Out of Pocket Costs for a Tonsillectomy

Michael15286 on 23/02/2024 - 22:26
Last edited 24/02/2024 - 14:54

Hey guys,

I'm going in for a tonsillectomy soon and I was very surprised at the out of pocket costs.

Basically the surgery cost is $1150, with $650 paid by medicare and my medibank PHI, and $500 out of pocket for me. Further, the anaesthesiologist is charging me $300 out of pocket too. So it's $800 out of pocket so far. While that is quite a lot of money for me right now, there's no denying it'll be worth it if the surgery is successful.

Looking at this government health page for my procedure, it seems this is a pretty normal rate, but it also shows that 25% of people in my state managed to get it done with no out of pocket costs. I'm wondering if I did something wrong or if these people did something different. I suspect it's generally people who have a higher tier PHI or people going solely through the public health system (which I don't know how to access either).

I have a Health Care Concession card but it seems none of these fees have been reduced by that.

Unfortunately I've paid the deposit to my ENT today but was there a better way for me to do this?

EDIT: Thank you all for your comments and replies. I'm feeling a lot better about this procedure and am excited to get it done! So I'll be going forward with my private option to get it done ASAP

There is a lot of information here that I wish I knew before hand, but at least now I know. And hopefully this post can help someone else out in the future!

Health & Beauty

Comments

  • AustriaBargain on 23/02/2024 - 22:30
    +1

    Is it an elective surgery? Why did you do it though private hospital?

    • Benoffie on 23/02/2024 - 22:50

      I would assume so as public requires multiple cases of tonsillitis in a year before even being considered for removal.

    • Michael15286 on 23/02/2024 - 22:55
      +1

      It's a bit complicated, but I'll try summarise.

      I am having this surgery for Obstructive Sleep Apnoea (I cannot sleep without a CPAP).
      I talked to my GP back in 2021 wanting to go on the public list but he refused multiple times (not sure if that was legal), but I did eventually get a referral to a private ENT.
      My initial consult with the ENT suggested a tonsillectomy and surgery on the soft pallet.
      I delayed the surgery because the ENT wouldn't do it without private health.
      I waited 12 months with Medibank PHI.
      Old ENT retired in meantime, so I got another referral from a new GP (as I had moved houses)
      Didn't think of going public as I was under the impression I'd be doing soft pallet cutting too (which I was told was almost impossible to be done on public).
      New first consult with new ENT, he said 60% chance a tonsillectomy will be sufficient for me.

      • 7ekn00 on 24/02/2024 - 09:48

        OSA relates to visceral adipose in the tongue, not the tonsils nor soft pallet …

        When I went from 170kg > 105kg, my OSA completely vanished …

        • parsimonious one on 24/02/2024 - 10:25

          OSA can be caused by obstruction at any point in the upper airway

  • johnno07 on 23/02/2024 - 22:45

    Did your GP that referred you ask if you'd like to go public?

    • Michael15286 on 23/02/2024 - 22:55
      +1

      No he did not. The first GP I saw actively advised me he wouldn't do it.

      • johnno07 on 23/02/2024 - 23:17

        Did he say why? The only reason to avoid public is the wait time - which is determined by how urgent your situation is.

        • Michael15286 on 24/02/2024 - 04:14

          It was almost 2 years ago, but I think he said the public system wouldn't do it.

    • IgG on 24/02/2024 - 12:02
      +1

      This varies hugely by State (due to local demand vs surgeon availability). I suspect the GP is referring to the statewide referral guidelines (eg for Victoria - https://src.health.vic.gov.au/obstructive-sleep-apnoea) which appear to not include OSA caused by tonsilar enlargement. Some local public health networks in Victoria will additionally include "Significant tonsillar hypertrophy" ie enlarged tonsils causing OSA in their public clinic referral criteria but most do not, so perhaps that is why your GP did not refer publicly.

      I suspect some of the No-gap operations include children, which is easier to meet criteria than adults for surgery in public hospitals, and far more likely to have a no-gap operation in private.

      On the flip side, a lot of "elective" surgery has resumed now, so may as well try and get a public referral again as COVID changed a huge amount of things, especially for ENT surgeons due to airway procedures and risk appetite during COVID

      *I am not a GP/ENT/Sleep physician so take all this with a grain of salt on the logistical side of things.

      • Michael15286 on 24/02/2024 - 13:47

        Thanks for explaining what might be going on in my GP's head and behind the workings of medicare. Children getting no gap makes a lot of sense too.

        For now, I'll be going ahead with my private just because I've already waited a while and want to get this ovwr with. But this info is still very helpful!

