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The healthcare system in Australia is a complex mix of Commonwealth and State Government funded services and services funded by private health insurance. How do doctors, physiotherapists, optometrists, dentists and other health professionals fit into this framework of public and private health services? Which health services are funded by the governments and which are privately funded? Read on to understand more about the Australian healthcare system.

Compared with health systems in other developed countries, the Australian health system delivers us above-average health outcomes. Spending on health is on a par with other prosperous countries and Australia ranks well for healthy life expectancy.

However, unfortunately there is still a large discrepancy between indigenous and non-indigenous life expectancies and much work needs to be done to close the gap. Our indigenous people have much poorer life expectancy with indigenous males having a life expectancy 10.6 years lower than non-indigenous males (69.1 years compared with 79.7 years) and indigenous females having a life expectancy 9.5 years less than their non-indigenous counterparts (73.7 compared with 83.1 years).

National Health Act

At the core of the health system is the National Health Act. This was passed in 1953 to regulate the provision of pharmaceutical, sickness and hospital benefits and of medical and dental services. The Act covers nursing homes, the Pharmaceutical Benefits Scheme and registration of health funds.

Medicare

Medicare has been the Commonwealth Government’s universal health insurance scheme since 1984. Medicare provides Australian residents with free treatment as a public patient in a public hospital and free or subsidised treatment for some optometrist services, some dental care services, some psychology services, and treatment by doctors. In some circumstances, Medicare rebates are available for a certain number of treatments by allied health professionals such as physiotherapists, dietitians and speech pathologists.

Medicare is partially funded by an income tax surcharge — all Australian taxpayers earning over a certain threshold pay a Medicare levy (currently 1.5 per cent of their taxable income or 2.5 per cent for those on high incomes who don’t have private health insurance).

Medicare pays a benefit to the user for various healthcare costs including:

• doctors’ and specialists’ consultation fees;
• tests and examinations your doctor orders for you;
• eye tests carried out by optometrists; and
• most surgical procedures.

For people with chronic conditions and complex care needs, Medicare gives rebates for visits to allied health professionals, including physiotherapists, psychologists, dietitians and occupational therapists. You can claim for only a certain number of visits per year. The allied health professional must be registered with Medicare, and your GP must refer you to them. Your GP must also draw up a special care plan for you stating that you have a chronic (long-lasting) medical condition and complex health needs and that you need these allied health services.

Rebates for a certain number of dentist visits per year are also available for people with chronic conditions and complex care needs, but only under a GP care plan. To be eligible, your dental problem must be making your chronic medical problem worse.

Medicare Schedule fee

Medicare benefits are based on a list of standard fees for medical services — the so-called ‘Schedule fees’.

Despite these Schedule fees, doctors are free to set their own fees for consultations and procedures. They are covered by the Trade Practices Act. After all, just like hairdressers and plumbers, they need to cover their costs of being in business and hopefully make a profit, too!

Many doctors follow the Australian Medical Association’s list of suggested fees. This list has been indexed to keep up with costs and recommends higher fees than the Medicare Schedule fees.

Medicare benefits

General practice

For most general practice consultations, meaning interactions with your doctor in which he or she asks you questions, examines you and discusses a plan of treatment, Medicare now rebates 100 per cent of the Schedule fee. Even so, you may still have to pay a certain amount (a ‘gap fee’), as many doctors charge more than the Schedule fee. For most other GP services, such as procedures like removing skin lesions or injecting joints, the rebate is 85 per cent of the Schedule fee.

For an example of how this works in practice, a GP might charge $50 for a standard consultation. The Medicare rebate for this is $36.30, leaving a gap of $13.70 for you to pay.

Unless you have been bulk-billed (see below), you used to have to pay the full consultation fee, get a receipt from your doctor and claim back the Schedule fee from Medicare. This can be done in person at a Medicare office or by mail. However, many doctors now offer Medicare electronic claiming. This allows you to claim your Medicare rebate when you pay your account at the doctor’s surgery. If the doctor uses the EFTPOS system your rebate is paid into your nominated account almost immediately. If the doctor uses the internet-based system, your rebate is paid into your account within a few days.

