Medibank Private releases list of procedures not covered at Calvary hospitals

      Operating theatre

A big list of medical procedures and complications will not be covered by Australia’s biggest private health insurer, Medibank Private, as the stoush between it and health provider Calvary stands at a stalemate.

At the centre of the dispute are private hospitals run by the not-for-profit Catholic organisation Calvary in South Australia, Canberra, Wagga Wagga and Tasmania.

The insurer’s list of 165 “Adverse Events” it will no longer cover includes falls in hospitals and readmission to hospital as a result of a wound infection.

But the Australian Commission on Safety and Quality in Health Care said the inclusion of about 131 of the 165 events on Medibank’s list was “based on inaccurate information”.

Calvary has refused to accept “quality and safety” measures demanded by Medibank Private as part of contract renewal negotiations.

Calvary wanted the changes delayed for 18 months and said Medibank terminated its current contract with Calvary, which was due to expire at the end of the month.

Instead of working collaboratively with hospitals and doctors to improve quality and eliminate waste, Medibank Private has been using aggressive behaviour … to get out of paying benefits for their members.

AMA president Brian Owler

A Medibank spokesman said meetings had been held at a “variety of levels” with Calvary representatives almost daily for the past two weeks but the talks were at a stalemate.

He said the insurer was acting in the interest of patients and 40 other private hospitals around the country had already agreed to accept the list of 165 “Adverse Events” that would no longer be covered.

Medibank contends that Calvary asked for higher payments than other hospitals.

If a new contract agreement is not struck, Calvary said patients who previously had no-gap payments at their hospitals would have to pay an average gap of about $500.

Childbirth would attract a gap payment of about $500 and hip replacements up to about $1,000.

The failure to agree to a new contract would lead to payments made by Medibank to Calvary for patient treatment dropping to a default level of 85 per cent of the average it pays to comparable hospitals in that state or territory.

Insurer being ‘aggressive’ about payments

Tasmanian independent MP Andrew Wilkie has joined with the Australian Medical Association (AMA) in calling on the Federal Government to intervene immediately, because Medibank Private members using Calvary hospitals could be forced to pay as much as 25 per cent of the cost of their hospital stay.

“This will make healthcare simply unaffordable for many people,” Mr Wilkie said.

Earlier this month AMA president Brian Owler said the insurer was trying to not pay benefits.

“Instead of working collaboratively with hospitals and doctors to improve quality and eliminate waste, Medibank Private has been using aggressive behaviour … to get out of paying benefits for their members,” Dr Owler said.

Federal Health Minister Sussan Ley is maintaining her stance that it is inappropriate for the Government to be intervening in individual contract negotiations.

On the weekend Ms Ley ordered a review to identify a list of high-priority complications in hospitals be fast tracked and finalised by the end of this year.

“Hopefully it’ll also help end the current cynical Game of Thrones where certain private health insurers and hospitals are more focused on painting each other as villains rather than supporting patients,” Ms Ley said.

That review is being overseen by the Australian Commission on Safety and Quality in Health Care.

The commission’s chief executive, Debora Picone, urged Medibank Private to hold off on signing up other hospitals to its list of “Adverse Events” until the review was complete.

Professor Picone said Medibank Private was unwise to continue to proceed with its list of 165 “Adverse Events”.

“For example patient falls, which accounts for about 131 of the 165 events that Medibank Private are using is based on inaccurate information,” Professor Picone said.

Wider review of health insurance needed

Canberra-based organisation Consumers Health Forum of Australia (CHF) said health funds should not be required to pay for avoidable adverse events like falls in hospital and surgical mistakes.

CHF spokesman Mark Metherell said the dispute underlined the need for a wide-ranging inquiry by the Productivity Commission into private health insurance, its cost and its impact on health care.

“We’re seeing year after year increases in premiums that seems to be the only certainty … while often the level of cover offered by health funds is shrinking,” Mr Metherell said.

“To avoid a wider Game of Thrones down the track we really do need to have a more thorough going, comprehensive look at health insurance.

“We haven’t had one for getting on for 20 years. A lot has changed in that time, there are a lot more people with health insurance and there’s a lot more cost factors bearing down on people as the population ages.”