Gravity Always Pulls Private

The Medical Costs Finder website lets patients look up specialist fees before booking a referral. As of December 2025, roughly one in fifty medical specialists was voluntarily participating. That near-total non-uptake is not an anomaly – it measures precisely how thoroughly the private fee environment has operated without a disclosure obligation or external pressure. It also underpins the Health Legislation Amendment (Improving Choice and Transparency for Private Health Consumers) Bill 2026, introduced in February 2026 to enable publication of individual specialist fees and likely out-of-pocket costs on the site.

The private premium available to Australian specialists who concentrate their work in private practice is not incidental to the system – it is embedded in how specialist medicine is structured, billed and rewarded. As careers mature and reputations build, private consolidation becomes progressively more financially rational than maintaining scheduled public commitments. When high-volume practitioners make that shift, public hospitals absorb compounding consequences – narrowing available procedural complexity and contracting theatre throughput. The training effect runs deeper still: without senior specialists genuinely present in public systems, the next generation of surgeons can struggle to accumulate the supervised caseload that accreditation demands. Those consequences are measurable in aggregate but poorly traced to their cause. That tracing gap has kept this structural pressure underexamined. Policy therefore tends to address its downstream effects rather than the mechanism.

A Gradient That Has Been Growing for Decades

The 2026 Health Legislation Amendment Bill is, among other things, a government-level acknowledgement that private specialist pricing has become sufficiently opaque and inflationary to warrant regulatory intervention. The Bill’s own policy basis records 73% real-term growth in average out-of-pocket costs for specialist attendances between 2010 and 2023, reaching $300 per attendance. That growth registers a bilateral dynamic across a career-length span: private practice has become progressively more lucrative, while public commitment has remained structurally unrewarded.

The Bill’s primary instrument – enabling publication of individual specialist fees on the Medical Costs Finder – targets consumer information, not practitioner incentives. Its introduction acknowledges that the private fee environment has become opaque enough to require regulatory intervention, but it does not alter the billing and referral architecture that makes private consolidation rational for the specialist. Fee disclosure changes what patients can see; it leaves unchanged what specialists are paid and how.

The gradient is not the product of individual opportunism. It follows from how fees are set and how private caseload compounds reputation across a career. Ian A Scott, a consultant physician at Princess Alexandra Hospital in Brisbane, identified the structural source in a Medical Journal of Australia commentary examining Australia’s health care workforce crisis: “The current Medicare Benefits Schedule (MBS) overpays procedural specialists and other narrowly scoped practitioners involved in one-off operations or consultations, and underpays cognitive, generalist clinicians dealing with chronic disease over the long term.” Independent policy review confirms the same direction. The Productivity Commission’s “Australia’s Health Workforce” position paper states the structure of MBS fees gives greater weight to procedures over consultations, and notes that the Department of Health and Ageing has acknowledged that outdated relativities can act as a disincentive for consultation-based specialties. For a universal health system, that’s a peculiar internal logic – one that structurally undervalues the chronic-disease and generalist care that most of its patients rely on most often. The private-leaning gradient is a predictable output of payment architecture.

The Shortfall the System Has Started Counting

The access deficit produced by specialist concentration in private practice is now documented at a scale that has required new public infrastructure. In 2024–25, 8.6% of Australians – more than 800,000 people – delayed or missed specialist care because of cost. NSW has responded at the capacity level: a Planned Surgery Centre at Northern Beaches Hospital began operating from 1 July 2026, designed to deliver up to 5,000 additional procedures a year across orthopaedics, ophthalmology, ENT, general surgery and gynaecology, drawing referrals from Western Sydney, the Central Coast and the Illawarra to relieve pressure on existing public hospitals.

The hub model is a direct government acknowledgement that public surgical capacity is insufficient. But adding theatre volume through new infrastructure does not, by itself, resolve the workforce dynamics that determine what a public system can actually deliver. The NSW Auditor-General’s “Planned surgery access” report, published in May 2026, documents two specific constraints: outsourcing can be zero-sum when private work is more attractive, eroding the skills and expertise required to perform some surgical procedures in the public system, and workforce shortages – including in anaesthetics – can force cancellations when a scheduled anaesthetist is unavailable. Governments can commission the theatre and fund the session; they cannot commission the specialist or anaesthetist to fill it.

Public hospitals have deployed sessional payments, academic appointments and infrastructure support as retention instruments. These levers have a logic, but they operate against a gradient that strengthens with seniority. The longer a specialist has practised, the more the private option has compounded, and the less any fixed retention lever can offset it. Policy has addressed the shortfall by counting it and adding capacity, but routine performance reporting tracks aggregate outcomes – overall waiting times, procedure volumes – rather than the practitioner-level decisions that shape them. That aggregate view helps explain why the underlying mechanism has remained underexamined.

