Patients facing huge out of pocket expenses as surgeons and specialists increase fees

Private health funds increasingly aren’t able to cover out-of- pocket expenses due to soaring surgeons’ fees. These are the biggest hikes.

Surgeons have hiked their fees by more than 30 per cent as they make up for lost income during Covid-19 hospital bans – costing health fund members thousands of dollars per procedure.

A News Corp investigation has found since the start of 2020 to the end of 2021, the average medical out-of-pocket payment for orthopaedic surgery such as hip and knee replacements increased by 34 per cent from $314 to $422.

Out-of-pocket bills for plastic and reconstructive surgery increased by 31 per cent from $411 to $538, and urology surgery for prostate cancer increased by 25 per cent from $176 to $221.

“One of the issues facing funds coming out of the pandemic is spiralling out of pocket costs for some medical services,” Private Healthcare Association CEO Dr Rachel David said.

“Cardiothoracic prices increased massively after the pandemic, and this could possibly be occurring because specialists are practising to an annual income,” she said.

Private Healthcare Australia chief Dr Rachel David is on the health fund lobby group in Canberra. Picture: Kym Smith

Health funds are reporting they also saw significant increases in out-of-pocket costs for gastrointestinal endoscopy such as colonoscopies, as well as pregnancy and childbirth.

According to the Australian Prudential Regulation Authority, 88.7 per cent of medical services covered by private health insurance currently have no patient gap.

However, gap fees are more common in speciality areas such as hip and knee replacements (27 per cent), ear, nose and throat surgery (31 per cent), plastic surgery (42 per cent) and urology (28 per cent)

Unexpected out-of-pocket costs are the largest area of complaint about private health insurance and threaten confidence in the system, Ms David said.

Data compiled by health funds shows in NSW the typical surgeon’s fees for a total knee replacement soared 33 per cent from $4500 to $6000 since 2019.

And the typical patient gap fee for the procedure soared 46 per cent from $3182 (2019) to $4641 (2021).

In Victoria the typical surgeon’s fee for a hip replacement has risen 13 per cent since 2019, rising from $3800 to $4284.

The typical patient out-of-pocket expense for a hip replacement increased by 20 per cent from $2199 in 2019 to $2633 in 2021.

Unexpected out-of-pocket costs are the largest area of complaint about private health insurance and threaten confidence in the system.

Australian Orthopaedic Association vice president Associate Professor Chris Morrey said the body “does not condone extortionate or manifestly excessive fees” and they were a breach of the AOA Code of Conduct.

However, he said the reason patients faced increasing gap fees was that Medicare rebates did not cover rises in the cost of employing receptionists and practice nurses, rent, medical equipment, electricity, computers and insurance.

“The overwhelming majority of Australia’s orthopaedic surgeons are responsible, ethical and always act in the best interest of patients, charging fees that reflect the skill, time and resources required for orthopaedic procedures,” he said.

The Royal Australasian College of Surgeons said it “does not prescribe or mandate any schedule of fees, but believes full disclosure and transparency are essential”.

“We encourage patients who have any complaints or concerns about a surgeon to raise this directly with the surgeon or the hospital or can contact the Australia Health Practitioner Regulation Authority,” the college said in statement.

Consumer’s Health Forum chief Leanne Wells.

Consumers Health Forum CEO Leanne Wells said some specialists – but not all – may be guilty of charging patients egregious out of pocket costs.

“Consumers should shop around and remember they are not locked into using the first specialist their doctor refers them to,” Ms Wells said.

The government’s medical cost finder website can help patients find out to help determine if they are paying fees that are higher than average.

OUT OF POCKET EXPENSES JAN 2020-DEC 2021

■ Orthopaedic surgery up 34 per cent from $314 to $422

■ Plastic and reconstructive surgery up 31 per cent from $411 to $538

■ Urology surgery up by 25 per cent from $176 to $221

LARGE INCREASES BY STATE 2019-2021

■ NSW knee replacement up 46 per cent from $3182 (2019) to $4641 (2021)

■ Victoria hip replacement up by 20 per cent from $2199 in 2019 to $2633 in 2021

■ NSW prostatectomy up 52 per cent from $5277 (2019) to $8013 (2021)

■ NSW ACL repair up 25 per cent from $2232 (2019) to $2791 (2021)

■ QLD Sleeve gastrectomy up by 18 per cent from $5337 (2019) to $6324 (2021.

Originally published as Patients facing huge out of pocket expenses as surgeons and specialists increase fees