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 (third) for 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. Indigenous people have much poorer life expectancy with indigenous males having a life expectancy of 71.6 years (8.6 years lower than non-indigenous males) and indigenous females having a life expectancy of 75.6 years (7.8 years less than their non-indigenous counterparts).

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 2 per cent of taxable income). In addition to the Medicare levy, Australians who don’t have an appropriate level of private patient hospital cover may have to pay a Medicare Levy Surcharge (see below).
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.

GP Management Plans and Team Care Arrangements

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. If the provider accepts the Medicare benefit as full payment, there won’t be an out-of-pocket cost.

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 Management Plan. To be eligible, your dental problem must be impacting your general health.

Medicare Schedule fee

Medicare benefits (the refunds or rebates payable to you, the user) are based on a list of standard fees for medical services — the so-called ‘Schedule fees’. These Schedule fees are set out by the Australian Government in the Medicare Benefits Schedule (MBS).

Even though there is a Schedule of fees, doctors are free to set their own fees for consultations and procedures. (They are covered by the Trade Practices Act.) 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 Benefits Schedule.

Medicare benefits (rebates)

General practice

The Medicare benefit you receive is calculated as a percentage of the Medicare Schedule Fee for that service – not the amount charged by the doctor or other healthcare professional. You may still have to pay a certain amount (a ‘gap fee’), as many doctors charge more than the Schedule fee.

Rebates differ according to the type of service:

  • 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 rebates 100 per cent of the Schedule fee.
  • Other GP services, such as procedures like removing skin lesions or injecting joints, Medicare rebates 85 per cent of the Schedule fee.
  • In-hospital services (if you are a private patient): 75 per cent of the Schedule fee.

For an example of how this works in practice, a GP might charge $80 for a standard consultation. The Medicare rebate for this is $38.75, leaving a gap of $41.25 for you to pay.

Example general practitioner’s fees
EXAMPLE: Standard consultation Cost
Doctor’s consultation fee $80.00
Medicare Schedule fee $38.75
Medicare rebate to patient (100 per cent of Schedule fee) $38.75
Out-of-pocket expense to patient $41.25

How to claim your Medicare rebate

Unless you have been bulk-billed (see below), you can claim back the Schedule fee from Medicare. This can be done at the doctor’s office, online, via an app, by mail or in person at a Medicare service centre.

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.

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. The doctor bills Medicare directly.

Normally, if you are bulk-billed, your Medicare card will be swiped and you sign a form or press OK on the EFTPOS terminal. 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 $38.75 for a standard GP consultation.

How can you find a bulk-billing doctor?

You can search for a bulk-billing doctor on Healthdirect’s ‘Find a health service’.

As an incentive to improve bulk-billing rates, Medicare now provides an extra payment to doctors in eligible rural areas each time they bulk-bill vulnerable patients, such as pensioners, health care card holders and those aged 16 and under. Additional bulk billing incentives were also introduced during the COVID-19 pandemic to encourage doctors to bulk bill vulnerable patients.

Specialist consultations

Most out-of-hospital specialist consultations attract only an 85 per cent Medicare rebate of the Schedule fee.

If the specialist 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.

Safety nets

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.

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.

Veteran healthcare cards

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 (DVA).

The original DVA White, Gold and Orange cards are being replaced with a redesigned “Veteran Card’. The entitlements of each level of card remain the same.

Veterans healthcare cards
Type of card What it covers
Veteran Gold Card Clinically required treatment for all medical conditions
Veteran White Card Medical treatment for accepted service-related injuries or conditions, mental health, cancer and pulmonary tuberculosis covered under non-liability health care.
Veteran Orange Card Concessional rate for prescription items, including medicines, wound care and nutritional supplements.
Wider range of medicines available on RPBS than PBS.

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.

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 Pharmaceutical Benefits Scheme, bulk billed doctor visits (subject to your doctor), and a bigger refund for medical costs when you reach the Medicare Safety Net. You may also be eligible for concessions offered by utility 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 nets covers a range of doctor visits and tests that you receive out of hospital. Families and couples need to register if they want to combine their costs, but individuals are automatically registered.

There are 3 Medicare safety net thresholds currently.

Original Medicare Safety Net (OMSN): 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 $477.90) 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.

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.

Extended general safety net (EMSN). This is the third safety net. This applies to all Medicare cardholders and comes into play if out-of-pocket costs reach the threshold of $2169.20. 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.

