Navigating the healthcare system
Australia is a hub for healthcare innovation, with advancements across multiple domains transforming patient care, system efficiency, and health outcomes. Find summaries of the latest advancements here.
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Primary care
Primary care is the first point of contact for individuals seeking healthcare. It focuses on everyday health needs, prevention, and early intervention. It is community-based and designed to provide accessible, continuous, and comprehensive care. Primary care acts as the gateway to tertiary care, with GPs and other providers identifying the need for specialist input or advanced treatment.
Providers:
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General Practitioners (GPs)
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Community health centres
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Pharmacists
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Allied health professionals (e.g., physiotherapists, dietitians, and psychologists)
Services:
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Diagnosis and treatment of common illnesses and injuries
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Preventative care, including vaccinations and health screenings
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Chronic disease management (e.g., diabetes or asthma)
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Referrals to specialists or higher levels of care
Access and Funding:
Medicare subsidises most primary care services, and some GPs offer bulk billing (no out-of-pocket costs). Private health insurance may cover services not subsidised by Medicare, such as some allied health services.
Dental care
Dental and similar healthcare services (e.g., physiotherapy, podiatry, optical care) are not fully covered by Medicare, unlike essential medical services. Funding for these services comes from a mix of public programs, private health insurance, and out-of-pocket payments.
Public Dental Services:
Public dental care is available to:
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Concession card holders (e.g., Pensioner Concession Card, Health Care Card).
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Children eligible under specific government public programs.
Public programs:
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Child Dental Benefits Schedule (CDBS), which covers basic dental services (e.g., check-ups, x-rays, fillings) for children aged 0–17 years. Funded through Medicare, a capped amount per child is available over two calendar years. More information can be found on the Services Australia website.
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State and Territory Programs, where the state governments run public dental clinics with subsidised or free treatment for eligible individuals.
Access and Limitations for public services:
Long waiting times are common. Services focus on essential care, not cosmetic procedures.
Private Dental Services:
Patients can pay for private dental care not covered by public funding through out-of-pocket self-pay, or through private health insurance via extras cover (also known as ancillary cover) which may reimburse part or all of the cost for routine and advanced dental care. Limits apply to the amount reimbursed annually.
Allied Health
Allied health services, including mental health, hearing, optical, physiotherapy, podiatry, speech therapy, and occupational therapy, are funded through a combination of public programs, private health insurance, and out-of-pocket payments.
Public Funding (Medicare Subsidies):
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Chronic Disease Management (CDM) Plan: Provides up to 5 Medicare-subsidised allied health services per year with a GP referral.
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Mental Health Treatment Plans: Up to 10 Medicare-subsidised sessions per year with psychologists or other mental health professionals. Additional sessions may be available under exceptional circumstances.
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Hearing Services Program: Eligible individuals, such as pensioners and veterans, receive free or subsidised hearing aids and services.
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Optical: Medicare covers eye exams conducted by optometrists but not glasses or contact lenses.
Eligibility:
Access to Medicare-subsidised services requires GP referrals, and eligibility criteria may restrict some individuals.
Community and Public Services:
Public hospitals and community health centres offer free or low-cost allied health services, prioritising essential and high-need cases. Publicly funded services often have long wait times, especially in rural and regional areas.
Private Funding:
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Private Health Insurance (Extras Cover) may cover part or all of the cost for services like physiotherapy, podiatry, speech therapy, occupational therapy, mental health therapy, and optical needs. Annual limits and co-payments apply, and coverage varies depending on the policy.
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Patients often pay out-of-pocket payments to privately self-pay for the service or to cover a gap between the provider's fee and the amount covered by Medicare or private health insurance. Costs can be significant for services not fully covered, such as high-end hearing aids or extended therapy sessions.
Pathology
Pathology services support the diagnosis, monitoring, and prevention of diseases through laboratory testing. These services include blood tests, biopsies, and other diagnostic tests. Funding for pathology is a mix of public and private systems, with costs covered by Medicare, private health insurance, or out-of-pocket payments.
