6 key conditions for private health insurance in in general practice

Private health insurers are gearing up to enter the general practice market. But it appears their plan is a copy of the dreaded US-style ‘managed care’ approach.

It’s best to keep health funds at arm’s length or else they will decide what care can, and can’t be given – instead of the patient and the healthcare provider. Therefore, I suggest that six conditions must be met before private health insurers can engage with general practice:

#1: Universal access

Every Australian should have equal access to a GP, independent of insurance status.

#2: Freedom of choice

People should have the option to choose their GP and private specialists; this cannot be dictated by health funds. Patients together with their doctors are best at deciding which tests and treatments are appropriate, not third parties like insurance companies.

Patients should always be given the option to choose and change health funds and insurance products.

#3: Transparency 

Health funds must provide a straightforward package covering GP and/or basic private hospital care – as well as more comprehensive packages. Exclusions should be kept to a minimum. Health funds should make patients aware of exclusions and any other limitations before they buy a product.

To assist consumers choosing the best health insurance that suits their circumstances, an independent Government website should monitor, compare and publicise all available insurance packages.

#4: Professional autonomy

GPs and practice staff need support to be able to provide good care; this also means they should not be overloaded with red-tape, reporting requirements and KPIs. For the same reason health funds should not cause delays in treatment. GPs have the right to set fees to ensure practice viability.

#5: Evidence-based care

Only proven, appropriate, and cost-effective care should be covered.

#6: Stakeholder involvement

Health consumer organisations and the medical profession need to be engaged, as this will likely lead to better outcomes. New regulation should be put in place to safeguard compliance by all parties.

How to save the PCEHR

The resignation of NEHTA’s top National Clinical Leads in August 2013 was the final straw for the PCEHR. I have said it before and I will say it again: if clinicians are not on board the PCEHR will fail. There are some big decisions to make by the relevant authorities if they want to save the project, and making these decisions without clinical advice is impossible.

The PCEHR Act 2012 states that the data in the PCEHR can be used for law enforcement purposes, indemnity insurance purposes for health care providers, research, public health purposes and ‘other purposes authorised by law’. This is far from reassuring. There are many grey areas and unanswered questions. There are too many agendas. The PCEHR should first be a useful clinical tool to improve patient care.

What we need is an open, well-informed discussion about the purposes of the PCEHR. What are consumers and clinicians exactly saying yes to when they sign up?

Dr Mukesh Haikerwal
Two of NEHTA’s Top National Clinical Leads: Dr Mukesh Haikerwal and Dr Nathan Pinskier in Geraldton (August 2013). Photo: Dr Ian Taylor

Consumers must know exactly what happens with their data after they have visited the doctor or the hospital. We need to agree on secondary use of the data and informed consent by clinicians and consumers is a basic requirement here. The PCEHR Act 2012 and the participation contract should both be reviewed and made 100% acceptable to consumers and clinicians.

Most of all we need genuine stakeholder engagement. This is a big challenge but certainly not impossible. Let’s hope common sense prevails.