  • Iwantthebestprice on 23/02/2024 - 22:51

    Get a GP referral and go to your local public hospital and join the waiting list is an option, but FYI if it’s not due to an emergency reason I.e infection etc you will be waiting a good year or two minimum for the surgery to come up. And it will be done in a public hospital. If I was you I would pay the $800 out of pocket and have it done in a private hospital and much faster.

    • Michael15286 on 23/02/2024 - 23:01

      I'm at that point where I'm basically resigned and just going to have it done. I feel bad because I've paid for private health ($130 per month) for 14+ months now and seen 2 different ENT's (with their $300+ new patient consult fees). But I recognise it's a bit of sunk cost fallacy. That said, I would like to know more so if there is a next time I can better navigate these issues.

      • parsimonious one on 24/02/2024 - 10:29

        Your PHI will cover the hospital cost and part of the cost of the surgery and anaesthetic

        The hospital fee alone would be in the region of $2k and far more if you required ICU or had a prolonged stay

        • Michael15286 on 24/02/2024 - 13:51

          The high hospital fee explains why my first ENT laughed and said I wouldnt be able to afford the procedure without private health.

          It would have gone against his self interest, but it would have been good if he suggested going public if I was going to wait 1 year anyway.

  • jv on 23/02/2024 - 22:53
    +7

    So it's $800 out of pocket

    WOW !!! That is cheap.

    That's not too bad to pay for a qualified surgeon, anaesthesiologist, nurses, an operating room and recovery bed !!!

    My electrician charges more than that just to replace a fuse box !!!

    • Michael15286 on 23/02/2024 - 23:08
      +2

      I can definitely appreciate the cost of the skilled professionals needed to do such a task. That said, this surgery is almost inaccessible to me due to the price. The compromise in my case has been to put off repairing my car for the last month so I can afford it.

      • jv on 23/02/2024 - 23:13
        +4

        Just be thankful you don't live in the USA.

        • AlienC on 24/02/2024 - 03:38
          +1

          yep pretty much this.. if you have any issue in life just remember you are in australia and not somewhere where getting bombed is more of an issue

          we whinge a lot for living in one of the best country in the world

          • Michael15286 on 24/02/2024 - 04:17

            @AlienC: That is very true, I'm grateful for every day that I live in this beautiful country. Still, being good doesn't mean we can't strive to do better!

            • AlienC on 24/02/2024 - 04:34
              +1

              @Michael15286: Definitely of course. It is what makes the human race great.. we keep striving for better.

      • parsimonious one on 24/02/2024 - 07:48
        +2

        Those out of pocket costs a very very reasonable

        I doubt you’d find a better deal than that being treated privately

  • freefall101 on 23/02/2024 - 23:45
    +2

    Referrals are generic, they might list someone specific but you can go to any provider with one (public or private).

    Being elective though, if it improves your quality of life in anyway I'd cough up the $800 because you'll be waiting quite a while. As someone else with sleep apnea I'm fine with my cpap machine but that thing definitely cost me more than $800 so it seems a pretty cheap surgery.

    • Michael15286 on 24/02/2024 - 04:27
      +1

      I still don't really know how to find or see a public ENT specialist. That said I will be going forward with my private ENT now. Time is valuable in it's own way and I'll earn another $800 sooner or later.

      Unfortunately, I also spent more than $800 on my CPAP machine. I think it was closer to $1500 including the home sleep study.

      But even with the machine, my sleep gets interrupted all the time. I roll around in my sleep a decent amount which makes the hose and fittings move and leak. And recently there have been some blackouts at night, which is a great way to wake up choking.

      Finally, I miss camping and going outdoors, traveling and even crashing at my parents or friend's houses. I can't get more than an hour or two of sleep without my machine and electricity. So I'm looking forward to doing that stuff again!

      • freefall101 on 24/02/2024 - 11:57
        +1

        Yeah, I flew to Vancouver last year and didn’t use it on the flight, that really sucked. I would totally go the surgery as well if the machine is t working.

        For future reference, usually finding an outpatient service at a hospital is the way to go. It will usually mean the initial consult can be bulk billed too. I did that for my sleep study too, did it in the royal Melbourne hospital with no out of pocket, however I had a bit of a wait time for the initial consult.

        • Michael15286 on 24/02/2024 - 14:00

          Your flight story reminded me of another huge thing I miss; being able to take a nap!
          I mean, I can still nap but I usually feel more tired after the nap than before haha

          Thank you for the suggestion to go outpatient service route. That's exactly the information I was looking for when starting this thread. Hopefully, this info can help someone else. And maybe if I am unlucky enough to have another issue down the line.

          I was not too happy with my first GP as he also denied me a public referral for a sleep study, but was quick to offer up a home sleep study provided by the chemist attached to his office.

