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Care needed in doctor-health fund collaboration

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AMA President Associate Professor Brian Owler has warned the private health insurance industry off arrangements that compromise the doctor-patient relationship and crimp access to care.

In a period of upheaval for the sector marked by the privatisation of the country’s largest health fund and an aggressive push by insurers into primary care, A/Professor Owler said in a major speech to the peak body for private insurers, Private Health Australia, that the time had come for discussion about the role GPs could play in private health insurance arrangements.

But he said this should only occur in ways consistent with the principles that made Australia’s health system one of the most efficient and effective in the world, including universal and equitable access to care, the independence of the doctor-patient relationship, community rating and the right of practitioners to set their own fees.

“The AMA believes it is time for a discussion about how GPs could play a more prominent and central role in private health insurance arrangements,” the AMA President said. “[But] any move to expand the role of private health insurers should be carefully planned and negotiated with the profession to ensure that the outcome is in the best interests of patients, and does not compromise the clinical independence of the profession, or interfere with the doctor-patient relationship.”

The AMA Council of General Practice has been examining the possibilities for some time, and has identified a number of possible areas of collaboration including wellness programs, the maintenance of shared electronic health records, hospital in the home initiatives, palliative care, minor procedures and GP-directed hospital avoidance programs.

The Federal Government has encouraged insurers to look at ways of expanding their operations, and Health Minister Peter Dutton has remarked approvingly on the controversial Medibank Private/IPN trial in Queensland in which the fund contributes to the administrative costs of selected general practices in exchange for preferential access to care for its members.

But A/Professor Owler said the Medibank arrangement jarred with the principle of equity of access to care and was unacceptable.

He said any model of care agreed to by doctors and insurers must respect the foundation principles of the health system and avoid any hint of managed care.

“If we can agree on a model that ensures the integrity of the doctor-patient relationship, equity of access, and universality, then this is an area where the AMA and PHIs [private health insurers] can work together,” the AMA President said.

“That discussion can only proceed if the independence of the doctor-patient relationship is preserved.

“We cannot have a situation develop where a doctor’s ability to order a test, prescribe a treatment, or refer to another doctor is influenced by a third party or ‘payer’. That is a managed care system.”

A/Professor Owler said that, in addition, the AMA would like to see the health funds dump policies and practices that were having undesirable consequences.

He said one of the big gripes of patients and doctors were policies with multiple exclusions.

The President, who works as a paediatric neurosurgeon, said he had personal experience of patients in need of surgery only to find that it was not covered by their insurance policy.

“Too often, my members see patients who think they have cover, but don’t, because they purchased a cheaper product several years ago,” he said. “Sometimes treatment is planned and surgery is booked, only to be cancelled shortly beforehand because the hospital’s health fund check reveals that the patient is not covered. It is not an unusual scenario.”

In addition, he called on health funds to stop exaggerating how often patients are charged gap fees.

“It would be preferable if some of you were a bit more open and honest with your members that the vast number of services are provided at the level of benefit set by the insurer, instead of portraying isolated cases as the norm, or even going to the extent of briefing the media with specific cases,” A/Professor Owler said.

He said almost 90 per cent of services were provided at no gap, and only a “very small” proportion involved higher charges.

He said the AMA was keen to work with insurers and the Health Department to ensure that neither they nor Medicare was billed for purely cosmetic surgery, and said there were opportunities for the health funds to support quality assurance and outcome measurement activities.

Adrian Rollins