Referred medical specialist attendances

Specialists generally only see their patients after receiving a ‘referral’ from a primary health care practitioner. They provide diagnostic and treatment services in a specific area of medicine, generally for a particular disease or body system. This is distinct from other practitioners, such as specialists in General practice, allied health and other primary care services, where a referral is not usually required.

Common referred specialties include: cardiology, dermatology, gynaecology, neurology, obstetrics, oncology, paediatrics and rheumatology. All specialists have completed advanced training, and must be registered with the Australian Health Practitioner Regulation Agency in order to practise in Australia.

Whilst many referred medical specialist attendances are rendered in hospital, not all of these are subsidised through the Medicare Benefits Schedule (MBS). Common examples of non-MBS subsidised services include:

• services provided by hospital doctors to public patients
• services provided under the Department of Veterans' Affairs National Treatment Account
• services covered by third party or workers' compensation.

This page reports on referred medical specialist attendances subsidised through the MBS, and based on the financial year of processing between 2015–16 and 2020–21. It also highlights the impact of COVID-19 on specialist attendances processed to the end of 2021.

How many Medicare-subsidised referred specialist attendances were there?

In the 2020–21 financial year, there were 36.6 million MBS-subsidised referred medical specialist attendances (consultations) in a range of settings (Table 1). These attendances were provided to 8.6 million Australians (34% of people). Of these attendances, most (77%, or 28.2 million services) occurred in non-hospital settings, such as private consulting rooms and private outpatient clinics – and were provided to 8.3 million patients in total.

1. Specialist attendances are Medicare-subsidised referred patient/doctor encounters, such as visits, consultations, and attendances by video conference, involving medical practitioners who have been recognised as specialists or consultant physicians for Medicare benefits purposes. Specialist attendances include psychiatry and obstetric care, including antenatal and post-natal attendances. In many cases, antenatal and post-natal attendances are performed by General Practitioners (GPs). These services have been regarded as specialist attendances.
2. Services provided to public inpatients or outpatients are not included in the table.

Source: AIHW analysis of MBS data maintained by the Australian Government Department of Health; ABS 2021a.

Non-hospital specialist consultations

In 2020–21, 32% of people had at least one Medicare-subsidised referred medical specialist consultation in a non-hospital setting. The most widely accessed specialties (in terms of the percentage of the population receiving a consultation) were:

• ophthalmology (5.1%)
• cardiology (4.6%)
• general surgery (3.8%)
• dermatology (3.7%) (Figure 1).

Across all referred medical specialties, there was an average of 3.4 specialist attendances per patient in 2020–21 (patients may have seen different types of specialists). The specialties for which patients received the most repeat services on average within the year included:

• psychiatry (4.7 services per patient)
• addiction medicine (4 services per patient)
• medical oncology (3.8 services per patient).

In 2020–21, the specialties with the highest number of non-hospital consultations subsidised by Medicare within the year were:

• obstetrics and gynaecology (2.6 million)
• ophthalmology (2.2 million)
• psychiatry (2.2 million)
• cardiology (2.2 million)
• general surgery (1.7 million)
• dermatology (1.6 million)
• orthopaedic surgery (1.4 million)
• paediatric medicine (1.3 million) (Figure 1).

These 8 specialties accounted for over half of all non-hospital specialist consultations subsidised by Medicare (54%). In total there are over 40 specialist specialties.
 

Trends

The number of patients who had a Medicare-subsidised referred medical specialist consultation in a non-hospital setting increased from 7.5 million in 2015–16 to 8.3 million in 2020–21. However, the proportion of people who had a consultation with a specialist only increased slightly (31% and 32% of people respectively). 

After adjusting for differences in the age structure of the population, the number of specialist consultations per 100 people increased slightly in the 5 years to 2020–21, from 96 to 101 consultations.

Patient characteristics

Older people received more Medicare-subsidised referred medical specialist consultations in non-hospital settings than younger people. In 2020–21, just under 2 in 3 Australians (63%) aged 65 and over had at least one Medicare-subsidised referred medical specialist consultation, whereas just over 1 in 4 (27%) aged under 65 had at least one consultation.

Among all patients regardless of age, a higher proportion of females (36%) had at least one specialist consultation in a non-hospital setting than males (29%). This difference is partly associated with pregnancy-related consultations. Without the pregnancy-related consultations, the proportion of females receiving a specialist consultation was only 2.9 percentage points higher than for males.

The proportion of Australians who received at least one referred medical specialist consultation in a non-hospital setting varied depending on where they lived. The proportion of people who had at least one referred medical specialist consultation was similar for residents of Inner regional and Major cities areas (34% and 33%, respectively), but decreased with increasing remoteness to 14% of people living in Very remote areas. The lower use of Medicare-subsidised referred medical specialist attendances in Remote and Very remote areas may be partly attributed to these populations relying more on General Practitioners (GPs) to provide health care services, due to less availability of local specialist services (AIHW 2019b).

Spending

In 2020–21, $4 billion was spent on Medicare-subsidised referred medical specialist consultations in non-hospital settings. By funding source:

• $2.5 billion in Medicare benefits was paid by the Australian Government
• $1.5 billion in out-of-pocket costs was paid by patients.