Specialists

Most specialist consultations attract only an 85 per cent rebate. For a consultant physician, the Medicare rebate for an initial attendance is only 85 per cent of the Schedule fee of $150.90, amounting to $128.30. Unless the specialist bulk-bills, you would have to pay the difference between $128.30 and what they charge.

If the specialist or consultant physician services are given as part of an episode of hospital treatment where you are an inpatient, the rebate is only 75% of the Schedule fee. Similarly, if the services are rendered as part of a privately-insured episode of hospital substitute treatment, the rebate is only 75% of the Schedule fee.

Medicare also incorporates safety nets (see below) to cover 2 different types of gap — between the Schedule fee and the Medicare rebate, and between the Schedule fee and what the doctor actually charges. These safety nets cap the fees you pay at a certain level per year and are explained below.

Bulk-billing

Bulk-billing is when the doctor accepts the Medicare benefit (that’s 85 or 100 per cent of the Schedule fee) as full payment for the services rendered. You don’t have to pay the gap.

Normally, if you are bulk-billed, your Medicare card will be swiped and you sign a form. You do not have to pay anything — the doctor recovers 85 or 100 per cent of the Schedule fee directly from Medicare as payment for his/her services — currently $36.30 for a standard GP consultation.

As an incentive to improve bulk-billing rates, which had been declining since their peak in 1996-7, Medicare now provides an extra payment to doctors in eligible areas each time they bulk-bill pensioners, health care card holders and those aged 16 and under.

Nonetheless, there is an ever-widening gap between the Medicare benefits doctors can recoup and the costs of running a practice. This explains why some GPs have limited bulk-billing to certain times of day or to concession card holders only and why others don’t bulk-bill at all.

Item numbers

The bill from your doctor or other healthcare provider will have an item number on it for the particular service you have had. This item number will be matched to the item number on the Medicare Schedule fee list and so your rebate is determined as either 100 or 85 per cent of the Schedule fee (for out-of-hospital services). The rebate is 75 per cent of the Schedule fee for in-hospital services.

Some medical services, despite being effective treatments or investigations, do not have item numbers and so there is no Medicare rebate for them and the entire cost must be paid by you, the patient. Your doctor should make you aware if this is the case.

Healthcare cards for veterans

War veterans, war widows, widowers and their dependants are entitled to a wide range of healthcare benefits which are funded by the Department of Veterans Affairs.

People who are eligible are issued with one of 3 levels of healthcare card.

The gold card provides the full range of healthcare benefits, either free or at concessional rates. The white card covers the holder only for specific conditions that are accepted as being related to their war service and a few general disabilities. The orange card provides certain medicines at reduced rates to some war veterans, for example, the scheme is currently restricted to those over 70.

Low Income Health Care card

If you are a low income earner, you and your dependants may be eligible for a healthcare card. This entitles you to discounted prescription medicines under the Phamaceutical Benefits Scheme and you may also be eligible for concessions offered by private companies and on Commonwealth, State and Local Government health services.

Medicare safety nets

These provide a mechanism to protect people who need to see the doctor regularly, or have tests regularly, from having to pay large numbers of gap fees which could amount to a substantial cost. The Medicare safety net covers a range of doctor visits and tests that you receive out of hospital. Families and couples need to register, but individuals are automatically registered. There are 3 Medicare safety net thresholds currently.

To reach the first safety net threshold, your gap fees (the difference between the Schedule fee and the Medicare rebate) for out-of-hospital services must accumulate to a certain amount (currently $430.90) within a calendar year. Once the threshold is reached, you will receive 100% of the Medicare Schedule fee for all out-of-hospital services. However, a person will still have to pay the additional difference if the doctor charges more than the Schedule fee.

The second safety net is for concession card holders and families eligible for FTB (A). Once out-of-pocket costs (the difference between the Medicare benefit and what a doctor actually charges) reach the threshold, Medicare will meet 80 per cent of any further out-of-pocket expenses for out-of-hospital services for the remainder of the year. This includes costs above the Medicare Schedule fee.

The third safety net is the extended general safety net. This applies to all Medicare cardholders and comes into play if out-of-pocket costs reach the threshold of $1248.70. For any out-of-hospital services beyond this, Medicare will pay 80% of out-of-pocket costs or the EMSN benefit cap.

