Overview of the Australian healthcare funding system

Healthcare services in Australia are funded through a mix of public (government) funding, private health insurance, non-government organisations and out-of-pocket costs paid by individuals. Most health care services in the cancer pathway, including primary care, screening, specialist services, rehabilitation, allied health and palliative care, are accessible in the public or private sector. Australian doctors can practice exclusively in the public or private sector or across both, and determine the fees for services they provide. In the private sector, doctors can bill the health insurers directly for their fees in full (no-gap arrangement) or charge a fee that is consistent and transparent to all clients (known-gap) for that service.

Medicare

Medical services

One pillar of Australia’s universal healthcare system is Medicare, a national scheme providing free or subsidised medical services. Through the Medicare Benefits Schedule (MBS), rebates are paid towards the cost of approved medical services, such as GP or specialist appointments. Public sector healthcare services that ‘bulk bill’ charge a fee equal to the MBS rebate, resulting in no out-of-pocket costs for patients. In other instances, Medicare pays 75% of the MBS rebate for private sector or 85% for public sector services, resulting in a ‘gap payment’, which is an out-of-pocket cost the patient pays for the difference between the fee and rebate. Once a patient's contributions (gap payments or out-of-pocket costs) reach the MBS Safety Net threshold, Medicare pays a higher rebate to reduce their out-of-pocket costs for the remainder of the calendar year.

Medicines

The Pharmaceutical Benefits Scheme (PBS) provides government-subsidised medicines to Medicare-eligible patients. Patients pay a co-payment, at a concessional rate or general rate, towards the subsidised cost. Like the MBS, the PBS Safety Net reduces the amount paid by patients (gap or co-payment) once a threshold is reached for a calendar year. 

Public hospitals

The National Health Reform Agreement between the Australian Government and state and territory governments sets how much funding they receive from the Commonwealth to deliver public hospital services. This enables Medicare-eligible individuals to receive public hospital services free of charge.

Private health insurance

Individuals can choose a private health insurance policy to cover costs towards eligible healthcare services accessed in the private sector. These policies also offer coverage for services not covered by Medicare, such as physiotherapy, dental and optical services.