Australia has an excellent private health care system, of which we can be very proud.
Patients cannot be denied coverage, and those with pre-existing conditions can join a health fund and receive insurance coverage following a reasonable waiting period. There is a range of health insurers in a viable industry.
The system respects patient autonomy by allowing members to choose their doctor.
Private health insurance – which funds the majority of elective surgery in Australia – significantly reduces a burden that would otherwise be imposed on our overworked public hospital system.
However, the benefits of our private health insurance system are now at serious risk.
With the float of Medibank Private in 2014, the largest single health insurer (29.1 per cent market share and 3.8 million members) now has the primary goal of maximising returns for shareholders – apparently at the expense of patients who are their members.
The current dispute between Medibank Private and the Calvary Health Group underlines the problem.
As things stand, Medibank Private members will no longer be fully covered for treatment in a Calvary Hospital. This is particularly concerning for patients in the ACT, Tasmania, and South Australia, where Calvary Hospitals are most prominent.
Medibank Private has asserted that they will not pay for treatment in the instances of a number of so-called ‘preventable complications’.
The AMA has no problem with insurers refusing to cover sentinel events that are entirely avoidable. Identification issues such as operating on the wrong limb, providing the wrong blood type in a transfusion and providing medication prescribed to the wrong patient should not happen with the right checks and balances.
However, the Medibank Private list of 165 different ‘preventable’ clinical conditions or events includes complications that occur despite full preventative measures. Their list is unilateral, based on spurious evidence, and flies in the face of work being done by authoritative bodies such as the Australian Council for Quality and Safety in Healthcare.
As a clear example, despite every risk reduction measure undertaken by clinicians and hospitals, deep venous thrombosis and subsequent pulmonary emboli will still occur as a consequence of conditions such as cancer.
Unbelievably, the rare but tragic incidence of maternal death associated with childbirth from conditions such as amniotic fluid embolism is considered a ‘preventable’ clinical event by Medibank Private. They say this absolves them of the responsibility to provide insurance coverage for the care provided.
These examples should alarm the entire medical profession. It indicates a fundamental lack of understanding of, or respect for, the medical culture that puts patient care first. It also demonstrates an intent to ignore clinical expertise and evidence, and an attempt by an insurer to dictate terms to those providing care.
So what does all of this mean?
It means patients get less value for their money.
It means hospitals are punished inappropriately despite delivering the best possible systems of care.
It means more patients will be compelled to seek care in the public system.
And it means that a major health insurer thinks it knows better than the medical profession when it comes to medical care.
We need transparency on health insurance practices and policies. Many patients remain confused about fundamental aspects of their health insurance policies, and practices such as encouraging minimal private insurance – so called “junk” health policies – need to go. Informed consent is an obligation doctors take seriously. So it should be when it comes to health insurance.
We don’t want to follow the American path, where insurers dictate the terms. Under that system, costs blow out, care is compromised, and patients suffer. The AMA will do all it can to avoid this appalling scenario coming to Australia.