"It's not a one operation fits all": A qualitative study exploring fee setting and participation in price transparency initiatives amongst medical specialists in the Australian private healthcare sector

Abstract

The Australian government, through Medicare, defines the type of medical specialist services it covers and subsidizes, but it does not regulate prices. Specialists in private practice can charge more than the fee listed by Medicare depending on what they feel 'the market will bear'. This can sometimes result in high and unexpected out-of-pocket (OOP) payments for patients. To reduce pricing uncertainty and 'bill shock' faced by consumers, the government introduced a price transparency website in December 2019. It is not clear how effective such a website will be and whether specialists and patients will use it. The aim of this qualitative study was to explore factors influencing how specialists set their fees, and their views on and participation in price transparency initiatives. We conducted 27 semi-structured interviews with surgical specialists. We analysed the data using thematic analysis and responses were mapped to the Theoretical Domains Framework and the Capability, Opportunity, Motivation and Behavior model. We identified several patient, specialist and system-level factors influencing fee setting. Patient-level factors included patient characteristics, circumstance, complexity, and assumptions regarding perceived value of care. Specialist-level factors included perceived experience and skills, ethical considerations, and gendered-behavior. System-level factors included the Australian Medical Association recommended price list, practice costs, and supply and demand factors including perceived competition and practice location. Specialists were opposed to price transparency websites and lacked motivation to participate because of the complexity of fee setting, concerns over unintended consequences, and feelings of frustration they were being singled out. If price transparency websites are to be pursued, specialists' lack of motivation to participate needs to be addressed.

Keywords: Australia; Behavior change; Out-of-pocket costs; Price transparency; Private health insurance; Specialist fees.