Providers:
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Public Pathology Services are delivered through public hospitals and government-run laboratories.
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Private Pathology Services are operated by private companies such as Sonic Healthcare, Australian Clinical Labs, and Healius Pathology.
Services:
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Routine Tests: Blood tests (e.g., full blood count, cholesterol levels), urine tests, and glucose tolerance tests.
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Specialised Tests: Biopsies, genetic testing, hormone level testing, and cancer markers.
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Screening Programs: Tests for cervical screening (Pap smear) and bowel cancer detection.
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Monitoring Chronic Conditions: Regular testing for diabetes, kidney function, and heart disease.
Public Funding:
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Most medically necessary pathology tests are covered under Medicare when requested by a GP or specialist. Bulk-billed tests are fully subsidised, meaning no out-of-pocket costs for patients. Tests must be listed on the Medicare Benefits Schedule (MBS) to qualify for coverage.
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Pathology services provided as part of public hospital treatment are free for Medicare-eligible patients.
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If not bulk billed, patients may pay a gap fee, which is the difference between the provider’s charge and the Medicare rebate. Private hospitals and clinics may use private pathology providers, and costs may vary.
Private funding:
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Private health insurance typically does not cover outpatient pathology tests unless they are part of a hospital stay. Some higher-tier insurance policies may offer additional benefits for specialised testing.
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Patients may bear the full cost for tests not listed on the MBS or for tests requested without a medical referral.
Pharmacy
Pharmacists play a vital role in Australia’s healthcare system, providing a range of services beyond dispensing medications. These services include medication management, vaccinations, health checks, limited prescribing and over-the-counter advice.
Providers
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Community Pharmacies are the primary point of care for medication dispensing, advice, and minor health services.
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Hospital Pharmacies provide medication support and advice to inpatients.
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Specialist Pharmacies focus on compounding medications or specialty areas like fertility or oncology.
Services:
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Supply of prescription and over-the-counter (OTC) medications and medication management advice.
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Pharmacist-administered vaccinations for influenza, COVID-19, and other vaccines (e.g., whooping cough) are available without a doctor’s prescription in most states and territories.
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Advice on managing conditions like diabetes, asthma, and hypertension.
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Health Checks and Screening Services including blood pressure checks, blood glucose testing, and cholesterol monitoring.
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Limited prescribing in some states and territories.
Funding:
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Pharmacists are reimbursed by the government for dispensing Pharmaceutical Benefits Scheme (PBS)-listed medications.
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The PBS subsidises the cost of most prescription medications, ensuring affordability.
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Out-of-pocket payments applies to non-PBS-listed medications, OTC medicines, and pharmacist-administered services like health checks or vaccinations not covered by public funding.
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Private health insurance extras cover may contribute to the cost of some services like vaccinations, health checks, or smoking cessation products.
Radiology and imaging
Radiology and imaging services play a critical role in diagnosing and monitoring medical conditions. These services include x-rays, CT scans, MRIs, ultrasounds, and other advanced imaging techniques. Funding for radiology is a combination of Medicare rebates, private health insurance contributions, and out-of-pocket payments, depending on the service and provider.
Providers:
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Public radiology services are offered in public hospitals and government-funded imaging centres. Prioritised for urgent or essential cases.
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Private radiology services are operated by private imaging clinics and providers, such as I-MED, Sonic Healthcare, and Lumus Imaging.
Services:
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Diagnostic Imaging including X-rays.
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CT (Computed Tomography) scans for detailed cross-sectional imaging.
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MRI (Magnetic Resonance Imaging) for soft tissue and neurological conditions.
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Ultrasounds for pregnancy, musculoskeletal conditions, and internal organs.
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Mammograms for breast cancer screening.
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Interventional Radiology including procedures such as biopsies, injections, or catheter placements performed under imaging guidance.
