely in hospital, doesn't appear in the data. Yet the debate is being used to paint all specialists with the same brush. The anaesthetist's work is billed under the Relative Value Guide, which already accounts for the complexity of the procedure, its duration and patient risk. That is a more transparent basis for fees than most of medicine has.
Why the clawback would backfire.
The Medicare rebate belongs to the patient. Recovering it from the doctor at an arbitrary threshold creates a cliff: a specialist just under the line repays nothing, while one just over could repay a full year of rebates. That gives doctors a reason to manage their billing around a threshold instead of around their patients. It also risks pushing some specialists away from Medicare altogether. Where fees are genuinely excessive, the answer is fee information before treatment and peer review of persistent outliers, with fair process, not a blunt penalty.
Underfunding is a choice too
Grattan ends by saying that charging unjustifiable fees is a choice. So is freezing patient rebates. So is leaving public clinics with waiting lists measured in years. So is rolling over training funding without adding a single place. Those choices belong to governments, and they are the main reason patients face the costs and waits Grattan describes.
Penalising specialists won't create one extra appointment.
If we want affordable specialist care, we need to index patient rebates properly, fund public clinics and fund the training posts we already know we need.
Disclosure: I have made a submission to the parliamentary inquiry into access to specialists and will give evidence at a public hearing.
See also: What 316 comments tell us about specialist fees and Fees are only one side of the equation.
The views in this commentary are my own and do not represent Alfred Health, ANZCA or any other organisation with which I am associated. The first section summarises the original article, which is linked.