On Jurisevic, Ross, Knight and Anonymous

I must say that I really have no idea what it is about my posts on this topic, or perhaps this whole issue in general, that has caused such a heated response.

I thought this was just an innocent comment on the activities of the ACCC and my own conjecture as to what might or might not have happened, and the wider implications of the ACCC's actions. I must make clear that I do not know Craig Jurisevic, Iain Ross, or John Knight, or anyone at the ACCC. I have never met them, have no inside information about what happened, and don't have any opinion on their character or skill.

Nevertheless, a series of anonymous posters seem to think that I am a dyed-in-the-wool Craig Jurisevic-hater when this is not the case. Why should some lowly general surgeon working in the middle of nowhere have anything to do with a high-flying, TV-appearing, book-writing, decorated cardiothoracic war surgeon? I don't know what his book is about - it could be about bird-watching for all that I care! What does that have to do with me? He could walk past me in the street and I would not know or care. I neither like nor dislike Craig Jurisevic - so Anonymous, please stop accusing me of being out to get him. I am not out to get Craig Jurisevic but I am not here to defend or promote him either.

In order for everyone to see clearly what I am being accused of, here are links to the two relevant blog posts and the amalgamated comment exchange on this topic.

ACCC Strikes Again, August 2007
Bleeding Hearts in Private Hospitals

Comments:

Milk & Two Sugars said...

Ah, but 'desirable' is not the same as 'required', is it? Do you think it's possible that the problem stemmed from Ross and Knight's inability to formally take action to prevent a surgeon they considered inexperienced and therefore dangerous from being allowed to take such a position? I'm not familiar enough with the College of Surgeons practices to know whether such an avenue was available.

6:18 PM, August 20, 2007 

Anonymous said...

The surgeon in question had several years as a trauma surgeon on top of his cardiothoracic training and had a Masters I Surgery in the field of cardiac surgery, so experience was never an issue, nor was patient safety.

9:39 PM, August 22, 2007 

Sheepish said...

You make a good point, M&TS. Ross and Knight may have felt that way for reasons apart from CJ's professional qualifications. There is no practicable means to limit someone's activity in private, as the whole point is that the market decides whether such qualities are a problem.

I have written a further post about my opinions on this.

Thanks for your insight, Anonymous. Please keep reading, and letting me know what you think.

2:20 AM, August 24, 2007 

Anonymous said...

Sheepish,
Why no response to posts that highlight the fact that CJ was more than qualified and competent??

9:53 PM, September 13, 2007 

Sheepish said...

Hi Anon - I assume you are the same Anon from the postACCC Strikes Again on this topic.

I don't claim to know CJ personally or professionally, so I can't really comment on his qualifications. My observations didn't relate to how skilled or competent he is, and I assume that he is appropriately trained to the level of an FRACS(CT). They were about the issues around the ACCC's actions and private hospital accreditation.

By the way, if you comment again it would be nice if you gave yourself a nickname or logged in to Blogger - it's a bit weird replying to "Anonymous".

10:31 PM, September 13, 2007 

Honest Doc said...

Dear Sheepish,
I am not the Anon from other posts referred to. This is my first time on this site. I have recently developed an interest in the case as I have worked in SA all my life, and I , and most other docs in the public and private hospital system know of the past behaviours of the two surgeons charged by the ACCC. The finding is of no surprise as these "Old Adelaide" exclusive practices have destroyed many a young medico in Adelaide.
Lets see what the Medical Board, our independent aribiter of professional conduct, has to sy about the actions of Messrs. Ross and Knight!

10:49 PM, September 13, 2007 

Anonymous said...