Funding:
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Many radiology services are partially or fully covered if referred by a GP or specialist and listed on the Medicare Benefits Schedule (MBS). Bulk-billed services are free for Medicare-eligible patients.
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Imaging services provided during inpatient or outpatient care at public hospitals are fully covered for Medicare-eligible patients.
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Private health insurance hospital cover may cover radiology services performed as part of inpatient treatment in private hospitals.
Community health centres
Community health centres are vital hubs for delivering comprehensive, multidisciplinary healthcare services at a local level. They focus on prevention, early intervention, treatment, and support for individuals and families, especially in underserved or vulnerable populations.
Providers
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Most community health centres are publicly funded and operated by state or territory governments.
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Some centres are managed by non-profit groups or charitable organisations, offering specialised or additional services.
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In some cases, private organisations are contracted to deliver community health services.
Services:
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GP consultations, immunisations, and chronic disease management.
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Physiotherapy, occupational therapy, podiatry, speech therapy, and dietetics.
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Counselling, therapy, and support for anxiety, depression, and other mental health conditions.
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Prenatal care, parenting support, child health checks, and immunisations.
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Basic and emergency dental care for eligible patients.
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Rehabilitation, home care, and respite services for older adults and individuals with disabilities.
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Services targeting vulnerable populations, such as the homeless, Indigenous communities, and refugees.
Funding:
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Funded primarily by state and territory governments, often supplemented by federal programs.
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Medicare rebates cover GP visits and some allied health services accessed through a Chronic Disease Management (CDM) Plan.
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Funding is also accessed through programs such as the National Disability Insurance Scheme (NDIS) and public dental schemes for concession card holders.
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Community health centres operated by non-profits may receive funding through donations, grants, or fundraising.
Urgent Care Clinics
Urgent Care Clinics provide walk-in medical care for non-life-threatening conditions and are designed to ease pressure on hospital emergency departments. These clinics are part of a government initiative to improve access to timely care.
Services:
Urgent Care Clinics treat conditions like minor fractures, infections, cuts requiring stitches, and mild asthma. They offer diagnostics such as X-rays and pathology, and some provide limited after-hours care.
Choice of Doctor:
Patients are generally seen by the next available clinician. You cannot usually choose your doctor, though all clinicians are qualified to manage urgent but non-emergency conditions.
Wait times:
Wait times are generally shorter than public hospital emergency departments, especially for non-life-threatening issues. Patients are triaged on arrival based on clinical urgency.
Costs:
Services at Medicare Urgent Care Clinics are free for everyone with a Medicare card. There are no out-of-pocket costs for eligible patients.
Funding model:
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Funded jointly by the federal and state or territory governments under the Medicare Urgent Care Clinics program.
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Services are bulk billed, meaning clinics claim payment directly from Medicare.
Access:
You do not need an appointment or referral to visit. Use the Healthdirect Australia website to find your nearest Medicare Urgent Care Clinic. Some state health websites also list locations and opening hours.
Tertiary care refers to specialised, advanced medical care provided by hospitals or specialist facilities. It typically requires a referral from a GP or primary care provider. Tertiary care is often episodic, addressing specific health issues that require high-level expertise and technology. After receiving tertiary care, patients often return to their primary care provider for ongoing management, monitoring, or rehabilitation.
Providers:
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Specialists (e.g., cardiologists, oncologists, neurosurgeons)
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Multidisciplinary teams in specialised hospitals
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Intensive care units (ICUs)
Services:
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Complex surgeries (e.g., heart surgery, organ transplants)
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Cancer treatment, including chemotherapy and radiotherapy
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Advanced diagnostic testing (e.g., MRI, genetic testing
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Rehabilitation for severe injuries or conditions
Access and Funding:
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Public hospitals provide free tertiary care for Medicare-eligible patients, but there may be waiting periods for non-urgent treatments.
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Private health insurance can cover access to private hospitals and specialists, often reducing wait times.