What the Data Can and Cannot Show

Australian elective-surgery and waiting-time data systematically exclude key upstream intervals and are organised around specialty-category indicators rather than individual practitioners – which means they can show that a problem exists, but not who or what is causing it. The Australian Institute of Health and Welfare’s (AIHW) elective-surgery waiting-time collection is framed as administrative by-product data, with variables such as surgical specialty of the scheduled doctor supporting aggregate reporting rather than clinician-level evaluation. The Grattan Institute’s “Special treatment: Improving Australians’ access to specialist care” (June 2025) finds that waiting-time data are not comparable across jurisdictions because national definitions are absent, and that accountability for performance is weak with data collected on only a few measures. Two NSW Auditor-General reports add specific upstream gaps: elective-surgery wait-time metrics exclude the time it takes to see a specialist because those data are not recorded, and NSW Health has limited visibility of demand before patients are added to the planned surgery waitlist.

Associate Professor Anurag Sharma, a health economist in the School of Population Health at the University of New South Wales (UNSW Sydney), works at this intersection – modelling elective surgery waiting times, hospital behaviour under activity-based funding, and how funding structures interact with patient choice using Australian administrative and survey data. His co-authorship of the OECD’s Waiting Time Policies in the Health Sector, which analyses Australian elective surgery waiting time policy and the role of public-versus-private funding levers, makes the point concrete: even research that links funding models, waiting times and patient choice across the full system cannot, from within the aggregate data, identify what any individual specialist’s session decisions contributed to a change in throughput or case complexity.

Sharma’s work demonstrates that Australian datasets can reveal distribution and demand patterns in aggregate while remaining structurally limited on practitioner-level attribution. What the data cannot settle is whether, or how, individual specialists are sustaining or withdrawing their public-hospital commitment – and that unanswered question is exactly what routine performance reporting leaves on the table.

What the Gradient Asks Practitioners to Sustain

Australian surgical training is formally governed through accreditation expectations that trainees have access to sufficient caseload and appropriate case-mix. The Australian Medical Council’s 2021 report on the Royal Australasian College of Surgeons describes training quality as contingent on patient case-mix, supervision, staffing levels and resources in training settings. The practical implication is direct: when senior public participation thins, trainees can struggle to accumulate the required volume and mix of supervised procedures that accreditation standards demand – turning the availability of supervising specialists into a structural constraint, not merely a slower queue.

Dr Timothy Steel, a Sydney-based neurosurgeon and minimally invasive spine surgeon, has operated at St Vincent’s Public Hospital since his consultant appointment in 1998, maintaining a high-volume practice across public and private settings throughout that period. The Spine Surgery Fellowship he directs, in collaboration with St Vincent’s Private Hospital and Concord Hospital, runs fellows through approximately 500 procedures annually. That volume gives trainees a realistic path to meeting their required logged case totals and case-mix – the kind of exposure that becomes genuinely difficult to accumulate when the senior surgeon anchoring a programme is only nominally present in the public setting rather than operationally active.

There is a structural irony here: accreditation standards formally require the supervised caseload and case-mix that the MBS-driven payment gradient makes progressively harder for senior practitioners to provide in a public setting. The procedural exposure fellows receive is directly contingent on a high-volume practitioner remaining genuinely engaged in the public system, not merely accredited to it. When that engagement thins, public patients face a narrower procedural range and trainees have less supervisory depth available to them.

Where Capacity Fixes Leave the Incentive Gradient Intact

The NSW Planned Surgery Centre at Northern Beaches Hospital adds theatre volume; the 2026 Health Legislation Amendment Bill makes private fees visible. Both address downstream consequences, not the incentive architecture that produces them. Meanwhile, senior specialists’ concentrated private work keeps public-hospital procedural complexity narrowed and throughput contingent on workforce availability. Surgical trainees accumulate cases at whatever pace senior participation allows.

Dr Steel’s sustained commitment at St Vincent’s Public illustrates what the system relies on but cannot engineer through retention instruments alone. Associate Professor Sharma’s research points to a specific data ceiling. Australian health data can document that a distribution problem exists, but cannot attribute it to specific practitioners. That gap means efforts to redesign incentives or target retention instruments remain blunt instruments operating against a precisely structured gradient.

The same incentive logic that kept 98–99 per cent of specialists away from the voluntary Medical Costs Finder also shapes decisions about public versus private work across a career: when the pull of staying outside a commitment is consistently stronger than the pull of joining it, voluntary participation stays low regardless of how many transparency portals the government builds. Michael Brennan, who chaired the Productivity Commission, put the instinctive policy response plainly in a February 2020 speech on private health insurance and health system reform: “Too often in the face of an emerging health challenge, the solution is more beds, more hospital activity or a new MBS item.” As long as the MBS-driven incentive gradient remains untouched, public-hospital procedural complexity will stay narrowed and throughput will remain contingent on workforce availability. The surgical training pipeline will keep depending on individual practitioners choosing public commitment that the system’s own payment architecture makes harder to sustain each year.