Hi to all- I have read enough peoples opinions and views of those who support Knight and Ross or try to make it seem that they were doing nothing wrong. I do personally and profesionally know Dr Craig Jurisevic, and in the past have worked under Dr Knight as a theatre nurse. Let me say that there are clear and distinct differences between these two individuals. While they are both immensly tallented and educated surgeons, the motivation behind Knights and Ross' actions were not in the interests of patients who might in future require the services of Dr Jurisevic. In my time working with Dr Knight, It was clear that money was a large motivator for him, while he is an excellent surgeon, and his patients are always the priority, money comes in at a very close second. This is not the case with Dr Jurisevic, while he may be earning a significant salary, and may be launching civil action as reported in the Australian, he has every right to do so. These men have attempted to tarnish this surgeons reputation in a decietful and pathetic manner, even making him believe that he was not qualified to work as a CT consultant surgeon. To Dr Knight and Ross, what you did was intentional, Dr Knight has at various times been very callous and decietful individual to get his way, and obviously has not changed since I have worked with him. While I do not directly work under Dr Jurisevic, I have assisted him in Surgery many times and saw first handedly what an experienced and caring individual he is. Money is not a motivator for him, nor is the position or titles. His main and only motivator is knowing that he is saving or greatly improving the life of another human being.

8:42 PM, October 31, 2007 

Anonymous said...

Why do you hate craig jurisevic so much? Have you read his book yet? now that you see he was MORE than qualified and Ross and Knight were being c**ts do you admit you are wrong?

2:41 PM, May 21, 2010 

Sheepish said...

Dear Anonymous:

I assume that you are referring to a series of posts that touch on news reports involving an ACCC finding regarding the failure to appoint Craig Jurisevic to an Adelaide private hospital. (Now I sound like Sir Humphrey!)

They are ACCC strikes again and Bleeding Hearts in Private Hospitals from August 2007.

Firstly it is helpful if you provide a name as many other commenters use the same pseudonym "Anonymous" and it makes it impossible to tell whether you are the same Anonymous as has commented on those posts.

Secondly, you may wish to post your comment on those posts rather than this one, as otherwise no-one has any idea what you are on about without me coming to your rescue.

Thirdly, I have never said, and can confirm that I do not, hate Craig Jurisevic nor bear him any ill will. I have not read his book nor do I have any immediate urge to go out and buy it as I don't have the faintest idea what it is about yet.

I have merely passed comment on the general issues raised in this ACCC case and theorised on what might possibly have happened. As I passed no judgement on Craig Jurisevic I really don't have the faintest idea what you are accusing me of, or what I could possibly be wrong about.

Next time I would appreciate it if you could write a comment that at least made sense, rather than a paranoid rant.

Sheepish.

11:56 PM, May 21, 2010 

Anonymous said...

Dear Sheepish,

I have read all those posts about the ACCC, and I am very close to the case of Mr Jurisevic and Mr Edwards. I know it well. Far better than you'd like to think you are - you are a nobody. You have no idea what you are talking about and you elude to the fact that Ross and Knight were shafted in some way. You need to go f*** (edited) yourself!

1:51 PM, June 10, 2010 

Sheepish said...

Dear "Anonymous":

I don't claim to know the case or any of the doctors involved well or at all, other that what I have read in the paper. I may well be nobody but I am entitled to pass comment and express an opinion. It is, after all, my blog.

I do not allude to anyone being shafted, but you are not doing your case any justice by your irrational, unjustified finger-pointing. I think it is fair to say that your attack on my comments is, to say the least, paranoid behaviour. If you have inside information then please feel free to share, as raving and ranting is clearly not doing much good for my education, nor your pent-up frustration (which may well be solved by the same action that you have asked me to perform).

8:40 PM, June 10, 2010 

Clubs and Cartels

The big news this week has been that the ACCC is on the prowl again. Medical work practices are not new ground here - the ACCC has previously stoushed with the RACS over surgical training, as well as Queensland obstetricians and more recently Adelaide heart surgeons (my previous posts ACCC Strikes Again and Bleeding Hearts in Private Hospitals). In fact the ACCC has so much interest in the medical industry that it provides an Info Kit for doctors.

The new case now concerns medical accreditation practices at St Vincent's Private Hospital in Sydney, in particular, the practice of limiting appointment of new anaesthetists to those who already hold appointments at the nearby St Vinnie's Public hospital.

In general, most private hospitals have Medical Accreditation Committees that review the qualifications of any medical staff that wish to work at that hospital. The majority of private hospitals are quite keen to have as many doctors on their books as possible and to make the accreditation or credentialling process as simple as possible, because generally more doctors means more patients (and more business).

