Patterns of specialist out-of-pocket costs for Australian Medicare services: implications for price transparency
Kelsey Chalmers
A E * , Adam G. Elshaug A F , Sallie-Anne Pearson A B and Bruce E. Landon C D
A Menzies Centre for Health Policy and Economics, School of Public Health, University of Sydney, Sydney, NSW 2000, Australia.
B Centre for Big Data Research in Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.
C Department of Health Care Policy, Harvard Medical School, Boston, MA, USA.
D Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
E Present address: Lown Institute, Needham, MA 02494, USA.
F Present address: Centre for Health Policy, Melbourne School of Population and Global Health and the Melbourne Medical School, University of Melbourne, Melbourne, Vic. 3010, Australia.
Australian Health Review 46(6) 645-651 https://doi.org/10.1071/AH21316
Submitted: 30 September 2021 Accepted: 14 February 2022 Published: 21 April 2022
© 2022 The Author(s) (or their employer(s)). Published by CSIRO Publishing on behalf of AHHA.This is an open access article distributed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND)
Abstract
Objective To explore out-of-pocket (OOP) costs within specialties and individual specialists, and use of Medicare Benefits Schedule (MBS) data for potential price transparency initiatives.
Methods We conducted a cross-sectional descriptive study of claims for a 10% random sample of Medicare enrolees for out-of-hospital MBS-billed subsequent and initial consultations between 1 January 2014 and 31 December 2014, specific to cardiologist, oncologist and ophthalmologists (with at least 10 patient visits in 2014). Our main outcomes were the number of locations per provider, number of unique OOP consultation costs per provider and provider-location, and the proportion of bulk-billed visits for these visits.
Results We studied 970 cardiologists, 913 ophthalmologists and 376 oncologists. At least 67% of specialists across each specialty had at least two practice locations: cardiologists had a median of three (interquartile range [IQR]: 2–4) and ophthalmologists and oncologists both had a median of two (IQR: 1–3). For subsequent consultations, cardiologists had a median of three unique costs per location (IQR: 2–3), whereas ophthalmologists had a median of four unique costs per location (IQR: 3–5). In contrast, oncologists had a median of one unique cost per location (IQR: 1–2) (57.6% of oncologists’ provider-locations charged only the bulk-billing amount).
Conclusions Specialists have distinct fee lists that can vary based on location. Summary statistics on price transparency websites based on a single amount (like a median or mean OOP charge) might mask substantial variation in costs and lead to bill shock for individual patients.
Keywords: consultation costs, Medicare Benefits Schedule, out-of-pocket costs, price transparency, specialist costs.
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