Tertiary care
Private Specialist Clinics
Private specialist medical clinics (private practices) offer advanced care from medical doctors who specialise in diagnosing, managing, and treating specific health conditions. They are found in the community or sometimes co-located on hospital grounds.
Providers:
Specialist medical doctors include paediatricians, cardiologists, psychiatrists, endocrinologists, dermatologists, neurologists, oncologists, orthopaedic surgeons, rheumatologists, and more.
Services:
Services may include initial assessments, follow-up consults, second opinions, diagnostic testing such as imaging or blood tests and minor medical or surgical procedures that can be performed in-clinic and do not require a hospital admission.
Access and funding:
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Medicare rebates apply to specialist consultations and services if referred by a GP. Rebates also apply to diagnostic or procedural services listed on the MBS. Specialists may charge above the MBS fee, resulting in a gap payment for the patient.
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Private health insurance does not cover specialist care delivered in private clinics. Specialist care is only covered by private health insurance when it is part of an inpatient hospital stay (e.g., pre-or post-surgery consultations or hospital-in-the-home).
Private hospitals
Private hospitals are funded through a combination of private health insurance, out-of-pocket payments, and government subsidies.
Services:
Private hospitals provide similar services to public hospitals but often offer additional comfort, shorter wait times, and access to elective procedures.
Choice of Doctor:
Patients can choose their preferred doctor or specialist.
Fees:
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Fees can include surgeon, anaesthetist, hospital stay, and theatre charges, with some covered by private insurance.
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If you see a specialist who is in a private clinic co-located on hospital grounds, you will pay their private fee which may be made up of a medicare rebate and/or an out-of-pocket copayment.
Costs:
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Patients are responsible for costs not covered by Medicare or private health insurance, including excess fees, gap payments, and out-of-pocket expenses.
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Private health insurance often helps cover a significant portion of these costs.
Funding model:
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Funded by private health insurance premiums and patient contributions.
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Patients often pay an excess fee (agreed upon in their insurance policy) and may incur out-of-pocket expenses for services not fully covered.
Access:
Check your private health insurer's website for affiliated private hospitals or visit the Australian Private Hospitals Association for information. Your GP can also provide recommendations and referrals based on your needs.
Public hospitals
Public hospitals are funded by the Australian government, primarily through Medicare, and provide free or low-cost healthcare to eligible patients.
Services:
Public hospitals offer emergency care, surgeries, and specialist services.
Choice of Doctor:
Patients admitted as public patients in these hospitals are treated at no cost but cannot choose their doctor.
Costs:
As a public patient, your care is covered by Medicare, and no private health insurance is needed.
Funding model:
Primarily funded by Medicare, with contributions from state and federal governments. Patients are billed directly to Medicare for eligible services. Minimal or no out-of-pocket costs for public patients with Medicare cards.
Waiting Times:
Elective surgeries and non-urgent treatments may have longer waiting periods.
Access:
Use the Healthdirect Australia website or state health department websites to locate public hospitals near you. Your GP can also provide recommendations and referrals based on your needs.
Public-Private Partnerships (PPPs) in Hospitals
Public-Private Partnerships (PPPs) in healthcare are collaborative agreements between government entities (public sector) and private organisations to design, build, finance, operate, or manage hospital services and infrastructure. They aim to combine the strengths of both sectors to deliver high-quality healthcare services efficiently and sustainably.
Long-Term Agreements:
PPPs are usually structured as long-term contracts, often spanning 20–30 years or more, ensuring continuity and shared risk management.
Design-Build-Finance-Operate (DBFO):
The private sector designs, constructs, and finances the hospital infrastructure, then operates and maintains the facility under public oversight.
Service Agreements:
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The public sector provides oversight and funding for healthcare services and ensures alignment with public health goals.
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The private entity offers expertise in construction, technology and operations, and often manages non-clinical functions, facility management or specific healthcare services.
Risk Sharing:
Risks such as construction delays, operational inefficiencies, or cost overruns are transferred to the private partner, reducing the burden on public resources.