In the case of anaesthetists, they generally provide a service at the request of a surgeon. With the exception of staff anaesthetists who are paid directly by a private hospital to be available full or part time for urgent or emergency cases, the majority of private anaesthetists are paid fee-for-service by the patient or their insurance fund. Patients generally choose their surgeons but not their anaesthetists, and therefore the surgeon-anaesthetist team usually comes as a single package.

A surgeon will choose to work with a specific anaesthetist in the private setting because they are competent, they work well with the surgeon and his team (often having worked together for years), and they are available to do a particular set of cases at a particular time. Usually if a surgeon moves to another private hospital the anaesthetist will follow, rather than the other way round. Therefore it makes sense that if a private hospital wants to attract a new surgeon to bring work over that they encourage simple, rapid accreditation by the associated anaesthetists.

In contrast, in a public hospital the surgeon has no say who their anaesthetist will be. It could be a junior registrar, or a seasoned consultant. It could be someone they have never met or worked with before. We have to trust that somebody, somewhere (usually the public hospital's appointments committee), has decided that this anaesthetist is up to the job. In most cases, there are no problems as many aspects of anaesthetics are commonplace and transferable. Having a pool of staff anaesthetists makes it easier to roster for emergency cover, or to squeeze as much work as possible from a smaller group of staff - essential in any cash-strapped public hospital - at the cost of breaking up the regular surgeon-anaesthetist team. Obviously for more complex operations there will be more in-depth decision making and efforts to pair experienced and familiar surgeons and anaesthetists (as well as other theatre staff) together.

So what is going wrong here at St V's? Well, to the frustration of the hospital management and the surgeons, an arbitrary rule has been applied to limit the accreditation of new anaesthetists. This means that otherwise qualified and capable anaesthetists are unable to work at that hospital and surgeons who go to that hospital must choose from the anaesthetists who already work there. It is effectively a closed shop and keeps those anaesthetists who already have appointments busy with private work, and potentially allows them to raise their fees above what might be market rates at a hospital with a more liberal accreditation process.

Unfortunately it means that surgeons are forced to work with anaesthetists that they may not wish to work with, as well as discouraging them from bringing work to that hospital, much to the disappointment of hospital management.

Sadly, this is not the only private hospital in Australia that engages in this type of activity. Sometimes it is instigated by the medical staff, sometimes it is instigated by management as a business decision (usually if they employ the anaesthetists directly). Sometimes the ACCC gets it wrong, but by my reading this is one that they have got right and things clearly have to change.

Links:

• ACCC demands answers from St Vincent's - The Australian
  (Click to Expand)
  
  
  

  ACCC demands answers from St Vincent's
  The Australian
  via AAP | August 17, 2009
  
  THE entire team of anaesthetists at St Vincent's Private Hospital is under investigation by the consumer watchdog for acting as a cartel.
  
  The Australian Competition and Consumer Commission (ACCC) last week demanded the group of 30 doctors, who are allocated nearly all the hospital's anaesthetic work, justify its membership rules, the Sydney Morning Herald reports.
  
  The investigation comes after the hospital applied to the commission last year to rule it could continue the practice of preventing outside anaesthetists from working in its operating theatres, even when requested by a surgeon.
  
  Individual doctors face possible fines of up to $500,000 if they are found to have breached competition laws.
  
  The private hospital's pool is restricted to anaesthetists who also work at St Vincent's Public Hospital.
  
  The process is supposed to be competitive and to benefit public patients, but has been criticised for being skewed towards doctors trained at St Vincent's.
  
  The hospital withdrew its application in December, but the commission is investigating fresh complaints from anaesthetists who say they are still locked out of work at St Vincent's.

  
  
  
• St Vincent's a closed shop, said leading anaesthetist - SMH
  (Click to Expand)
  
  
  

  St Vincent's a closed shop, said leading anaesthetist
  Sydney Morning Herald
  Julie Robotham Medical Editor
  August 19, 2009
  
  THE anaesthetist representing doctors in the St Vincent's Private Hospital cartel investigation told professional colleagues that work allocation practices there would not change, despite a deluge of adverse submissions collected by the competition regulator during its initial, later abandoned, inquiry last year into the scheme.
  
