The Australian Society of Ophthalmologists has welcomed a Grattan Institute report into specialist care but warns it paints a one-sided picture of the challenges posed to ophthalmology in Australia.
The Grattan Institute, Australia’s independent policy think tank, has turned its spotlight on Australian specialist medical fees and in the process worked to grapple with some of the biggest problems facing ophthalmology.
But not everyone agrees that it tells a full and fair story.
In its June 2025 report Special Treatment: Improving Australians’ Access to Specialist Care, the institute outlines what it sees as systemic flaws in the current ophthalmology landscape, from limited training capacity to high patient fees and poor public access.
It drew the conclusion that patients who need to see an ophthalmologist often face “a painful dilemma” – pay privately out-of-pocket, sometimes double or triple the Medicare schedule fee, or join the queue for an appointment in the public sector.
While the report attempts to confront long-standing issues in the sector, the Australian Society of Ophthalmologists (ASO) says it misses some key points, potentially obscuring more fundamental problems within Australia’s healthcare system.
“The Grattan report is a good piece of work, but it draws many wrong conclusions,” says ASO president Dr Peter Sumich. “When I see smart people making flawed assessments, I start to wonder whether it was massaged to support an ulterior motive.”
A sector under pressure
Ophthalmology was one of four specialities the report identified as critically under-supplied, alongside obstetrics and gynaecology, psychiatry and dermatology. The number of ophthalmologists in Australia has increased by 19% over the past decade, well below the average growth seen across other medical specialities.
A persistent mismatch between training capacity and community need is central to the report’s diagnosis.
“The issues start in the training system,” Ms Elizabeth Baldwin, senior associate in Grattan’s Health Program, tells Insight. “Decisions on what type of specialists to train, and where, are made without an overall plan or assessment of the community’s health needs.
“Specialties such as ophthalmology have been growing slower than average, despite being identified as under-supplied by the Department of Health.”
The report also pointed to a bottleneck in specialist training. Though demand for ophthalmology training positions is high, places are limited – influenced by hospital workforce needs and specialist colleges, the Grattan report says.
However, Dr Sumich says this framing doesn’t strike at the root of the problem.
“Firstly, we have to clear up this urban myth about the colleges not training enough specialists. Specialists are trained in public hospitals, not inside a college,” he says. “If public hospitals are not doing enough surgery or outpatient clinics, then we can’t train more specialists. Simple maths.”
Dr Sumich argues that the Grattan report fails to grasp the underlying issue: the deteriorating performance of the public hospital system.
He points to figures showing the ratio of eye surgeons to Australians is roughly one to every 24,181 set of eyes. Yet, only an estimated one in 10 positions is in the public sector.
“If the public hospital system was operating in a reasonable manner, then people would not need private specialists in the numbers they do,” he says. “The government is outsourcing by proxy into a highly inflationary private environment and then complaining about the outcome.
“If medical services were cheap to provide, the government would not have trouble funding them.”
The ‘painful dilemma’
As an indication of Australia’s eroding public eye health service, the Grattan Institute confirmed the well-documented statistic that the vast majority of ophthalmology services occur in private clinics.
In fact, it found 80% of ophthalmology appointments happen privately. But access is patchy: some communities receive far fewer appointments than others, and public clinics aren’t filling the gap. In areas with the least private ophthalmology care, there are 25 fewer appointments per 1,000 people than average – and just six more via the public system.
The cost of private care, meanwhile, varies. While the median out-of-pocket cost for an initial ophthalmology consultation in 2023 was around $100 (placing it 17th out of 34 specialties), 6% of initial consultations were charged at more than triple the Medicare schedule fee. Around 7% of ophthalmologists were said to charge “extreme fees”, averaging $215 per consultation.
Still, the report acknowledges those charging extreme ophthalmology fees remain significantly lower than other specialties like psychiatry (over $650) and cardiology ($350).
The authors recommend introducing measures to reduce what they describe as excessive charging. One proposal is particularly contentious: to strip Medicare funding from specialists who charge excessively, and name them publicly.
This, Dr Sumich warns, would be both ineffective and potentially inflammatory. He points out that the Medicare rebate itself is fundamentally broken.
Granted, the Grattan report does call for a review of the Medicare schedule fees to ensure they reflect the cost of care. But Dr Sumich questions why it is being used as a benchmark in the first place when “the Medicare patient rebate is uncalibrated, and unrepresentative and unindexed”, meaning it then serves “as no useful metric for specialist services”.
“The Medicare rebate is out of date. It has no meaning in the commercial world,” he says. “It’s been frozen, cut, and has never kept up with inflation or average wages. Therefore, as a metric of a medical service, it is unreferenced and meaningless.”
This is on top of another proposal for the federal government to direct the Australian Competition and Consumer Commission to study how specialists set prices, including how closely their prices reflect the costs of providing care.
Dr Sumich stresses that specialist fees reflect real-world costs – wages, insurance, rent, medical technology, and more.
He also rejects “the implied threat” to remove patient rebates.
“The Medicare rebate belongs to the patient, not the doctor. If it is withdrawn by the government, then specialists would go the way of dentists and charge their own fees regardless,” he warns.
“Most patients would be furious if the rebate was withdrawn.”
A five-point reform plan
For ophthalmology specifically, the report recommends targeted investments in low-access regions through new public clinics ($500 million a year across the medical sector), expanded virtual care, and support for existing clinics to serve more patients. It also urges state governments to develop strategies to reduce hospitals’ reliance on registrars for service delivery.
The report authors want governments to set up a workforce planning body to ensure Australia is training enough ophthalmologists and other doctors, where they are needed.
“Governments should also increase the funding available for training. The federal government should double the funding available for flexible training approaches (an extra $9 million a year), led by colleges, that expand the number of training positions available,” Baldwin says.
“Training standards should be more consistent and transparent. Some work is under way to do this, and the effects of these changes should be reviewed in three years to ensure they have made training more consistent and responsive to community needs.”
Some things the report recommends are already under way, such as making it simpler for overseas-trained specialists to work in Australia – although this new fast-tracking initiative has received criticism from RANZCO and the ASO around safety and quality.
For Dr Sumich and the ASO, the core message is clear: any real reform must start with fixing public hospital capacity.
“The most egregious aspect of this coordinated media blitz is the smokescreen it provides for the woeful failure of public hospitals,” he says.
“Inadequate surgical volumes, reduced medical outputs, inefficiencies and bureaucratic wastage feature squarely.”
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