The thresholds are changed annually to account for inflation. There is also a PBS safety net (see below) which helps if you have a lot of medicine costs in a calendar year.

Tax rebate for medical expenses

Net medical expenses are the medical expenses you have paid minus any refunds that you received (or could have received) from Medicare or a private health fund. The net medical expenses tax offset is being gradually phased out. You used to be able to claim a tax rebate for net medical expenses, once the total reached a certain amount in a given year.

Now, the tax offset is subject to the expenses being for disability aids, attendant care or aged care, and also you can only claim if you already claimed in the previous year. See the Australian Tax Office website for full details.

Private health insurance

Australians can take out private health insurance — in fact, Australians are encouraged by the Government to take out private health insurance by way of the Medicare levy surcharge. This is applied to people earning over a certain amount who do not have appropriate hospital cover. However, it’s not necessary to have private health insurance — you can go to a public hospital if you have an emergency and they will treat you, or if you need hospital treatment your doctor will refer you and you will be treated.

Having private health insurance means that you can choose the doctor or specialist who treats you in hospital and you can go to a private hospital or be treated as a private patient in a public hospital.

Private health insurance rebate

One of the methods used to attract people to take out private health insurance is the Federal Government private health insurance rebate. The way it works is that if you take out an appropriate private health insurance policy with a registered health fund, you may be entitled to a rebate of a certain proportion of your premiums paid during the year. This is true for hospital cover, extras cover or combined cover and also ambulance cover. It is now income tested, so if you earn more than the threshold, your rebate may be reduced or you may not be entitled to one at all.

The size of the rebate also depends on your age. The ATO website has details of the income thresholds and the entitlements.

Medicare levy surcharge

If you earn over a certain threshold and you elect not to have hospital cover (having extras or ancillary cover does not excuse you) you are required to pay an additional surcharge of between 1 and 1.5 per cent of your taxable income on top of the 1.5 per cent Medicare levy.

Lifetime Health Cover

Lifetime Health Cover is a government initiative that rewards people who take out hospital cover earlier in life and maintain it.

If you take out hospital cover after you turn 31, you will have to pay a loading over and above the lowest premium — this loading increases the older you are when you take out hospital cover. However, under rules introduced in 2007, the loading is removed after you have maintained cover for 10 years. People who were born before 1934 and people who took out hospital cover before 15 July 2000 are exempt from these loadings — they always pay the lowest premiums. Having extras or ancillary cover only does not qualify you for Lifetime Health Cover benefits. You must have hospital cover to qualify.

Types of private health insurance

Private health insurance policies are usually categorised as hospital cover, ancillary or extras cover or combined cover.

Private health insurance schemes differ widely, with lots of options and varying levels of excess. If you have private health insurance always check with your provider to see exactly what you are covered for. By law, health insurers are required to provide Standard Information Statements for their products. These statements allow you to see the key features of your cover, including waiting periods and benefit limits, and allow you to compare private health insurance products.

Hospital cover

Having private health insurance does not mean that you will not have to pay for any healthcare consultations or services when you go into hospital. Private health insurance doesn’t pay for the doctor or specialist — only Medicare can do that. Medicare rebates 75 per cent of the Schedule fee for in-hospital services. Hospital cover usually covers the remaining 25 per cent of the Schedule fee, but if your doctor or specialist charges more than the Schedule fee, you will still have to pay the difference between the Schedule fee and the charge unless your private health insurance covers the gap or part of the gap (see gap cover).

Hospital cover is taken out to help pay the cost of treatment by your doctor or specialist, and to help pay your accommodation costs while you are in hospital. Other costs, such as theatre fees, pathology tests and rehabilitation treatments in hospital should also be covered. Hospital cover may not refund you the full amount of costs incurred while in hospital — there may be out-of-pocket expenses that you will still have to pay. If you have hospital cover you may also have to choose the level of excess you wish to pay. Being prepared to pay a higher excess should bring down the price of your premium.

Changes to private health insurance regulations in 2007 have enabled private health funds to offer a broader range of services within hospital cover. The rules were changed so that funds can include services such as dialysis and chemotherapy that can now be performed safely outside the hospital setting.