  Minutes of a meeting of the NSW branch of the Australian Society of Anaesthetists, obtained by the Herald, reveal Gregory Deacon's resistance to the idea that closed-shop anaesthetic rostering might breach the Trade Practices Act.
  
  According to the minutes, from February, ''GD reminded committee members that St Vincent's Hospital is a privately owned business and therefore has the legal right to appoint staff, including doctors, as it chooses … GD felt the appointment process at St Vincent's Hospital was unlikely to change as a result of the application to the ACCC.''
  
  At issue is the practice of allowing only the limited number of doctors with an appointment at St Vincent's Public Hospital to work at the private facility. The private hospital argued this ensured adequate anaesthetic cover for the public hospital. However, NSW Health, which funds the public hospital, told the commission that claim was specious because there was a surfeit of anaesthetists in the eastern suburbs willing to work with public patients.
  
  Other doctors told the commission the real intention was to keep lucrative private work within a select group of associates.
  
  The commission last December dropped its first examination of the arrangement when St Vincent's withdrew its application to be exempted from the law.
  
  Now the anaesthetists - who as a formal association manage anaesthetic staffing for the hospital - are again under ACCC scrutiny, following new complaints from doctors excluded from working there.
  
  Dr Deacon, as the public officer representing them, must respond by Friday to the commission's questions regarding the group's history, policies and reasons for refusing work to qualified doctors. He refused to comment last night.

  
  
  
  
• Elite hospital old boys' network targeted by competition watchdog - SMH
  (Click to Expand)
  
  
  

  Elite hospital old boys' network targeted by competition watchdog
  Sydney Morning Herald
  Julie Robotham Medical Editor
  August 17, 2009
  
  THE entire team of anaesthetists at St Vincent's Private Hospital - more than 30 doctors - is under investigation for acting as a cartel.
  
  The Australian Competition and Consumer Commission is moving to end what other doctors claim is a decades-long history of restrictive behaviour by an old boys' network which is bent on protecting its exclusive access to some of Sydney's most lucrative private operating lists.
  
  The ACCC last week demanded the group - a consortium of doctors employed as independent contractors but allocated nearly all the hospital's anaesthetic work - justify its existence and membership rules and defend how its members set patients' fees.
  
  Other doctors said giving anaesthetic shifts to a limited pool of specialists could also compromise patient care, barring surgeons from choosing anaesthetists experienced in particular operations.
  
  The commission's move could see individual doctors hit with fines of up to $500,000 if they are found to have breached competition laws. It comes after the hospital last year applied to the commission to rule it could continue the practice of preventing outside anaesthetists from working in its operating theatres, even when requested by a surgeon.
  
  The private hospital's pool is restricted to anaesthetists who also work at St Vincent's Public Hospital - appointed through what the hospital describes as a, ''competitive process '' intended to benefit public patients, but which others say includes a system of patronage skewed towards doctors trained there.
  
  The application prompted a huge backlash, as individuals and specialists' groups told the commission the closed roster was unjustified and unique in NSW.
  
  In its submission, NSW Health, which funds St Vincent's Public Hospital, said public patients did not benefit from the exclusivity arrangement, because there was no, "current or foreseeable shortage of anaesthetists," in the eastern suburbs, and, "indeed if anything there is an oversupply''.
  
  The hospital withdrew the application in December and is understood to have told the doctors, who effectively run the anaesthetic department and charge some of Sydney's highest rates, to change how they allocate work.
  
  But the commission is now investigating new complaints from anaesthetists who say they are still locked out of work at St Vincent's Private.
  
  Early this year the hospital's executive director, Robert Cusack, signed a rejection letter saying there was, ''sufficient anaesthetic cover within the existing cohort of anaesthetists,'' and the candidate therefore, ''did not satisfy a business need of the hospital.''
  
  Despite this, Mr Cusack is understood to be furious with the anaesthetists' position and to have told them he will not pay their legal costs or any fines.
  
