PETER BROOKS. If specialists cannot be fair in their fee charging – should we not be supporting a Royal Commission into medical fees

Well done John Menadue for starting 2019 off with something that must strike at the heart of all Australians- out of pocket medical expenses. Some of the highest in the world and showing no sign of slowing and driven by – let’s be honest – greed on the part of some of our most highly paid doctors. Despite comments over the last few years from some of the Colleges saying that they do not support the significant fees charged by some doctors (and remember it is not a small minority),  little has changed. Comments from the Colleges have stopped and out of pocket expenses continue to increase. Australians are opting out of health insurance, placing strains on both the public and private systems. How long should Australians put up with this behaviour from the medical profession which seems hell bent on destroying the ‘golden goose’ (uncapped fee for service – i.e. charge what you think you can get away with) that has funded their lifestyle.  

How many saw this article in the Sydney Morning Herald just before Christmas –   threatening  Minister Hunt about the MBS (Medicare Schedule) review report on anaesthetic funding   https://www.smh.com.au/politics/federal/greg-hunt-moves-to-appease-anaesthetists-over-medicare-rebate-changes-20181221-p50nqn.html0 and the recommendations of the MBS Review.

Now let us put this in context. I note that the  recommendations of the MBS review still sit on the government website, so we can only assume that the decision is not yet final. That the Australian Society of Anaesthetists – the ‘union’ arm representing some of the most highly paid doctors in Australia – is actively lobbying the Minister, there is no doubt. After all they seem only to be interested  in the fees they can charge – patient perspectives do not seem an issue. To argue as the Society does  in the article that the changes will lead to a significant increase in out of pocket expenses to the patient is a little simplistic : it may BUT only if this highly paid group of doctors  do not change their practice and actually absorb at least some of what they may refer to as increased practice costs – something that most other industries have had to do over the past ten years.

To quote the article: “Peter Seal, president of Society of Anaesthetists – welcomed Mr Hunt’s response which came after months of lobbying by the peak body”. Remember this is the “Society” of Anaesthetists – the Union, not the College of Anaesthetists – the professional body- which is the ‘Peak ‘ body and likely to be a little more interested in standards of care and how these changes might impact on patients .  Let’s consider the real issue here. The MBS Review as set up under the  government has been one of the better things it has done. It has acted with extraordinary rigor under Chair, Professor Bruce Robinson, and has established large discipline-specific committees in many specialties with consumer representatives  included. The reports are all available on the  MBS Review website and  the level of evidence-based discussion has been exemplary. The Anaesthetic Schedule – like most of the  schedule of fees –  has not been reviewed for a  number of years and certainly not with the rigor and independence that has been a feature of the MBS Review.  For the Society to say that the Review has been carried out ‘without any clinical understanding’ is ludicrous in the extreme.

If the Minister has caved in to this self-interested lobby group, that is  very sad and certainly not in the interests of the health system as a whole. Dr  Seal is quoted: “we are white hot angry”.  Well,  Dr Seal, one might ask how the patients feel about your rapacious comments. Not very happy, I suspect .

The Minister should remember that his responsibilities (and electorate ) are not just the well paid specialist anaesthetists  but also the patients – and a patient who is at a very vulnerable time when they are facing being put to sleep for surgery!

Australians now pay some of the highest out of pocket expenses in the world and specialists here are amongst the highest paid globally. Few will know that there is a very significant gap between what we pay the general practitioner and what we pay the specialist in this country  – yet we boast (and so we should) that our health system is based on the fact that GPs provide much of the care and we pay them on average about a third to a quarter of what a specialist is paid . The comments of Dr Tony Bartone – President of the AMA, and a general practitioner – in the same SMH article  are interesting: “any savings from the review of the MBS —must be reinvested in the health system”. I am sure many would agree and perhaps a solution would be to take all of the savings from the specialist groups and use that to increase the funding of general practitioners who have seen their incomes stagnate (in comparison to their specialist colleagues) and who are the real ‘specialists for life’ (the RACGP mantra) on which our health system is based. If the  medical profession cannot control the fees they charge then surely we should be pushing for a Royal Commission into medical fees to get things right once and for all. I suspect that, like the Banking Royal Commission, Australians would be shocked by the data that will come to light.

I reiterate the Medicare Review has been one of the really good initiatives instituted by this Government – it is independent and seems to have very thoughtfully considered the evidence behind all of its recommendations. It would be unfortunate if the Minister was swayed by such a lobby group as the Society of Anaesthetists who have not shown any desire to act in the interests of good patient care. They, and other specialists, might remember one of the basic tenets of Medicine – ‘First do no Harm ‘ – and that should mean financial harm as well. Stay strong Minister – remember – patients should come first.

