What the Sydney Morning Herald reported
On 8 November, the Sydney Morning Herald reported on new Grattan Institute analysis of specialist fees. Fees rose 4 per cent faster than inflation in the past year, on top of a 73 per cent real increase between 2010 and 2025. More than two million Australians paid at least one "extreme" fee last year, which Grattan defines as more than three times the Medicare Schedule Fee. More than 800,000 people skip or delay specialist care each year because of cost.
Grattan proposes that specialists whose fees average more than three times the Schedule Fee should repay the Medicare rebates linked to their services. It estimates fewer than 6 per cent of specialists would be affected. It also calls for the Schedule Fees to be reviewed, for GPs to have easy access to specialist advice, and for urgent action on a projected shortfall of 7,000 specialists by 2033. The AMA argues the underlying problem is years of Medicare underfunding.
Read the original at the Sydney Morning Herald
My view of the report
Some fees can't be justified, and I won't defend them. Where fees are genuinely excessive, they deserve scrutiny, and I support a fair process for identifying them. That process should use the data to find outliers and then have specialist peers review them.
But I don't accept that the Medicare Schedule Fee is the right measure of what is excessive. The Schedule Fee isn't a fair price for medical care, and it was never meant to be. It is simply what the government is willing to pay as the patient rebate. For years that rebate was frozen, and since then it has been poorly indexed. As a result it has fallen well behind the real cost of providing care: staff, rooms, equipment, indemnity insurance and the time each patient needs.
A fee three times the Schedule Fee says as much about how far the patient rebate has fallen as it does about the doctor.
Measuring fees against a figure the government has let fall behind risks calling reasonable fees excessive.
Fees are the most visible part of the problem, not its cause. The patient rebate hasn't kept pace with the cost or complexity of care. Public hospitals can't fund enough clinics. Training numbers are limited by the posts governments fund. A penalty aimed at fees, however well targeted, leaves all of that untouched.
What the comments told me
The article drew more than 300 comments. Many come from people who have been hurt by the system: a parent paying hundreds of dollars a visit for a child's ADHD assessment; someone trying to help a friend see a psychiatrist; families who were out of pocket after a major operation and didn't see it coming. Those experiences are real. If I were in their position, I would be angry too.
What concerns me is how much of the debate rests on misunderstandings, and how those misunderstandings point people away from the changes that would actually help.
"The colleges restrict training to keep incomes high."
This came up again and again. Colleges accredit training posts so trainees are properly taught and supervised, but the number of trainees depends on how many posts governments fund in public hospitals. In my own college, that is the limit. Several doctors in the comments described the same thing: departments with no new specialist funded in 20 years, and waiting lists capped at what one surgeon can operate on in a month. Recognising overseas-trained specialists is often seen as slow, but in my own college the assessment is faster than the government-run pathway. That assessment exists to protect patients, as the Bundaberg Hospital case showed.
"Specialists are wealthy and motivated by money."
Specialists are well paid, and I won't pretend otherwise. But that comes late. A medical degree of up to seven years, with its fees and debt, is followed by around ten more years of hospital training and exams. Most specialists are in their mid to late thirties before they earn a specialist income. Even so, arguing about incomes doesn't help anyone waiting a year for care.
"The surgeon cost me nothing, but the anaesthetist charged me."
As an anaesthetist working in both public and private hospitals, I understand why this feels unfair. Many people think the anaesthetist simply puts them to sleep and the job is done. In reality, we assess each patient beforehand, plan the anaesthetic around their health and their operation, and then take responsibility for their breathing, heart, blood pressure and pain throughout surgery. We stay with them until they are safely in recovery.
While the surgeon concentrates on the operation and solving the problem, the anaesthetist keeps the patient alive.
A surgeon whose bill is fully covered hasn't charged less. Their whole fee is met by the patient rebate and the insurer, and that fee is usually considerably higher than the anaesthetist's total fee for the same operation. The difference is that the patient rebate for anaesthesia covers a smaller share of a reasonable fee, and it has fallen further behind over 20 years of inadequate indexation. When there is an out-of-pocket cost, patients should know about it beforehand, and that is our responsibility.
"Make specialists do public work, or cap their fees."
I work in both public and private hospitals, and I see both sides every week. Many specialists would welcome more public work, but hospitals can't create posts or operating time they aren't funded for. Price caps risk a two-tier market, with budget care for some and fees separated from Medicare altogether for others.
The real problem
One GP who has practised for more than 30 years put it plainly in the comments: private fees wouldn't be such a problem if there were a functioning public system. I agree.
When the debate becomes a contest between angry patients and defensive doctors, everyone loses except those responsible for planning. Each misunderstanding that goes unchallenged gives governments another reason to focus on fees instead of on the things only they can fix: indexing patient rebates properly, funding public clinics, and funding the training posts we already know we need.
Patients deserve to know what they'll pay before treatment, to see a specialist without waiting years, and to trust that the system is being planned. Doctors and patients want the same thing, and we should be asking governments for it together.
Disclosure: I have made a submission to the parliamentary inquiry into access to specialists and will give evidence at a public hearing.
See also: 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 reporting section summarises the original article, which is linked. Reader comments are paraphrased and not attributed.