Threshold Amount Who is eligible? Calculated on Benefit after threshold reached
Original (OMSN $477.90 All Medicare cardholders Gap amount 100% of schedule fee for out-of-hospital services
Extended concessional and FTB(A) $692.20 Concession cardholders; Families eligible for family tax benefit (A) Out-of-pocket costs 80% of out-of-pocket costs or the EMSN benefit caps for out-of-hospital services
Extended general (EMSN) $2169.20 All Medicare cardholders Out-of-pocket costs 80% of out-of-pocket costs or the EMSN benefits caps for out-of-hospital services
Out-of-pocket costs = difference between Medicare benefit and the doctor’s fee.
Gap amount = the difference between the Medicare benefit and the Schedule fee.
Schedule fee = the fee for service set by the Australian Government.
EMSN = Extended Medicare Safety Net
Adapted from Medicare Australia

Tax rebate for medical expenses

The net medical expenses tax offset was phased out in July 2019, and is no longer available. 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.

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.

You may be able to claim for medical expenses for prior income years, but the tax offset is subject to the expenses being for disability aids, attendant care or aged care, and subject to you having 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 incentivised by the Government to take out private health insurance by way of the Medicare levy surcharge (see below). This is applied to people earning over a certain amount who do not have appropriate private patient hospital cover.

But, it’s not mandatory 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 in a public hospital.

However, 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. This is an amount the Government contributes towards the cost of your private health insurance premiums.

If you take out an appropriate private health insurance policy with a registered health fund, you may be entitled to this rebate of a certain proportion of your premiums paid during the year. This is true for hospital cover, extras (general) cover or combined cover. It is 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 rebate is either applied as a reduction to your premiums, or is calculated when you lodge your annual tax return.

The size of the rebate may also depend 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 do not have an appropriate level of private patient 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. This is additional to the 2 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.

Age-based discount

From 1 April 2019, insurers can offer discounts of up to 10 per cent off hospital premiums to people aged 18-29 years. The discount lasts until they turn 41. The age-based discounts apply equally to existing policy holders as to new policy holders.

Types of private health insurance

Private health insurance policies are usually categorised as hospital cover, general (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 a Private Health Information Statement (PHIS) for their products at least once a year. These replace the Standard Information Statements (SIS). The 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.

By law, in Australia, health insurance is ‘community rated’ and everyone is entitled to buy health insurance products at the same price. Meaning you can’t be discriminated against on the basis of your health status or your claims history – so you can’t be asked to pay more than someone else for the same product.

 

Types of private health insurance
Type Examples of services which may be covered (always check your individual policy or contact your health fund) Notes
Hospital cover
  • Doctors’ fees: the remaining 25% of Schedule fee, after Medicare rebate of 75%
  • Accomodation costs while in hospital (including meals)
  • Theatre fees
  • Diagnostic or pathology tests while in hospital
  • Dressings while in hospital
  • Medicines while in hospital
  • May still be out of pocket for some items, e.g. doctors often charge more than Schedule fee. See the Medical Costs Finder to see how much people have paid out of pocket for a medical service.
  • Health insurers may have ‘gap cover’ arrangements. There are ‘no gap’ and ‘known gap’ schemes
  • Choose your level of excess
Extras, ancillary or general treatment cover
  • Physiotherapy
  • Optical
  • Dental
  • Podiatry
  • Osteopathy
  • Chiropractic
  • Acupuncture
  • Weightloss classes
  • Gym memberships
  • Policies vary widely as to which services are covered
  • Rebates often fall very short of fees
Combined cover Combination of hospital and extras cover Policies vary widely as to which services are covered
Ambulance cover Australia-wide ambulance cover Ambulance cover differs from state to state in Australia: residents of some states are covered by their electricity bills or local council, but may only be covered for the state in which they live; residents of some other states may not be covered at all.
Private Health Information Statements (PHIS) are available on all private health insurance products in Australia. These statements allow you to review and compare features, such as waiting periods, benefits payable and excesses, of different products.

Hospital cover

All hospital cover insurance policies are now classified into one of 4 tiers – Gold, Silver, Bronze or Basic hospital cover. The tiers should make it easier to compare products across different private health insurers. All existing health insurance policies have been categorised into a tier.

Each tier has minimum standard categories of treatment called Clinical Categories, but insurers can opt to include more in each tier. If a policy has additional coverage it is denoted as ‘Plus’, e.g. Bronze Plus.

The Clinical Categories set out groups of hospital treatments that are covered under each tier. Examples of clinical categories are: ‘Ear, nose and throat’, ‘Pregnancy and birth’, and ‘Joint reconstructions’. The higher a tier, the more categories are covered. If a health insurance product covers a particular Clinical Category, it must cover all the treatments in that category.

What does hospital cover actually 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 as a private patient. Talk to your health fund and specialists beforehand to ask what out-of-pocket costs (gap fees) you can expect. Gap fees can be in the hundreds or thousands of dollars. Remember that you may have to pay some fees first and obtain your refund later from your fund.