Peter Brooks MD FRACP, is Professor Centre for Health Policy, University of Melbourne, and  Research Lead Northern Hospital Eppin.

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6 Responses to PETER BROOKS. If specialists cannot be fair in their fee charging – should we not be supporting a Royal Commission into medical fees

  1. Richard Barnes says:

    I am a specialist anaesthetist.
    The Australian Society of Anaesthetists has behaved as one would expect a muscular union to behave. But its hypocritical statements that its actions have been taken to protect patients’ interests are breathtaking. And the fact that it has been allowed to totally overturn the recommendations of the anaesthetic fees sub-committee of the MBS review is outrageous.
    To be fair, the rapaciousness of anaesthetists is no different from that of all the procedural specialist and surgical groups with whom they work. Tables of Australia’s highest earners show anaesthetists, ophthalmologists, neurosurgeons, ENT surgeons, orthopaedic surgeons, plastic surgeons, cardiologists and gastroenterologists all more or less on a par. GP’s, with the same level of skill and the same length of training, lag way behind with a remuneration about 50% of that of their specialist peers. I don’t understand why the AMA, the majority of whose members are GP’s, doesn’t lobby for a cost-neutral re-balancing of doctors’ remuneration.

  2. Myrna Tonkinson says:

    As an uninsured person, I am all too aware of the gulf between specialists’ fees and the scheduled fees. A recent dermatologist charged $800+ for a procedure in his rooms, Medicare rebate was $240. In my experience over-charging is rampant and patients have no choice but to pay. A wide MBS review of specialists’ fees, not just anaesthetists’ seems justified and I hope the Government will make sure it occurs.

  3. I completely agree that a Royal Commission (“RC”) into Medical Specialist fees is necessary at this time. It may be that another RC is appropriate into Radiology and Pathology fees. These areas are also headed up by medical specialists. The AMA has always been an effective voice in promoting that elite sub-group. The issue for the outside observer, and subset subject to obscene costs, is whether this elite group is excessively rewarded within a societal context. Who can that uncompromised assessment agent be?
    A review of RCs to date indicates that malfeasance of high order was identified. I suspect, with a high degree of confidence, that the RC into the Aged Care sector will be equally effective. Perhaps RCs into the Murray Darling Water Authority, or the Child Care sector, or the Education fiasco, are other examples of egregious waste of public funds. There is scope to investigate any and all of others that are your arena of expertize or interest.
    Perhaps it is time to review the cost benefit of RCs and why the need for such scrutiny has emerged. I submit that the regulatory and compliance functions that audited and reviewed a wide range of activities was deactivated during the preceding decades of neo-liberalism. A chorus call to move to market based mechanisms saw reductions in public ownership in utilities, health and education. Remaining Government Departments were required to deliver efficiency dividends. The KPOs of executives of these entities are primarily assessed by delivery of programs. I submit that regulatory and compliance functions were the easiest cost centres to decimate while continuing to roll out the programs. The savings accrued were miniscule compared to the malfeasance that ensued. A contentious fact which can be established by forensic scrutiny of data – namely back end propagation. Failure to provide an effective deterrent to all behaviours up to criminality, significantly being need and greed, has accumulated over decades to the necessity for RCs now. The diversion of wealth to the legal sector conducting RCs is probably greater than funding the regulatory and compliance functions for decades. RCs provide succour to a smaller subset of society than appropriate compliance and regulatory functions. If society was asked, I suspect that it would rate the regulatory subset of Government more favourably than the legal profession. It may be a human failing that we rate anyone beavering away in any stove-piped activity less worthy than our own. Can a benign dictator perform such a demanding function?
    Is it possible to rise up in that mystic helicopter and observe that specialist fees at any price are futile when the intangible costs of continuous economic growth are appropriately valued? The health of the planet due to unsustainable population growth potentiating climate change and inequalities of wealth. Which is the bigger fish to fry – the health of the Hobbesian masses or the ecosystem of the planet?

  4. Bob beadman says:

    Consider why a privately insured patient pays more for a procedure than someone in the public health system.
    Could rorting be a possibility?

  5. Evan Hadkins says:

    I don’t know Peter.

    Do you have figures for the median take home pay of the specialists?

  6. Rosemary O'Grady says:

    In fact – into the professions at large?

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