  An anaesthetist, David Bollinger, told the Herald : ''I've had a professional relationship with a surgeon I've worked with for 15 years, and he moved to St Vincent's and they won't let me work there. It's … mean-spirited, and bordering on unethical.''
  
  Another anaesthetist refused work said: ''St Vincent's is very highly regarded in the community [but] the way they do things is not necessarily in the best interests of patients … it's in the best interests of themselves.''
  
  Gregory Deacon, public officer of the St Vincent's Private anaesthetists' consortium, declined to comment, saying the matter was being handled by lawyers. The hospital also refused to comment, citing the ACCC proceedings.

Bleeding Hearts in Private Hospitals

Obviously things were more complicated that they have been portrayed, and there is not enough information in the public domain to understand what was happening.

No doubt Craig Jurisevic was qualified to be an independent cardiothoracic surgeon. He had passed his exams and gained his fellowship. That does not automatically qualify him for accreditation to any particular private hospital.

Clearly Ross and Knight did not approve of his entry into private practise (at whichever hospital they worked at). Whether their reasons were financial, altruistic, or otherwise I do not know.

Perhaps they were asked their opinion by the Hospital's accreditation committee and they gave it honestly. Perhaps they actively tried to block his accreditation by portraying Jurisevic dishonestly. Perhaps what they did or did not say didn't matter, and the hospital itself would have made an independent decision about Jurisevic's accreditation based on other factors.

In any case, the ACCC saw the outcome and Ross and Knight's actions as stifling competition. That's why they prosecuted and succeeded.

Nevertheless, in a small, saturated or mature market, qualities such as overseas experience may be desirable. And if, in effect, the ACCC is saying that private hospitals must approve accreditation to everyone who applies (without regard to their other qualities, or lack thereof), then this is a big deal.

Let us say, for example, that Surgeon X has a reputation for poor results, or creating staff conflict, but is an otherwise qualified surgeon in his specialty. Do other surgeons in his specialty have the right to prevent his appointment in order to maintain quality or harmony at that private hospital? (NOTE: I am not implying anything about Craig Jurisevic here)

Does the hospital have a right to refuse accreditation on these "soft" criteria?

Would things have been different if Knight and Ross had threatened to withdraw services if Jurisevic were appointed, rather than saying that he was not qualified? The hospital has a reputation to protect, and not appointing a singular new surgeon in order to keep the business of two other surgeons would be merely a commercial decision.

Maybe the hospital felt that it had enough CT surgeons, and would not accredit another one unless they were "outstanding"?

Perhaps things are skewed because cardiac surgeons are a service profession (unlike most other specialties), and there are only a limited number of hospitals with coronary pump facilities. Maybe if your career is under the thumb of a cardiologist it makes you do weird things.

I'm sure Craig is a smart man, and has plenty of options to further his career. The ACCC's action was presumably to benefit Adelaide residents by maximising their access to cardiac surgical services. It was all about what Ross and Knight did, and little or nothing to do with Craig Jurisevic or his personal interests.

As for overseas or post-fellowship experience being desirable - there would be no issue if Craig's appointment to a public hospital were declined due to Ross and Knight's actions. A public hospital has every right to set it's standards as high as it likes before appointing another surgeon. As far as I am aware, a public hospital is not involved in a commercial marketplace, and therefore the ACCC and the Trade Practices Act has no jurisdiction.

But the rules for a Private Hospital are different - Craig Jurisevic did not miss out on a job, he missed out on a right to enter a competitive market for surgical services at that hospital. I wonder if the ACCC's win means that private hospitals will be compelled to maximise competition within their own walls. We might start sueing each other over whether our names appear more prominently around the hospital, as it may stifle business and competition. What a world.

ACCC strikes again

Doctors fined for breaching trading laws from The Australian, July 5 2007.

Doctors fined for breaching trading laws
July 05, 2007
TWO leading Adelaide heart surgeons have been fined a total of $110,000 for trying to stop a third surgeon operating on private patients in South Australian hospitals.
In a judgment handed down in the Federal Court today, John Knight and Iain Ross were each fined $55,000 and ordered to attend a compliance seminar after breaching competition laws.

