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Insurers muscling in on care

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Surgeons are facing demands to sign-off on the clinical necessity of a range of procedures as health funds intensify their push for a bigger say over the care provided by doctors and hospitals.

In the latest instance of the drive toward US-style health arrangements, The Australian has revealed that the nation’s two largest health funds are demanding that doctors attest that procedures including operations on eye lids and tear ducts are medically justified and not purely cosmetic.

The Australian Society of Ophthalmologists told the newspaper that Medibank Private and Bupa were asking doctors to sign pre-eligibility forms for procedures they suspected might be cosmetic, even where a Medicare rebate is being claimed.

Medibank said the forms were needed because of changes in the definition of several potentially cosmetic procedures on the MBS, but Society President Dr Michael Steiner said funds were “putting themselves above Medicare”.

The revelation came as infection control experts backed AMA warnings that the refusal of some insurers to cover the cost of treating hospital-acquired bugs will push up patient out-of-pocket costs and increase the pressure on public hospitals.

AMA President Professor Brian Owler cautioned last year that a deal between Medibank and the Calvary Health Care under which the insurer would no longer accept responsibility for 165 medical events it described as highly preventable, including hospital-acquired infections, was “a pivotal moment” for the health system.

Professor Owler warned that this would destabilise the health system by creating a situation in which private hospitals refuse to admit patients with complex needs or considered to be at high risk.

“We know that there will be patients that won’t be able to be readmitted should they develop problems with their wound or other complications, and they will have to go to the public hospitals,” the AMA President said. “There are other patients that won’t be able to afford the out of pocket expenses that Calvary will have to charge, and they will have to be going to public hospitals as well.”

His concerns have been backed by the Australian College for Infection Prevention and Control.

College President Professor Ramon Shaban said the causes of hospital-acquired infections were complex, and it was wrong to dump the costs onto patients.

Professor Shaban said a heightened risk of infection was often due to factors outside the control of patients, such as undergoing chemotherapy, and this should not be a reason to increase charges or even refuse treatment.

He said the College was concerned hospitals would seek to recover the costs of treating acquired infections from patients, and warned that “an even worse outcome would see hospitals refusing to admit a patient, or charging them a premium based on their risk of infection”.

Medibank has argued that its arrangement with Calvary and other hospital groups was aimed at improving the quality of care.

But Professor Shaban said international experience showed financial disincentives did nothing to reduce the risk of infection.

Private hospitals themselves have been put on notice to improve the disclosure of information to patients.

The consumer watchdog has raised concerns about a lack of transparency from private hospitals in how they bill patients, citing the example of Calvary Health Care patients who faced additional charges if their hospital stay was shorter than anticipated.

The Australian Competition and Consumer Commission told the Australian Financial Review the intersection of hospital billing practices and health insurance policies can lead to unexpected results for the consumer and should, at the very least, be fully disclosed.

Adrian Rollins