Extras, ancillary or general treatment cover

Extras cover, also known as ancillary cover or general treatment cover, is to help you pay for out-of-hospital services, such as physiotherapy, optical, dental, podiatry and often complementary therapies, such as osteopathy, acupuncture and naturopathy. Some policies offer rebates for gym memberships and yoga courses. The rebates for extras may vary among levels of cover within the same fund and also between funds. Often they come nowhere near covering the actual charge you have to pay, for example, for an appointment with a physiotherapist that costs you $65, the rebate may be only $24.20.

Gap cover

So-called ‘gap cover’ or ‘no-gap’ schemes aim to prevent you from having to pay the difference between the amount you are reimbursed from Medicare and your health fund and what your doctor or specialist charges when you go into hospital under your private health insurance. Currently there are no gap cover schemes that include GPs.

All health funds have ‘no gap’ or ‘known gap’ schemes for hospital cover which help to reduce or eliminate out-of-pocket expenses for in-hospital medical services. However, not all doctors and specialists participate in these schemes. Each health fund usually has a list of doctors who have agreed to treat some patients with no gap or a known gap fee. Always check that they agree to do this in your case. This gap cover is only for your doctor or specialist’s fee — it doesn’t cover any gap on hospital accommodation charges or other in-hospital charges.

Waiting periods

To avoid people joining funds and then making large claims, for example, joining a fund prior to having large amounts of dental work done, and then cancelling the policy afterwards, there are waiting periods that apply before the insurance cover becomes valid. Individual health insurers set waiting times, but these must be within maximum limits set by Government, for example, 12 months for pre-existing ailments and 12 months for having a baby.

Ambulances

Ambulance fees are not covered by Medicare unless you are on a pension or have a health care card. Private health funds often have ambulance cover as part of their policies — either as part of extras cover or included in hospital cover. There are also separate ambulance cover policies which qualify for the 30 per cent government rebate.

Ambulance fees can be an unwelcome surprise for people transported from the scene of an accident. Emergency callout fees are often in the hundreds of dollars, with an additional levy per kilometre. Transfers to regional hospitals from remote areas may reach over a thousand dollars.

Residents of Tasmania and Queensland are covered by their state governments and do not need ambulance cover. From 2003 Queenslanders have paid for this Community Ambulance Service via their electricity bills. Residents of some other states and territories may not be covered for ambulance transport even if they have private health insurance with hospital cover. It depends upon the individual policy. You can often also arrange ambulance cover directly with the ambulance authority in your state.

Medicines and prescriptions

The Pharmaceutical Benefits Scheme (PBS) provides Australian residents with access to prescription medicines. Most prescription medicines are subsidised under the PBS. In September 2010, the PBS provided access to over 2600 brands of prescription medicine.

The Repatriation Pharmaceutical Benefits Scheme — the RPBS — provides pharmaceutical benefits to holders of Repatriation health cards. Card holders usually pay a concession rate for prescriptions.

Everyone can buy non-prescription medicines over the counter in pharmacies, and some products are also available in supermarkets.

People often wonder why, when they have heard about a supposedly effective new drug, it isn’t yet available in Australia, or it isn’t available on the PBS, only on private prescription.

This is because all new prescription drugs must be registered with the Therapeutic Goods Administration (TGA) before they can be used in Australia. This is a rigorous process designed to protect Australians and ensure the quality, safety and effectiveness of the prescription medicines available to us. If the active ingredient in the medicine has not been previously used in Australia, then the manufacturer has to submit large amounts of evidence in support of its medication. On average, it takes 250-300 working days to evaluate an application and that’s just to get the product registered.

People can legally import small quantities of many other medicines that aren’t approved for use in Australia for their own or their immediate family’s use, under the Personal Import Scheme or the Special Access Scheme. You should contact the TGA to see whether you are eligible and which scheme to apply under.

Listed medicines, such as sunscreens and most complementary medicines, are considered to be of lower risk than registered medicines and are not assessed for their effectiveness — just their safety and quality. They are available over the counter and have the prefix L (for listed) on the packet or bottle.