In action brought by the Australian Competition and Consumer Commission (ACCC), Judge John Mansfield ruled that doctors Knight and Ross had come to an arrangement to hinder or prevent a colleague, Craig Jurisevic, from performing surgical services on private patients unless he underwent further training.

The judge said on six occasions between February 6, 2001 and March 9, 2001, Knight and Ross advised hospitals where Dr Jurisevic had wanted to work or surgeons who had been asked to support his applications, that he was insufficiently trained or had not completed his training.

This was despite Dr Jurisevic having been legally qualified and being admitted as a fellow to the Royal Australian College of Surgeons after completing the advanced surgical training program.

Judge Mansfield said Ross and Knight had also come to an arrangement with another surgeon, James Edwards, not to work at a hospital where he operated provided he did not work at a hospital where they performed surgery.

Judge Mansfield said the admitted conduct of Knight and Ross involving Dr Jurisevic stemmed from a decision by him not to take up an 18-month training position in Boston and to begin performing surgery on private patients in Adelaide instead.

"This upset Messrs Knight and Ross,'' the judge said.

He said it was not possible to determine the extent of loss suffered by Dr Jurisevic.

But he said the actions of Knight and Ross had raised barriers to other surgeons entering the Adelaide market.

"As a result ... newly qualified cardiothoracic surgeons in Adelaide were likely to consider they were, in effect, required to undertake further training, overseas or interstate, in order to practise as a cardiothoracic surgeon,'' Judge Mansfield said.

He said the result of this case should serve to ameliorate the impact of any such ongoing effect.

The judge said he also accepted that both Knight and Ross genuinely believed Dr Jurisevic needed more training and praised the two doctors for cooperating with authorities.

Their admissions had saved both the court's and the ACCC's time, he said.

In a statement Knight and Ross said their actions were motivated by concerns over patient safety.

"At all times, patient safety was very much in our minds,'' the surgeons said.

They also expressed concerns over the operation of competition rules on the medical profession.

"Whilst we recognise the importance of competition rules in the market place, we are concerned that the legislators have had insufficient regard to matters of patient safety in seeking to apply those rules to the medical profession,'' they said.

What bothers me about this case is how close a line we tread to breaking the law.

For example, doctors in Australia are not allowed to advertise their services. But when does marketing become advertising? How big an entry in the Yellow Pages is allowable? Is it OK to have a small sign outside your clinic, or a big sign outside your clinic, or a big billboard down the road?

When we give advice to each other about which areas are underserviced and would be better places to practise, is that inviting someone into a non-compete arrangement?

Judge Mansfield said the admitted conduct of Knight and Ross involving Dr Jurisevic stemmed from a decision by him not to take up an 18-month training position in Boston and to begin performing surgery on private patients in Adelaide instead.

...

But he said the actions of Knight and Ross had raised barriers to other surgeons entering the Adelaide market.

"As a result ... newly qualified cardiothoracic surgeons in Adelaide were likely to consider they were, in effect, required to undertake further training, overseas or interstate, in order to practise as a cardiothoracic surgeon,'' Judge Mansfield said.

Hang on, I thought that there was already an expectation that some form of post-fellowship training or experience was desirable. Perhaps this means I can cancel the PhD and the two unpaid overseas posts I had planned?

Mind the Gap: Part 7 - Private Hospitals

And now we return to normal programming. This is the last instalment of a series outlining the Australian Health Insurance industry from the perspective of a health provider.

7. Private Hospitals

Private hospitals get some money from the Governments but on the whole these are relatively small amounts compared to Public hospitals. They make their money by charging their patients. If a patient has no insurance then they have to pay out of their own pockets. If they have insurance then they can get the insurance company to pay the hospital, or the patient pays the hospital and gets the money back from the insurance company.

This only covers the costs of the beds, the food, the nursing staff, any equipment used during the patient's treatment and other care that is received at the hospital. Usually there is also a co-payment that the Insurance company charges the patient (often $50/day), though this depends on your level of cover and whether the hospital has an agreement with the insurance company.

