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Government, health funds, private hospitals or usurper groups – who is the true opponent?

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BY AMA VICE PRESIDENT DR CHRIS ZAPPALA

As all doctors know, we have discussions with various groups in order to protect the interest of doctors and our patients. We should not be ashamed of the component of self-interest in this – let’s own that whole heartedly and do it well. When doctors are well-trained, have good working conditions, are rewarded for their efforts, and valued and compensated for working long hours or becoming expert in a field, the quality of health care that results is good. There is of course a large component of public health and patient advocacy that the AMA does as well. So, where does our biggest threat come from? 

Look for example at the perplexing suggestion for surgical assistant fees to be bundled with the surgeon and/or reduced. This is unequivocally a dumb idea and one we hope we can dissuade Government from enacting and are working hard to do so. This is indeed a threat, but one I think we can push back and/or divert with ongoing representation. Like a great deal of advocacy, it takes finesse, contacts, access, understanding and persistence. I do think we achieve real improvement.

I’ve said many times before that the threats we face from usurper groups aspiring to back-door role substitution result, in part, from our failure to assist in a true solution of the geographic maldistribution of doctors in this country. We will continue to endure blunt, often misguided Government tools or ideas attempting to solve this problem. This is one area where the AMA and Colleges need to get together – but the threat from usurper groups can be quelled if we do this quickly and effectively.

Private hospitals are at least partially and vicariously responsible for us when working in their institutions and we usually work well together. Indeed, our interests of high-quality health care, stable businesses and good working conditions coincide. Occasionally there will be a hospital that fails to act when it should, or acts too precipitously when it shouldn’t, but these instances are rare.  One of the profession’s defences against this is strong, empowered medical leadership in all institutions. More on this another time.

So that leaves the health funds. Insurers are facing more difficult market conditions and desperately want to preserve their nearly $2 billion profit. Selling less valuable insurance products that leave patients bereft and create hardship for doctors/private hospitals is part of their game, along with an unrelenting desire to pay as little as possible at every opportunity and make this decision someone else’s fault. For example – “The doctor is using the wrong prosthesis” or “the hospital has charged too much” or “we want to reduce unnecessary care”. Whatever that means?

I was taking part in a panel discussion recently at the Ramsey Health Managers national conference. Among the panel members was Mr Marc Miller, Chief Strategy Officer, Medibank. Setting aside that he volunteered he had opted out of the My Health Record, he made some other very interesting comments. We were asked about the imminent Gold, Silver, Bronze and Basic categorisation change to private health insurance (PHI). Rather than accepting that having many thousands of policies is not appropriate and there is undeniable need to make private health insurance more transparent, affordable and useable (i.e. less exclusions), he lamented about the time allowed for Medibank to prepare for the changes and indicated they were probably not going to make a huge amount of difference. 

I agree that the categorisation of policies is a passably reasonable idea that will likely miss the mark. It is, nonetheless, curious to me that there is not greater fund recognition of the current problems with PHI products and a want to reverse current membership decline. One cannot make up for the increasingly inappropriate burden of exclusions by offering a Westfield gift voucher for $100.  The portion of total PHI funds paid to doctors is small – we are not the problem, but there is a predictable and relentless desire to unfairly blame doctors for the poor affordability of PHI. The health funds clearly need to forget the vouchers, and supporting non-evidence based care and substitutes for quality medicine; and offer a limited range of understandable, credible products with minimal to no exclusions that people can actually depend on at any stage of the life cycle.

The real clanger Mr Miller dropped was the suggestion that the system would be improved if all doctors were contracted, including at private hospitals. We should never forget many of the funds want to control everyone and everything, including the choices doctors can make in treating their patients – not necessarily in the best interests of patient outcome, but in minimising their costs (remember they already make close to $2 billion). Managed care and/or any inappropriate control of treatment decision-making or options by health funds must be aggressively avoided. Measures that frustrate the referral process under the guise of fee transparency are equally fraught for the same reason. The independent doctor-patient relationship is sacrosanct, and in this, private hospitals are our firm ally. The public health departments are also allies because Government realises the total funding pool for health care requires PHI and the public system could never efficiently manage significantly increased workloads, e.g. beyond current overstretched built capacity.

Ponder also that Medibank is responsible for nearly half of all complaints to the PHI ombudsman. Their payments to patients are far from the highest and frequently inferior to the not-for-profit insurers. Refer to the AMA Private Health Insurance Report Card:

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In general, my patients tell me they have greater issues claiming with the for-profit funds. It also appears that hospitals have greater difficulty negotiating contracts with for-profit funds – recall the terrible limitations Medibank attempted to write into hospital contracts a couple of years ago that started their public relations decline. We should also all be wary of the BUPA-led charge to restrict gap payments to contracted hospitals only.  Funds now have to use a large portion of premium income to advertise products with more and more exclusions that represent declining value for money.    

For-profit health funds, including Medibank, want doctor fee transparency and control of our behaviour – but seem unwilling to create transparency and value for money in regard to their own product. They could embrace the spirit of Gold, Silver, Bronze and Basic categorisation to improve the transparency and value of health insurance products to improve membership – but seem to rail against the change or side-step it. Rather than tightening their grip on healthcare decision-making and restricting costs to preserve profit, they should invest in good quality health care with independent doctor decision-making which we know produces good outcomes – which is what people will pay for. The true antagonist is revealing itself.

 

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