For a prescription drug to get on the PBS, a submission has to be made to the Pharmaceutical Benefits Advisory Committee (PBAC), usually by the manufacturer. The PBAC has to ensure that the medicine is effective, is safe and is cost-effective. Sometimes, although a new medicine may be very effective, the cost is prohibitive to it being put on the PBS, especially where there other medicines that could be used. In these cases, the medicines have to be obtained by private prescription — and some cost in the hundreds of dollars for a month’s supply.

PBS safety net

The PBS safety net helps keep medicines affordable by limiting out-of-pocket expenses for people who need large numbers of prescriptions. Once you or your family spend more than the safety net threshold, which is lower for concession card holders than for the general population, you can apply for a safety net card from your pharmacist. This entitles you to free or cheaper medicines for the rest of the year; however, the safety net only applies to medicines on the PBS — ‘private prescriptions’ do not count.

Doctors

Not many health issues happen without a doctor being involved somewhere down the line and Australia has more than 25,000 doctors registered in general practice and around 24,000 specialists. All doctors must be registered with the medical board. The medical board looks after complaints about doctors and issues of professional conduct. The medical board also ensures that only properly trained doctors are registered and administers the registration of doctors who have trained overseas.

The Royal Australian College of General Practitioners (RACGP) works to improve standards in general practice and of doctors’ education and training. The Australian Medical Association (AMA) is the other large body that impacts on doctors. The AMA lobbies on behalf of doctors and public health.

Indigenous health

Aboriginal and Torres Strait Islander people suffer a higher burden of ill health and die at a younger age than non-indigenous Australians — 10 years earlier for women and 11.5 years earlier for men, on average. Poor nutrition, low birthweight babies, diabetes and obesity are features sadly all too common in Aboriginal communities, with hazardous alcohol consumption and drug use sometimes part of the picture too.

Indigenous people have a higher prevalence of coronary heart disease than other Australians and 3 times the prevalence of diabetes.

Overall, more money is spent on health services for indigenous Australians per person than for other Australians. Unfortunately, this hasn’t resulted in better health outcomes. Factors affecting the ongoing poor health of indigenous Australians are various and include distance from urban centres, access to facilities and socioeconomic disadvantage.

Immunisation Register

The Australian Childhood Immunisation Register records vaccinations given to children under 7. It was started in 1996 to improve childhood immunisation rates, which were falling. You can request the records of your child from the Register. The records help Medicare Australia to keep track of immunisation coverage levels. The immunisation register details can help with eligibility for some Australian Government family assistance payments.

Organ Donor Register

The Australian Organ Donor Register is the national organ and tissue donor register for transplantation. If you’re registered, in the event of your death, your relatives can be informed of your wishes as they are recorded in the Register, and your relatives can then grant access to your organs for transplantation. More than 1.5 million Australians have signed up. Only authorised personnel can access the list. Holding a driver’s licence where you have stated your wishes does not mean that you will automatically be on the Register.

Ophthalmologists and optometrists

There is overlap between the functions that these 2 groups of health practitioners carry out.

Optometrists are the people that carry out eye examinations and prescribe spectacles and contact lenses. They are also trained to detect eye disease. They go through a rigorous 4-year university course before they can be registered. Optometrists are not doctors. They also don’t perform eye surgery. Eye tests carried out by optometrists qualify for Medicare rebates and you don’t need a referral; however, spectacles and contact lenses don’t qualify for a rebate.

Ophthalmologists are trained as medical doctors first, then undertake a postgraduate training programme offered by the Royal Australian and New Zealand College of Ophthalmologists. So, on top of the 4-6 years a person takes to get their medical degree, they have to do a further 5 years of training to become an ophthalmologist.

Ophthalmologists specialise in treating eye disease, usually with either medicines or surgery. They can also prescribe spectacles. It is ophthalmologists who carry out laser eye surgery to correct vision. To see an ophthalmologist you may need to be referred by a general practitioner or an optometrist and like other medical specialist services, there may be a Medicare rebate for the consultation.

Dentists

Dental examinations and treatment are not covered under Medicare. Private health insurance (extras or ancillary cover) can usually be purchased to cover dental care, but it doesn’t usually provide full cover.

Dentists must be registered — only suitably qualified dentists are eligible to register and some overseas dentists will be required to pass an examination to apply.

The Australian Dental Association is the national body representing dentistry in Australia, with more than 90 per cent of dentists having volunteered for membership.

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