  • pasey25 on 24/02/2024 - 04:40
    +1

    I can’t help with regards to the cost but I wanted to let you know that in 2015 I had 2 surgeries to assist with sleep apnoea, one (and most important of which) was a tonsillectomy

    It was life changing for me. My sleep improved so much and that improved my quality of life markedly. I should never have waited so long to get the ENT referral.

    • Michael15286 on 24/02/2024 - 04:52

      Thank you for your comment, it gets me excited to think of my quality of life improving like that.

      If you don't mind me asking, what was the second surgery you had and how much did it help you?

      • pasey25 on 24/02/2024 - 15:06
        +1

        The second surgery was a septoplasty (deviated septum) and turbinate reductions. Both designed to improve the airflow through my nasal cavity. They certainly did improve it, although the benefit has reduced a bit now. My real issue was huge tonsils though. Immediately prior to the tonsillectomy I was unable to sleep in any other position than face down.

        • Michael15286 on 24/02/2024 - 17:30

          Thanks for the reply! Now I'm curious how big your tonsils were.

          Mine are pretty big and can be easily seen when my mouth is normally open. My sister jokingly calls them my second set of balls haha

          Is your post surgery benefit reducing due to things slowly growing back?

          • pasey25 on 25/02/2024 - 08:24

            @Michael15286: They were huge. So big the surgeon kept them and gave them to me post surgery 😂. There was a size grading scale he used, 1-5 and these were a 5.

            They haven’t grown back but sometimes I feel that maybe my septum has deviated a bit again and the turbinates have returned a bit. I haven’t had this verified though.

  • barge-in hunter on 24/02/2024 - 07:52
    +1

    So a tldr of your answers above;

    1) it’s not emergency surgery as you have a working treatment (although you don’t like it)
    2) your first gp said it wasn’t covered in public (which is possibly due to 1)
    3) the first specialist you saw said there was only a 60% success rate for this surgery (which might add to 2 as well)
    4) you continued with the surgery despite all the above
    5) you took out private health insurance without checking to see the amount of coverage this specific elective surgery has
    6) now you’re surprised that an elective surgery with a low/moderate success rate that you specifically requested carries out of pocket costs

    I think this might be an opportunity to reflect and learn

    Edit - just to clarify, not questioning the personal value of having the surgery - improving your quality of life is always a good thing - more so reflecting on the process you took

    • Michael15286 on 24/02/2024 - 14:25
      +2

      Nice summary, and I appreciate you trying to make sense of it. Only corrections would be

      3) First ENT specialist said it would be cleared by soft palate and tonsilectomy. He didn't give a success rate, but he seemed confident it would resolve my issues.

      5) I asked medibank if this procedure would be covered on this plan, and they said yes. It's my fault for not doing more research on out of pocket costs.

      6) The second ENT suggests a 60% sucess rate, I assume, because it's just the tonsillectomy now. That said, even outside of that 60% would be an improvement to my airways.

      OVERALL I have a lot of reflecting to do, especially with how I plan out long term things like this. Even though I could have achieved the same result for either less time, money or both, I'm happy I'm still continuing.

  • Benno007 on 24/02/2024 - 08:36

    I paid about that for my tonsillectomy. I had been trying to get my tonsils out for years, with 4-5 bouts of tonsillitis a year, each lasting about 6 weeks, I became immune to amoxicillin. Even then my drs wouldn’t let me get a tonsillectomy.

    After I moved to a different area, the dr was like of course, here’s a referral to ENT. It was one at a private hospital and despite my private health covering tonsillectomy, I still had to pay a gap.

    I paid $500 excess + $300ish for anesthetist + $400ish for ENT (he did tonsillectomy, adenoidectomy, turbinate reduction and fixed deviated septum, which gave me much more air flow while running and also lowered my sleep apnoea from severe to moderate on my back.

    Right now I have a bit of the tonsil tissue growing back, and am getting tonsil stones for the first time in years 😩

    • Michael15286 on 24/02/2024 - 14:39
      +1

      Crazy how your previous GP wouldn't refer you. It can really be luck of the draw with GP's.

      Your case sounds quite severe and I'm glad you had a positive outcome. Did you ever go to the emergency room at a hospital while having tonillitis? I asked a doctor at the hospital while there on an unrelated even and they said they'd perform a tonsillectomy if it's bad enough.

      • Benno007 on 25/02/2024 - 09:51

        Nah I never did, I didn’t know you could!

  • autama92 on 24/02/2024 - 08:51
    +2

    The price is very reasonable, I had tonsillectomy done and nasal septoplasty/turbinate's done at the same time and went through the public system, was on waiting list for 2 years, if I had the money to go private it would have been done in 3 months following my ENT appointment (they literally gave me availability dates if I went private). The private quote just for my surgeon alone was $1,800, excluding hospital and anaesthetist fees. Medicare rebate on that would have been $575.