A doctor who consults on a patient or performs an operation at a private hospital will charge the patient separately. This is again eligible for a Medicare payment, and the doctor is entitled to charge the patient more if he feels that it was worth more than the CMBS rate. The CMBS fee itself usually relates to the type of operation and how difficult the operation was (in general terms). Where possible, most surgeons will give the patient an estimate of the expected surgeon's fees and gap costs, but this will depend what exactly was done at the operation, since it is impossible to accurately predict what needs to be done until the patient is on the table, asleep, and the operation starts.

Furthermore, unexpected complications that arise still need treatment, and therefore patients and insurance companies will occasionally receive further invoices beyond what was originally planned. This is part and parcel of all medical care, and while insurance companies understand this often patients do not, unless this is clearly explained to them early on in the piece.

The components charged by a surgeon in a Private Hospital will usually consist of consultation fees related to visiting the patient in hospital (prior to any operations) and surgical fees related to the time and effort involved in each operation or procedure performed. These fees usually include a component referred to as "aftercare" - namely postoperative management of a patient for reasonable time and effort incurred after an operation that proceeds smoothly. Where complications arise or a more complex situation develops, further consultation fees may be raised, but Medicare requires some justification that such fees are "Not Normal Aftercare (NNAC)".

Beyond the physician or surgeon who admitted the patient, fees may be raised by other specialists who are involved in the patient's care, such as the Anaesthetist, a Surgical Assistant (usually a qualified doctor assisting the primary surgeon), Intensive Care Physicians, Radiologists, and other Specialists (e.g. General Physicians, Cardiologists, other Surgeons etc.). The overall costs can be quite high, but again in most cases Medicare covers the CMBS portion of the fees, and the patient will only be left with small gap fees to pay.

All in all, a typical patient being admitted for a hip operation will receive bills for:

• Hospital charges (Nursing care, meals, bed and equipment costs) - usually reimbursed or paid by the insurance company, co-payments paid by patient
• Implantable Prosthesis charges (e.g. a Moore's Prosthesis) - usually reimbursed or paid by the insurance company
• Surgeon's Preoperative Fees (CMBS portion paid by Medicare via insurance company, Gap fee paid by patient)
• Surgeon's Operative Fees (CMBS portion paid by Medicare via insurance company, Gap fee paid by patient) - usually includes aftercare
• Anaesthetist's Fees (CMBS portion paid by Medicare via insurance company, Gap fee paid by patient)
• Surgical Assistant's Fees (CMBS portion paid by Medicare via insurance company, Gap fee paid by patient)
• Other specialist's fees where necessary (CMBS portion paid by Medicare via insurance company, Gap fee paid by patient).

In cases where a patient has no private health insurance, they will find that most of the fees raised by doctors will be covered by Medicare, and the Gap Payments should be relatively small. The most expensive out-of-pocket costs are those billed by the hospital for facility costs and prostheses. Not uncommonly, the Gap Payments may only add up to several hundred dollars, while the Hospital and Prosthesis charges may be many thousands.

Not all private hospitals are new and flashy.

• Public hospitals chase private patients
  
• Performance bonuses for veterans hospitals
  
• Abbott proposes private management of public hospitals

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Hopefully this series of posts have been enlightening, and help to unravel the world of Australian Private Health Care. Basically, there is a lot of money shuffling around the system, oblivious to the patients who receive the end-product. The costs of health care are far greater than many people think, and the current health insurance and Medicare system have done an amazing job of blinding patients to the true cost and value of health care - making it something that we take for granted.

Obviously it has done wonders for the underlying health of our society - we have some of the highest standards of health care in the world, and it is readily available to the vast majority of Australian Citizens (with notable exceptions in the Indigenous population). It has kept health-care costs down quite successfully. But it has also led to the result where we do not appreciate the value (both financial and otherwise) of our own health.

Health Insurance companies are making vast amounts of money by "value-adding" to a Government-funded service. They present the costs of having your operation in a Private Hospital as being something they pay for, when in fact it is still largely paid for by the Government. They are working hard to further hide the true cost of doctors' fees from the public, to make the Gap Fee an exception rather than the rule. And they are being very successful.

This is the end of this series of posts. I hope you enjoyed it.