So much of the public attention is on care in general practice, but specialist healthcare has some very serious problems. The first is excessive remuneration of many specialists. In some cases it could only be described as greed. The second is the lack of accountability for care by many specialists and the unwillingness of their organisations to tackle the problem. 

Remuneration

Specialists in Australia, on average, earn about twice as much as GPs. Survey data shows that average earnings of GPs in 2012 was $194,000. For specialists, it was $360,000.

In July-September last year, the bulk billing rate for general practitioners was 84%. For specialists it was a meagre 30%. At the bottom of the range for specialists who bulk bill were anaesthetists at 10%. For obstetricians it was 55%.

Many specialists have taken the opportunity through gap insurance provided by private health insurance funds to dramatically increase their fees. In this blog, Lesley Russell outlined some particular cases of fee-gouging.

  • For orthopaedics, the average cost in 2014 for hip replacements was $27,310. But it varied from $18,309 to $61,699;
  • For endoscopic prostate procedures in 2014, out of pocket surgery costs averaged $2802 in the ACT but only $183 in SA;
  • The Medicare scheduled fee for prostate surgery is just under $1500, yet out-of-pocket costs for robotic assisted surgery in this field is as high as $10,810;
  • BUPA, who admits that it can’t control costs, found that 17% of radical prostatectomies were fully covered by Medicare, but 28% had gap fees of between $5000 and $10,000;
  • In 2015, the president of the Urological Society of Australia and New Zealand spoke out about unreasonable costs for prostate surgery. He called for the society’s members to “refresh their awareness of their ethical responsibilities”; and
  • Last year, the president of the Royal Australasian College of Surgeons stated that “RACS cannot stand by if members are charging fees that cannot be justified as reasonable … There is no correlation between the size of fee charged and the quality of the surgery”.

Not surprisingly in all this, 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.

Data from the Australian Tax Office published in the SMH on October 5, 2016, also show the very high remuneration of medical specialists. On ATO figures in 2013-14, the top professionals were all medical specialists with neurosurgeons top of the list with an average annual income of $578,000, followed by ophthalmologists on $553,000. This was followed by a long range of specialists: cardiologists ($453,000), plastic and reconstructive surgeons ($449,000) and so on. Of the top 20 earning professions in Australia, 18 were medical specialists.

There is little sign that the Australian government, or the opposition, is considering ways to redress specialist fee exploitation. Many specialists indicate clearly that they are unable or unwilling to charge reasonably for their services.

One option that could be considered is for Medicare — and perhaps even private health insurance funds — to refuse to pay Medicare/permanent health insurance benefits, if the fee is in excess of the recommended fee. This might be one means to force specialists to be responsive to the interests of patients and the Australian taxpayer. At present, the Australian taxpayer, through Medicare, is underwriting this fee-gouging.

Accountability

In addition to the question of fee-gouging, there is also concern about the “closed shop” or “old boys’ culture” of many specialists associations. There is evidence that these associations are not addressing poor quality of care within their professions. One striking example of this lack of accountability was outlined by a speech in 2015 by Judge Geoffrey Davies to 1200 orthopaedic surgeons in Brisbane. Davies had headed the 2005 inquiry into the Bundaberg surgeon, Jayant Patel.

Extracts from the transcript of the speech by Judge Davies follow:

“Why won’t you do something about incompetent surgeons?”

— The Hon Geoffrey Davies AO

You all know that, in your midst, there are incompetent surgeons; surgeons whom you would never recommend to your friends or family. They may have varying degrees of incompetence and for different reasons. But all are a danger. All can cause injury.

Together you know who many of them are. But for various reasons you have done little individually and nothing collectively, to expose them or even to identify them confidentially for the purpose of retraining or limitation of practice.

Patients are entitled to know, before they choose you for their surgery, rather than one of your competitors, not only how your fees compare with those of your competitors, but also how your success rate compares with that of your competitors; and that that latter information, in the case of much orthopaedic surgery, is recorded in your National Joint Replacement Registry.

Why would surgeons who are otherwise honest and decent men and women and who are themselves competent, fail to speak out against what was plainly gross incompetence causing harm? The author of the Bristol Inquiry report described it as an “old boys’ culture”. But that is simply a euphemism. The true reason must surely be either a view that the reputation of your profession is more important than the health and safety of patients; or a view that the incompetence of your colleagues is none of your business. It can’t surely be a misplaced loyalty to your incompetent colleagues. It wasn’t in Bundaberg because none of the other doctors there really liked Dr Patel.

If, individually, you don’t speak out, patients may be injured, possibly seriously.

As you are aware, following my Inquiry, there is now a mandatory requirement that you notify the Health Ombudsman if you have a reasonable belief that another health professional has behaved in a way which constitutes a significant departure from accepted professional standards; and that such behaviour has placed the public at risk of harm. 

*Read the rest at John Menadue’s blog Pearls and Irritations

Peter Fray

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