    I had private health, but part of my coverage didn't cover turbinate's so I proceeded with public health system. Part of private health you have to remember is you get to go up in the queue. My ENT appointment when I was booked into the system in WA was 18/11/2021 and surgery was 1/5/2023 in WA.

    Whilst I didn't have sleep apnoea (huge tonsils that I kept getting infections from), my QOL noticeably improved after for both the turbinate's and tonsillectomy surgery (can breathe much better (was a bit like a pug before), snore less and can smell things again (sometimes having a sense of smell again can be considered a negative haha).

    Wish you all the best with your surgery, was quite painful for me but as soon as the surgery site is healed its all upwards from there :)

    • autama92 on 24/02/2024 - 09:20
      +2

      OP, saw your profile is WA, my ENT was Murdoch ENT. Public and Private.

      • Michael15286 on 24/02/2024 - 14:44

        Thank you for that. I appreciate you sharing your experience and advice. Ultimately I unded up waiting about 2 years (1 year without health insurance, 1 year with) anyway because of other massive life events happening around that time.

        I'm really kicking myself for not starting this thread way back when I first had sleep apnoea!

  • reactor-au on 24/02/2024 - 09:39

    I looked at a different procedure (under 1hr) in the private system recently, it seems the typical out of pocket start at:

    $500 PHI hospital excess
    $300 for anesthetist
    $500 for specialist

    I mean that's sort of the starting point I expect now when considering short procedures.

    • Michael15286 on 24/02/2024 - 14:46

      Yeah it does seem typical for the private sector. I was just curious as to how people got it done publicly and also other peoples experience with it in general.

      I feel a lot better after reading all the replies in this thread, so thank you and all the others :)

  • LoisLane101 on 24/02/2024 - 10:01
    +1

    You can use your referral to source a no gap surgeon. A large proportion of specialists will charge as a no gap generally or when specifically asked by the patient. They will chose which cases to do so if they are a known gap provider.
    The out of pocket expenses are incurred when the surgeon and anaesthetist are charging above the recommended fee set by Medicare.
    I'm having a procedure soon and my surgeon has a split of no gap, small gap and large gap for his patients. I asked to be treated as no gap and he agreed.
    You can also go back to your health fund and ask for some names of no gap ENT Dr's.

    • Michael15286 on 24/02/2024 - 14:50

      Oh amazing! This is the kind of information I wish I knew beforehand. I didnt even know I could ask the surgeon if I could do no gap or a smaller gap.

      I will ask the office on Monday but I have low expectations as I've already paid. That said it's great advice going forwards. Appreciating you and the info!

  • brendanm on 24/02/2024 - 10:30

    Wait for 12-24 months on public waitlist, it pay $800 and get it done now, I know what I'd be doing.

    • Michael15286 on 24/02/2024 - 14:33

      I have already waited and paid over 12 months for my private to kick in, so in hindsight public would have been better. But at this point it's better to do the $800 now than wait another 12-24 months.

      • brendanm on 24/02/2024 - 16:06

        Correct. $800 to be able to sleep properly seems like pretty good value. In another round of hindsight, perhaps would have been about the same price as getting health insurance, then waiting, as it would have been to pay the lot outright a year ago.

        • Michael15286 on 24/02/2024 - 20:42

          That is an unfortunate bit of hindsight, yes. I've paid around $2000 to PHI since starting and waited almost 2 years. Either route would have worked better but I ended up in some middle ground haha

          Long term planning is not my strong suite, but I hope I do better next time I face a choice like this.

  • EBG on 24/02/2024 - 11:32

    Might be worthwhile checking your Medicare Safety net (calculated on a calendar year basis) and see how far off the threshold you are. Could mean a higher rebate applies (up to 80% back IIRC)

    • Michael15286 on 24/02/2024 - 14:31

      Thank you, I've heard about the Medicare safety net, but it's a good reminder to check it out again. We are still in the first couple of months of the year, but I'll keep it in mind if I need anything else done this year.

  • Ten on 24/02/2024 - 16:25

    the kid needed his tonsils outs in about 2013. after 2 years on the public waiting list I just went direct to a specialist and paid 4k for the surgery. About 12 months later I had a call from public health asking me if I still need the surgery and they advised that there was still a lengthy wait.

    • Michael15286 on 24/02/2024 - 17:34

      Wow 3+ years sounds very rough, I don't understand how it can get that long on a waitlist. And that was 3 years with presumably other people pulling out and going private as well.

      Hope your kid is all right now :)

  • hazzad on 24/02/2024 - 19:05

    Cost of surgery can sting these days. Daughter had 4 wisdom teeth out in Jan. $2700 out pocket for surgeon and anesthesiologist even with PHI. Extras only covered $500 and PHI, half of the $800 for the anesthesiologist. Not cheap to go the private route but sometimes waiting for public can be a problem.

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