In recent times, several articles have appeared in the print and electronic media about the alleged ‘high fees’ and ‘poor accountability’ of medical specialists. A few weeks ago on his ‘Pearls and Irritations’ blog, John Menadue posted one such piece titled ‘Medical specialists – high fees and poor accountability’. The Australian Society of Anaesthetists (ASA) believes that some of John Menadue’s strongly asserted claims merit a measured response, and wishes to address some misconceptions that have arisen. There are almost 5000 specialist anaesthetists in Australia, and they comprise approximately 4.5% of the nation’s medical workforce. The ASA has been supporting, representing and educating anaesthetists in this country since 1934.
In his preliminary comments regarding remuneration, John Menadue affirmed some emphatic proclamations about bulk billing rates, while demonstrating an incomplete understanding of how this system works currently. He stated that ‘In July-September last year, the bulk billing rate for general practitioners was 84%. For specialists it was a meager 30%. At the bottom of the range for specialists who bulk bill were anaesthetists at 10%. For obstetricians it was 55%’.
‘Bulk billing’ per se requires a doctor to accept 85% of the Medical Benefits Schedule (MBS) fee for outpatient services. It refers to out-of-hospital and outpatient episodes of care. There is to be no additional cost incurred by the patient. This is the domain of the general practitioners especially, and others for whom a significant proportion of their practice consists of consultations. It has minimal relevance in anaesthesia which occurs within an inpatient setting for more than 90% of the time.
The analogous bottom line for anaesthetists’ patients is whether they pay anything out-of-pocket. Annually in Australia, there are approximately 8 million anaesthesia services in about 2.6 million patients. The most salient fact about patient billing by anaesthetists by far is that 76% of anaesthesia services attract absolutely no gap, which means precisely zero dollars out-of-pocket for the patient. ‘No gap’ simply becomes the bulk billing equivalent option for anaesthetists, and many other specialists. Another 14% of episodes of anaesthesia care have a ‘known gap’ charge, in which informed financial consent (IFC) is mandatory. This means that 90% of anaesthesia services are either no gap or known gap. When an out-of-pocket cost is charged for an anaesthetic service, this averages $85. Almost all anaesthetists forewarn their patients of any gap payments with the appropriate IFC requirement. Thus of course anaesthesia has a very low level of bulk billing, because it doesn’t match the above definitions.
John Menadue contests that ‘there are a whole range of specialists who charge fees that cannot be justified. They are having a field day at the expense of the public’. He seems to have based this assertion on the fable of the ‘recommended fee’. There is no recommended fee. This is a simple fact. No-one or no agency ever has defined this. If he is referring to the MBS fee, this has not matched adequately the Consumer Price Index since 1985. The ASA considers that it has become a grossly insufficient low estimate of what an anaesthesia service is worth. In addition to this minimal base, the MBS rebate has been frozen already for the last 4 out of an initially supposed 8 years. John Menadue makes no mention of this at all. This omission is extremely disappointing because it is a most crucial and pertinent point.
At the other end of the scale, the Australian Medical Association (AMA) annually publishes a List of Medical Services and Fees. This schedule serves as a guide as to what doctors deem to be a fair and reasonable estimation of the monetary value of a medical service. The ASA maintains an ongoing position that this AMA rate should be the maximal limit. It should not be forgotten that like other medical specialists who have undertaken many years training in a complex discipline, anaesthetists too are taxpayers, employers, and small business owners, and often pay sizeable running costs including indemnity insurance.
Within private medicine in Australia, it always has been the case that doctors’ fees and remuneration remain a minor fraction of the entire pool. The incomes and costs of private health insurance companies, private hospitals, and day care facilities completely overshadow those of medical practitioners. For anaesthetists, similarly restricted rebate indexing, at levels below the inflation rate, by the aforementioned health funds, contributes to the likelihood of patients incurring a corresponding increased charge out-of-pocket.
The suggestion of a withholding of Medicare and private health insurance benefits is manifestly unheralded and egregiously unfair to patients, who primarily will be hurt. Isolated charges by a few surgeons and other proceduralists are not common behaviours. When it comes to excessive wages, one needs to look no further than those fees and salaries commanded by some barristers, lawyers, chief executive officers and board members, particularly in the financial and banking world, and in the for-profit private health insurance industry.
The second section of John Menadue’s piece related to accountability of medical specialists. He refers to ‘concern about the “closed shop” or “old boys’ culture” of many specialists associations’. The Medical Board of Australia and the Australian Health Practitioner Regulation Agency independently control the process of determining accreditation and registration standards for all health care workers in this country.
The ASA patient information pamphlet Anaesthesia & You opens with the following sentence which is unequivocally true, ‘There is no safer place in the world to undergo anaesthesia than in Australia’. Despite this reality, it is also correct that within any field of endeavour, there will always be individuals who will be impaired or who will be underperforming. In a complicated system which has the capacity to deliver significant benefits to the health of human beings, the potential risk for harm to the public is ever present. The various medical colleges, societies and associations are cognisant of this. The ASA constantly reminds its members of this actuality, and advocates vigilance for detection of those whose performance and standard of care falls below what is safe and acceptable. In addition, the ASA promotes welfare and mentoring programs for all anaesthetists.
John Menadue concludes with the bold edict that ‘Surely a federal parliamentary enquiry into the performance of medical specialists in regard to fees and accountability is long overdue. Many of them are having a lend of us!’. Far from ‘having a lend’, the medical profession has delivered first-class, world standard health care, with the highest possible duty of care, to the people of Australia for more than a century and a half. The ASA does not support the need for such an investigation, or see the justification for its inevitable expense. If an enquiry were to be held nonetheless, we would welcome the opportunity to testify before it armed with all the relevant facts and numerical data at our disposal. Instead of opinion, we would be able to provide irrefutable information about medical specialists’ fees and accountability.
David M Scott is President of the Australian Society of Anaesthetists, an Adjunct Associate Professor at the University of Western Sydney, and is a clinical specialist anaesthetist in Lismore.
Peter Seal is Vice President of the Australian Society of Anaesthetists, and is a clinical specialist in anaesthesia and intensive care medicine in Melbourne.
I will be responding to this article in the next day or two. John Menadue