Australians with private health cover are being hit with soaring out-of-pocket costs, as new figures show a sharp rise in specialist doctors’ charges.
Data released by the Australian Prudential Regulation Authority (APRA) reveals hospital out-of-pocket fees have jumped 9 per cent in the past year, with patients needing orthopaedic surgery among those paying the most. Hip and knee replacements now carry an average specialist gap fee of $1531 when doctors choose to charge one, up 8.7 per cent from the year before.
Across the system, health insurers continue to pay close to 90 per cent of overall hospital bills. But the share left to patients has grown, with average hospital out-of-pocket costs increasing from $437 to $478 in just 12 months. Gap fees charged by specialists climbed 6.6 per cent to $271 on average, far outpacing the 3.2 per cent increase seen in allied health services such as dentistry, physiotherapy and podiatry.
Dr Rachel David, CEO of Private Healthcare Australia, said the charges were locking people out of care and adding strain to private hospitals. “Up to 20% of Australians are not seeing a specialist when they need to because of cost and this data tells us specialists are charging some people increasingly high fees for hospital treatment,” she said.
She pointed to growing inflation in medical fees as a risk that health funds and Medicare could not continue to absorb. “Health insurers are doing everything they can to strike ‘no gap’ fee agreements with doctors and hospitals so their members don’t pay extra fees when accessing private hospital treatment, but around one in 10 people are still getting hit with fees which are increasing all the time. Medicare and health funds cannot keep chasing rapid price inflation in medical fees,” Dr David said.
Despite the cost pressures, more Australians are signing up for health cover. The latest APRA report shows 12.5 million people, or 45 per cent of the population, now hold hospital cover, while 14.6 million (53 per cent) have extras cover for services such as dental and optical. Health insurers paid a record $19 billion to hospitals in 2024–25, an increase of 5.8 per cent, alongside $6.7 billion for general treatment services, up 6.9 per cent.
For patients, the figures highlight an uneasy trend: membership growth is delivering record payments to hospitals, yet the burden on individuals keeps climbing when they need to see a specialist.
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