Use the Medical Costs Finder to see what other people have paid out of pocket for the same procedure. Note that inclusion is voluntary on the part of the doctors, so the data is not comprehensive.

Ask if your health fund has any gap schemes, such as “no gap” or “known gap”. These schemes are complicated and vary between funds, so check carefully with your fund.

Informed financial consent – Knowing how much your treatment is going to cost before you go into private hospital is called informed financial consent. You can ask for a written estimate of fees and out-of-pocket costs before you go into hospital. Many hospitals require that you sign off on this estimate before proceeding with treatment. The Australian Medical Association has a guide for consumers explaining informed financial consent and a list of questions to ask.

Doctors’ fees. 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.
  • You will have to pay any difference between the Schedule fee and the doctor’s charge (if the doctor charges more) unless your private health insurance covers the gap or part of the gap (see gap cover).
  • Note that often a surgeon will have an assistant, who also charges a fee.

There is no relationship between cost of a surgeon and quality of their work, so paying more doesn’t necessarily mean you will get a better surgeon.

Anaesthetists. Their services are costed and billed separately to surgeons’ or doctors’ fees. Health funds often pay the gap between what Medicare covers and the actual fee.
Accommodation and meals costs. These are usually covered by private health insurance.
Theatre fees. Check if these are covered by your private health insurance.
Surgical prostheses. There may be out-of-pocket costs for prostheses, devices and implants.
Rehabilitation costs. Check if these are covered by your private health insurance.
Pathology and diagnostic tests. For example, X-rays and blood tests. As a private patient, you are privately billed for pathology tests, however, many health funds have no-gap arrangements with pathology laboratories. Not all pathology tests qualify for a rebate.
Dressings and bandages. Check if these are covered by your private health insurance.
Medicines. Check if these are covered by your private health insurance.

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.

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.

General treatment cover (extras, ancillary 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, and podiatry. It also covers a few complementary therapies, such as osteopathy, remedial massage and acupuncture. In 2019, the Federal Government’s reforms to private health insurance prevented health funds from offering benefits for some other natural therapies, such as aromatherapy, reflexology, homeopathy, tai chi, pilates and yoga.

Some policies offer rebates for gym memberships or exercise classes, if recommended by a health professional as part of a health management plan.

The rebates for extras may vary among levels of cover within the same fund and also between funds. You may be able to claim the full cost of the service or part of the cost. There is usually an annual limit beyond which there is no rebate. Often the rebates come nowhere near covering the actual charge you have to pay, for example, for an appointment with a physiotherapist that costs you $84, the rebate may be only $40.

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 can be an unwelcome surprise for people transported from the scene of an accident. Ambulance fees are not covered by Medicare.

If you have a Department of Veterans Affairs Health Care Card you are covered for state ambulance services in every state and territory.

In some states and territories residents with pensioner, concession or health care cards are entitled to free emergency ambulance services. Check with your individual state ambulance service for fees.

Emergency callout fees are often in the hundreds or thousands of dollars, with an additional levy per kilometre. Transfers to regional hospitals from remote areas may easily be in the thousands of dollars.

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.

Here’s a round-up of some of the states ambulance emergency fee charges (these are by road – doesn’t include fixed wing or helicopter):

  • New South Wales: $401 emergency call out fee, with additional $3.62 per kilometre cost.
  • Victoria: Minimum cost of $1265, or $1866 for rural pickups.
  • Queensland: residents are covered by the state government for emergencies anywhere in Australia.
  • Tasmania: residents are covered by the state government for emergencies in Tasmania.
  • South Australia: $1044 call out fee, with additional $6 per kilometre cost.
  • Northern Territory: $815 for call out, with additional $5.25 per kilometre.

Outside your home state or territory you may not be covered for emergency ambulance transport – it depends upon reciprocal agreements between states and territories. If you have private health insurance check your policy for ambulance cover. You can often also arrange ambulance cover directly with the ambulance authority in your state.

