Canberra private health insurance customers face the highest out-of-pocket costs for hospital treatment in the country, forcing more people to rely on the ACT's already overstretched public health system, advocates say.
It has led to calls for more transparent figures around what doctors, hospitals and health funds are charging.
The latest Australian Prudential Regulation Authority data revealed ACT had the lowest rate in the country of private health services where patients did not have to pay a medical gap, at 79 per cent.
The second lowest was WA where 87 per cent of all services did not incur a gap, while the Australia-wide average 89.5 per cent.
The average medical gap paid by Canberra private hospital customers was $290 - well above the Australian average of $192.72.
The percentage of hospital services where patients didn't have to pay a medical gap remained relatively steady over the past year, dropping from 79.4 per cent in December 2018.
Canberra has the equal highest rate of private health coverage in the country, with more than half the population covered. But Canberrans are also among the least likely to use private hospital services.
Health Care Consumers Association ACT executive director Darlene Cox said the out-of-pocket costs were cause from concern.
"People are priced out from using the private system and move on to a public system which is already struggling to cope or in some cases not coping at all," she said.
"While there is the view that Canberra is the wealthiest community in the country, that is not true for all families. There are still many families in this town who have insurance but can't pay the large out-of-pocket costs so don't use it."
She said the medical profession needed to be clearer about why it cost more to access healthcare in the ACT than in any other jurisdiction.
"Why is it we are paying more to see a specialist than up the highway in Sydney?," Ms Cox said.
"From a consumer perspective, we don't really know the answers as to why, we just know that it is more expensive."
It comes as new figures reveal the health funds which most commonly do not charge a cap for services.
Of all open membership funds in the ACT, Onemedifund had the highest rate of services with no gap (89.1 per cent), followed by Transport Health (87.3 per cent), GU Health Corporate (85.3 per cent) and Australian Unity (83.9 per cent).
It has nothing to do with the surgeon but a lot to do with the policy failing to cover what they thought was covered.
Australian Medical Association ACT president Antonio Di Dio
The funds with the lowest percentage of services with no gap were MDHF (45 per cent), GMHBA (47.7 per cent), CDH (57.1 per cent) and Latrobe (60.4 per cent).
Most funds offered fewer gap-free services in the ACT than in all other jurisdictions.
The ombudsman said most differences were due to the level of doctors' fees which varied significantly between the states.
"In some states, funds are able to provide more effective coverage of gaps because doctors charge less than the national average," it read.
"In addition, where a doctor's fee for an in-hospital service is at or below the Medicare Benefits Schedule fee, there will be no gap to the fund member.
"If a health fund's percentage of services with no gap is higher than that of a fund in another state, it does not necessarily mean the fund's scheme is more effective, because state-based differences could be the cause."
Australian Medical Association ACT president Antonio Di Dio agreed consumers should have access to greater transparency, with a break down of fees for each doctor, the hospital and health fund.
He said the vast majority of specialists in the ACT did the right thing with a tiny minority engaging in price gauging.
"I get literally hundreds of examples from colleagues where the surgeon has bulk billed the patient but they are irate because they have a several thousand dollar gap," he said.
"It has nothing to do with the surgeon but a lot to do with the policy failing to cover what they thought was covered."
Dr Di Dio said the higher out of pocket medical costs in the ACT came down to greater fixed costs.
"Canberra specialists are not large group practices like you often see in Sydney," he said.
"And, a lot of surgeries in Canberra are actually performed by Sydney surgeons - they charge more to travel.
"There are some very reasonable market forces here, there is no evidence, except very small examples, of inappropriate pricing by surgeons."