Nearly two-thirds (63%) or $1.6 billion of Australian Government spending on non-hospital referred medical specialist consultations was accounted for by 10 specialties:

• psychiatry ($370.1 million)
• cardiology ($207.3 million)
• obstetrics and gynaecology ($175.7 million)
• paediatric medicine ($160.9 million)
• ophthalmology ($131.6 million)
• gastroenterology and hepatology ($108.5 million)
• general medicine ($106.2 million)
• dermatology ($99.3 million)
• general surgery ($95.7 million)
• endocrinology ($95.1 million).

In 2020–21, 47% (13.1 million services) of non-hospital Medicare-subsidised referred medical specialist consultations were bulk-billed (indicating that patients did not incur costs for these services). For those who did pay out-of-pocket costs (71% of patients or 6 million people), the average cost per patient for non-hospital specialist attendances was $257 for all services received in the year (an average of $104 per service for those who incurred out-of-pocket costs).

Trends in spending

Overall, spending on Medicare-subsidised referred medical specialist consultations in non-hospital settings increased:

• Medicare benefits paid by the Australian Government increased in real terms (after adjusting for inflation), from $2.1 billion in 2015–16 to $2.5 billion in 2020–21. When accounting for changes in the number of patients (including through population growth), spending also increased on a per patient basis ($286 per patient in 2015–16 to $298 in 2020–21). 
• Patient out-of-pocket costs increased, in real terms, from $1.2 billion in 2015–16 to $1.5 billion in 2020–21 (Figure 2). On a per patient basis, there was an increase in real terms from $233 per patient to $257 during this period.

In the 5 years to 2020–21, the average referred medical specialist fee per service increased 0.3% per year (on average) in real terms, from $140.4 in 2015–16 to $142.4 in 2020–21. The proportion of provider fees covered by Medicare for non-hospital specialist attendances decreased by 1.2 percentage points, from 63% in 2015–16 to 61.8% in 2020–21.
 

Patient experiences

The Patient Experiences in Australia survey for 2020–21 (ABS 2021b) estimated that for people aged 15 and over who saw a medical specialist (in both hospital and non-hospital settings) in the previous 12 months:

• 19.1% of people who reported that they needed to see a referred medical specialist at some time in the last 12 months delayed their appointment at least once or did not see a specialist. Of this 19.1%, 5.9% of patients cited cost as a reason for delaying or not seeing the medical specialist.
• 21.7% waited longer than they felt acceptable to get an appointment with a medical specialist.
• A high proportion of people reported that the medical specialists they saw ‘always’ listened carefully, spent enough time with them and showed respect (80.9%, 81.8% and 85.2% respectively). Smaller proportions reported that the specialists they saw ‘often’ displayed these behaviours (12.4%, 10.8%, and 9.7% respectively).

Impact of COVID-19 on the use of specialist attendances

Whilst a number of limited scope video conferencing items relating to referred medical specialist attendances have existed in the MBS since 2011, the COVID-19 pandemic saw the introduction of telephone consultation items and a much larger range of video conferencing items on or after 13 March 2020. These items, known as telehealth items, were created to help reduce the risk of community transmission of COVID-19 and provide protection for patients and health care providers.

The introduction of these items has a clear impact on the way referred medical specialist attendances are delivered to patients, including:

• The number of face-to-face referred medical specialist attendances fell from 6 million in the March quarter 2020 to 4.3 million in the June quarter 2020.
• The volume of face-to-face attendances recovered to 5.4 million in the September quarter 2020, and continued to increase in the subsequent quarters until it reached 6.1 million in the June quarter 2021. Correspondingly, the volume of telehealth attendances decreased from 2.1 million in the June quarter 2020 to 1.1 million in the March quarter 2021, and into the next quarter.
• Due to widespread lockdowns in New South Wales, Victoria and the Australian Capital Territory in the September quarter 2021, the volume of face-to-face attendances fell back to 5.4 million whilst the volume of telehealth attendances increased to 1.8 million (Figure 3).
   

The billing profile of these telehealth items is also quite different from that of the face-to-face items. Discounting the March quarter 2020 (where these items had only existed for less than 3 weeks in the quarter), the bulk billing rate of telephone attendances was in the range of 80–90% up to the December quarter 2021. The bulk billing rate of video conferences was in the range of 59%–76% over these quarters, which was also much higher than the bulk billing rate of face-to-face attendances which was about 40% each quarter (Figure 3).

A lower number of services per patient was observed for both telephone and video conferencing from the June quarter 2020 to the December quarter 2021. These delivery methods had approximately 1.3 to 1.4 services rendered to each patient over the quarters, whereas face-to-face consultations had 1.6 services rendered per patient for each quarter (Figure 3).

Please refer to Impact on MBS service utilisation for additional details on how COVID-19 has changed the way Medicare-subsidised referred medical specialist attendances are delivered to patients.

Where do I go for more information?

For more information on specialist attendances, see:

• Medicare-subsidised GP, allied health and specialist health care across local areas: 2019–20 to 2020–21

References

ABS (Australian Bureau of Statistics) (2011) Australian demographic statistics, Jun 2011, ABS, Australian Government, accessed 2 February 2022.

ABS (2021a) National, state and territory population, Jun 2020, ABS, Australian Government, accessed 2 February 2022.

ABS (2021b) Patient Experiences in Australia: summary of findings, 2020–21, ABS, Australian Government, accessed 17 December 2021.