Healthcare costs: what you’re covered for
Who Doctors’ and specialists’ fees Hospital accommodation Theatre fees In-hospital medicines Ambulance fees Emergency department or outpatient services
Public patient in a public hospital Medicare covers all fees. Medicare covers all. Medicare covers all. Medicare covers all. Free to those on a government pension or who have a healthcare card. Can be in the thousands of dollars for accident victims. Free.
Private patient in a public hospital Medicare refunds 75% of Schedule fee. Private health funds will cover at least the remaining 25% of the Schedule fee. Private fund gap cover (no gap or known gap) may refund part or all of the gap between the Schedule fee and the doctor’s charge. You will be charged for accommodation. Medicare does not cover this. Private health insurers offer cover for some or all of your hospital accommodation costs. You will be charged. Private health insurers offer cover. You will be charged. Private health insurers offer cover. Private health insurers offer ambulance cover, but this varies from state to state. May not be needed if you live in Qld or if you are a pensioner or low-income earner. Free.
Private patient in a private hospital Medicare refunds 75% of the Schedule fee. Private health funds will pay at least the remaining 25% of the Schedule fee. Private fund gap cover (no gap or known gap) may refund part or all of the gap between the Schedule fee and the doctor’s charge. You will be charged for accommodation. Medicare will not cover this. Private insurers offer cover for some or all of your hospital accommodation costs. You will be charged. Private health insurers offer cover. You will be charged. Private health insurers offer cover. Private health insurers offer ambulance cover, but this varies from state to state. May not be needed if you live in Qld or if you are a pensioner or low-income earner. Private hospitals tend not to have emergency departments, but Medicare doesn’t cover if they do. Private health insurers offer cover for some or all of outpatient costs.

Medicines and prescriptions

The Pharmaceutical Benefits Scheme (PBS) provides Australian residents with access to prescription medicines. Many prescription medicines are subsidised under the PBS. In 2015, the PBS provided access to over 2066 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.

Non-prescription medicines are available in pharmacies – either off the shelf (Schedule 2) or from the pharmacist (Schedule 3). Some products are also available in supermarkets – often in smaller pack sizes.

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.

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. It can take on average 240 working days to evaluate an application and get the product registered. There is a priority review pathway to assess vital and lifesaving prescription medicines within 150 days.

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.

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.

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.

Where there are cheaper brands of a medicine, the extra cost you may have paid for a more expensive brand will not count towards the threshold.

Doctors

Not many health issues happen without a doctor being involved somewhere down the line and in 2017 Australia had nearly 37,000 doctors registered in general practice. In 2013 there were around 25,000 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 — for those born in 2015-2017 an estimated 7.8 years earlier for women and 8.6 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, 4 times the prevalence of pre-diabetes and diabetes, and almost double the rate of suicide.

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.

Australian Immunisation Register

The Australian Immunisation Register started out as the Australian Childhood Immunisation Register (ACIR) which recorded vaccinations given to children under 7. The ACIR was started in 1996 to improve childhood immunisation rates, which were falling. It was expanded to include vaccination records for young people (January-September 2016), and then again to include vaccination records for people of all ages (October 2016).

Vaccinations that are not recorded on the Australian Immunisation Register include:

  • childhood vaccinations (or any other vaccinations) before 1996
  • vaccinations received as a person aged between 7 and 20 years between 1996 and December 2015
  • vaccinations received as an adult before October 2016.

You can request immunisation records from the Register by printing a copy of your (or your child’s) Immunisation History Statement from your Medicare online account, by calling the AIR on 1800 653 809, by emailing air@humanservices.gov.au or by visiting Medicare or Centrelink.

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. Only authorised personnel can access the list.

Holding a driver’s licence where you have stated your wishes does not mean that you will be on the Register.

Ophthalmologists and optometrists

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

Optometrists 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.

Last Reviewed: 14/10/2020

myDr



References

1. Australian Bureau of Statistics. Life expectancy at birth. Updated Oct 2018. https://www.abs.gov.au/ausstats/abs@.nsf/Previousproducts/3302.0.55.001Main%20Features22014-2016?opendocument&tabname=Summary&prodno=3302.0.55.001&issue=2014-2016&num=&view=
2. AIHW. Australia’s health expenditure: an international comparison. Released June 2019. https://www.aihw.gov.au/reports/health-welfare-expenditure/health-expenditure-international-comparison/contents/table-of-contents
3. Australian Government. Closing the Gap Report 2020. Life expectancy. https://ctgreport.niaa.gov.au/life-expectancy
4. ATO. Medicare Levy. https://www.ato.gov.au/Individuals/Medicare-levy/
5. ATO. Medicare levy surcharge. https://www.ato.gov.au/individuals/medicare-levy/medicare-levy-surcharge/
6. Department of Health. Chronic disease management patient information. Updated March 2014. https://www1.health.gov.au/internet/main/publishing.nsf/Content/mbsprimarycare-chronicdisease-pdf-infosheet
7. Department of Veterans’ Affairs. Veteran healthcare cards. https://www.dva.gov.au/health-and-treatment/veteran-healthcare-cards
8. Services Australia. Low Income Health Care Card. https://www.servicesaustralia.gov.au/individuals/services/centrelink/low-income-health-care-card
9. ATO. Private health insurance rebate. https://www.ato.gov.au/individuals/medicare-levy/private-health-insurance-rebate/
10. Australian Government. Services Australia. What an immunisation history statement is. https://www.servicesaustralia.gov.au/individuals/services/medicare/australian-immunisation-register/what-immunisation-history-statement

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