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PHI opportunity? Not without risks

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There has been much criticism recently of the Medibank Private and IPN agreement GP services being trialled currently in Queensland, from me included.
I have publicly called on the Government to step in to stop the partnership amid concerns about the legality of the scheme and the impact it could have on established doctor-patient relationships and clinical autonomy.

Under the arrangement, it is believed that Medibank Private has side-stepped the law by covering the administrative costs of IPN rather than the gap on GP services. The Private Health Insurance Act currently stipulates that, as a general rule, out-of-hospital medical services covered by Medicare cannot also be covered by private health insurers. Given that the costs of running a practice, including administrative costs, are incorporated in the fees for patient billed services, it’s not hard to see why I’m concerned about the legalities.

The AMA Council of General Practice (AMACGP) has for some time been considering what role private health insurers (PHI) can play in general practice. The PHIs are only too aware that the answer to reducing costly hospital admissions is in general practice. This is where risks of future chronic health problems can best be identified and addressed. That is why they too are interested in the role they could play in general practice.

PHIs need to work effectively with general practice because it can lead to better patient outcomes. Unfortunately, their track record to date is not good. The various health improvement programs they provide often sideline the patient’s usual GP.

The AMACGP has sought to improve the relationship between PHIs and GPs to enable a more productive engagement. We had extensive discussions with Medibank Private, HCF and BUPA at the AMACGP Executive’s October Policy Day last year, and the AMA will continue to press the need for PHIs to implement programs that are supportive of GPs

The AMA position statement Private Health Insurance and Primary Care Services – 2006 discusses the risks of PHI expansion into primary care and the types of situations where the AMA would see it as being acceptable.

For any program to succeed, it must recognise the central role of the GP.  It must involve GP-led care and measures that support the continuity and quality of patient care. Eligible patients must retain their choice of program participation and of preferred practitioner. Program eligibility requirements must be fair and reasonable for purposes of the program.

To be acceptable to the profession, participating in a program must not restrict practitioners’ rights to set their own fees, result in any compromise of a practitioner’s clinical decisions or to the quality and standards of patient care. Use of services which attract a MBS rebate must not be a pre-requisite to accessing a fund’s program, nor should the program preclude patient access to Medicare. A patient’s choice of whether or not to participate in the program must not affect their access to insurance coverage. The program must not involve any form of fundholding or capitated payments inconsistent with AMA policy.

I would welcome your comments on how you think PHIs could work with and support GPs in keeping their members healthier without reducing the quality and continuity of care, and without the use of fundholding models that lead to rationed care. Email me at gpnn@ama.com.au.