Need to see a specialist? You might have to choose between high costs and a long wait. Here’s what needs to change
- Written by Peter Breadon, Program Director, Health and Aged Care, Grattan Institute
If you have cancer, a disease such as diabetes or dementia, or need to manage other complex health conditions, you often need expert care from a specialist doctor.
But as our new Grattan Institute report shows, too many people are forced to choose between long waits in the public system or high costs if they go private.
Governments need to provide more training for specialist doctors in short supply, make smart investments in public clinics, and regulate the extremely high fees a small number of private specialists charge.
High fees, long waits, missed care
Fees for private specialist appointments are high and rising.
On average, patients’ bills for specialist appointments add up to A$300 a year. This excludes people who were bulk billed for every appointment, but that’s relatively rare: patients pay out-of-pocket costs for two-thirds of appointments with a specialist doctor.
Increasing GP costs make national headlines, but specialist fees have risen even more – they’ve grown by 73% since 2010.
People who can’t afford to pay with money often pay with time – and sometimes with their health, as their condition deteriorates.
Wait times for a free appointment at a public clinic can be months or even years. In Victoria and Queensland, people with an urgent referral – who should be seen within 30 days – are waiting many months to see some specialists.
High fees and long waits add up to missed care. Every year, 1.9 million Australians delay or skip needed specialist care – about half of them because of cost.
Distance is another barrier. People in regional and remote areas receive far fewer specialist services per person than city dwellers (even counting services delivered virtually). Half of remote communities receive less than one specialist appointment, per person, per year. There are no city communities where that’s the case.
Train the specialists we’ll need in the future
Specialist training takes at least 12 years, so planning ahead is crucial. Governments can’t conjure more cardiologists overnight, or have a paediatrician treat elderly people.
But at the moment there are no regular projections of the specialists we’ll need in the future, nor planning to make sure we get them. Government-funded training places are determined by the priorities of specialist colleges, which approve training places, and the immediate needs of public hospitals.
As a result, we’ve got a lot of some types of specialist and a shortage of others. We’ve trained many emergency medicine specialists because public hospitals rely on trainees to staff emergency departments 24/7. But we have too few dermatologists and ophthalmologists – and numbers of those specialists are growing slower than average.
The numbers of some types of specialists are growing faster than others.
Grattan Institute, CC BY-NC-SA
The lack of planning extends to where specialist training takes place. Doctors tend to put down roots and stay where they train. A shortage of rural training places leads to a shortage of rural specialists.
To fix these problems, governments need to plan and pay for training places that match Australia’s future health needs. Governments should forecast the need for particular specialties in particular areas. Then training funding should be tied to delivering the necessary specialist training places.
To fill gaps in the meantime, the federal government should streamline applications for overseas specialists to move here. It should also recognise qualifications from more similar countries.
More public clinics where they’re needed most
Public clinics don’t charge fees and are crucial in ensuring all Australians can get specialist care. But governments should be more strategic in where and how they invest.
There are big differences in specialist access across the country. After adjusting for differences in age, sex, health and wealth, people living in the worst-served areas receive about one-third fewer services than people in the best-served communities.
Governments should fund more public services in areas that need it most. They should set a five-year target to lift access for the quarter of communities receiving the least care in each specialty.
More services are needed to help the least-served communities catch up.
Grattan Institute, CC BY-NC-SA
We estimate 81 communities need additional investment in at least one specialty – about a million extra appointments in total. Some communities receive less care across the board and need investment in many specialties.
With long waiting times and unmet need, governments should also make sure they’re getting the most out of their investment in public clinics.
Different clinics are run in very different ways. Some have taken up virtual care with a vengeance, others barely at all. One clinic might stick to traditional staffing models, while the clinic down the road might have moved towards “top of scope” models where nurses and allied health workers do more.
Not all specialists offer virtual appointments.
Grattan Institute, CC BY-NC-SA
Governments should lay out an agenda to modernise clinics, encouraging them to adopt best practices. And they should introduce systems that allow GPs to get quick written advice from specialists to reduce unnecessary referrals and ensure services can focus on patients who really need their care.
Curb extreme fees
Even with more public services, and more specialists, excessive fees will still be a problem.
A small fraction – less than 4% – of specialists charge triple the Medicare schedule fee, or more, on average. These can only be described as extreme fees.
In 2023, an initial consultation with an endocrinologist or cardiologist who met this “extreme fee” definition cost an average of $350. For a psychiatrist, it was $670.
One psychiatrist charged $670, but they weren’t the only specialist charging ‘extreme fees’.
Grattan Institute, CC BY-NC-SA
There is no valid justification for these outlier fees. They’re beyond the level needed to fairly reward doctors’ skill and experience, they aren’t linked to better quality and they don’t cross-subsidise care for poorer patients. Incomes for average specialists – who charge much less – are already among the highest in the country. Nine of the top ten highest-earning occupations are medical specialties.
The federal government has committed to publishing fee information, which is a positive step. But in some areas, it can be hard to find a better option, and patients may be hesitant to shop around.
The federal government should directly tackle extreme fees. It should require specialists who charge extreme fees to repay the value of the Medicare rebates received for their services that year.
Specialist care has been neglected long enough. The federal and state governments need to act now.
Authors: Peter Breadon, Program Director, Health and Aged Care, Grattan Institute
