In what should be familiar to readers from what you’ve heard about Canada or the United States’ Medicare program, Australia has a form of universal health care based on a single-payer system. Australia created their program—called Medicare—in 1984 to provide free public hospital care, substantial coverage for physician services, and pharmaceuticals. Australian citizens, residents with permanent visas, and interestingly, even some New Zealanders are covered under the scheme. Their federal government finances the Medicare system, but it has a very limited role in the actual delivery of health care.

Each of the six states in Australia own and manage service delivery for public hospitals, ambulances, public dental care, and community health, which can include anything from primary or preventative care to mental health care. Local governments play a role in the delivery of community health and preventive health programs, such as immunizations, which is obviously important during COVID.

Like in the United States, a substantial portion of the gross domestic product goes towards health care, but it’s only about 10 percent in Australia; in America it’s about 17 percent. I know we’ve been talking a lot about workforce oversupply in the U.S., but in Australia, there are workforce shortages, so physicians like Justin Hensley, MD, who moved from Texas to Australia last summer, benefit from the transition.

I recently spoke with Dr. Hensley about his experiences working as an emergency physician in Australia and what other differences he sees in health care in Australia.

You were an owner in the freestanding ED in Texas. One big difference between the U.S. and Australia is how fast reimbursement goes from public to private payers. Is it nearly as instantly as it seems?

Dr. Hensley: Ninety days was a good day to get reimbursed by any of the private insurers in the United States. It’s a reason why a significant number of freestanding clinics closed because they can’t keep the lights on if they’re not getting paid. The claims being pushed back by insurers was horrendous. It is significantly better here, yes.

Supposedly there’s an interoperable national eHealth program that’s based on personally controlled unique patient identifiers. I’m wondering how that works in comparison to the U.S. where we have so many different proprietary electronic medical record systems (EMRs), none of which seem to want to talk to one another, even if one hospital is across the street from another one?

Dr. Hensley: Every Australian patient has their own Medicare number and they can all get access to the system. The clerks also have 100 percent access the Medicare information they need. I can see what the patient has had to a degree on a kind of an HTML-based system. The hospital does not feed data to that. That just has their Medicare claims results. So if they’ve had imaging tests, I can see that, but it doesn’t indicate the results. It just has tests they’ve had and other conditions.

Our system here in Bunbury, Western Australia, is different than the system in Perth, is different than the system in Sydney and I can’t see their notes, but all the systems in Sydney can see each other. A lot of the systems in Perth can see each other. In Bunbury, we were attached to a private hospital, which is a unique amalgamation of what happens when you have publicly insured people and privately insured people in the same town. If we sent patients over there, all of our cardiac patients went over there, we couldn’t see any of their notes. If they got discharged and came back to our emergency department the next day, we couldn’t see anything. So it’s great on the billing side, it makes everything real efficient, smooth, and fast. Does not mean I can see their actual health care record.

In the United States, we’re heavily focused on the Emergency Medical Treatment and Labor Act (EMTALA). In Australia, are people ever referred away to another facility without being seen? Does that scenario happen?

Dr. Hensley: We don’t have to do any examinations or other types of things that you would normally feel you would need to do in the U.S. to kind of cover yourself from a malpractice lawsuit standpoint. You can tell the patient, “I’m not the proper person for it. You need to go see your general physician (GP) tomorrow,” and you can just sign them out and they leave.

They can still have trouble getting in to see their GP and it may take a couple more days than usual, but every Medicare patient here has a GP. There aren’t people here that don’t have primary care physicians. It’s glorious. The issue at play sometimes is geography and other things, like in the U.S., if you need somebody that has a specialized problem—hand surgery, ophthalmologic surgery, or something kind of specific—a specialist will see them in the U.S. because there’s EMTALA. In Australia, they’ll say either the patient needs private insurance or they’ll need to pay our fee schedule.

Let’s talk about pharmaceuticals, how does that work in Australia?

Dr. Hensley: The pharmacy benefit scheme (PBS) is essentially the preferred drugs list for any private insurer. However, because there’s really only one preferred insurer in Australia, you don’t have to look up all the ones for private insurance company X, Y, or Z. You go to the PBS scheme website, type in the drug you’re thinking of, and it brings up the first option that is available on the PBS website. You can look up and see how much you can give them, how much it’s going to cost them, and if there are any other options.

You learn pretty quickly what certain drugs cost. Most of them are $5 to $10 Australian dollars. It’s not a horrendous amount, but if you’re trying to give them some kind of novel prescription, you’ll quickly learn that it’s pretty expensive.

It does narrow my pharmacologic options a little bit, but it also makes it cost significantly cheaper because it only takes a couple of those outliers that cost $500 or $1,000 a dose to really push drug costs up.

Have you had the experience of being a patient there?

Dr. Hensley: I haven’t, but one of my friends was when we were here in 2019. It’s pretty different. The initial part of going in, being seen, evaluated, getting a bedside ultrasound by the physician—as opposed to getting a formal department ultrasound, because it was two o’clock in the morning and that wasn’t going to happen even in the city of Sydney. Getting all that done and getting the blood work back was about two to three hours in the emergency department. At the end they’re like, “okay, so you’re not Medicare, so you need to pay for this.” It was $500 as opposed to $3,000 or whatever it would cost in the U.S. for a 2 a.m. emergency department visit with multiple blood works, IV pain medications, and an ultrasound.

What have you learned from being in Australia that you think could inform how we do things in the United States?

Dr. Hensley: The biggest thing, and one of the reasons why I wanted to come to a place that had a system such as this, is Australia doesn’t allow non-physicians to dictate the way care is provided. When non-physicians are dictating how care is provided, like in the U.S., it makes things cost more. It just adds bureaucracy to medicine. It makes what we do not really practicing medicine anymore. It makes us practicing bureaucracy of medicine.

Is there anything that you miss about the U.S. that you wish was available in Australia?

Dr. Hensley: From Texas, I miss breakfast tacos. They make other really fantastic food in Australia and you aren’t living until you’ve had saltwater crocodile. I do not miss the weather. So, I haven’t experienced a single cyclone in the areas I’ve lived in since I’ve been here, which has been glorious. There are words and colloquialisms that take time to understand. Every single time you pronounce the name of a city in Australia they’ll make fun of you for it because you’re pronouncing it incorrectly. Driving on the other side of the road is not as big of a deal as people like to make of it. It only takes hitting a couple curbs to figure out where the other side of the car is. I really enjoy it and the plan is to go through permanent residency and then become a citizen because it’s got enough benefits for my kids and family.

Dr. Dark (@RealCedricDark) is assistant professor of emergency medicine at Baylor College of Medicine and the medical editor in chief of ACEP Now.