Health insurers 'restrict patient care options'

The Australian Private Hospitals Association (APHA) has welcomed a new report calling for better options for patients when choosing out-of-hospital care.

The 'Out-of-hospital models of care in the private system' report from the Australian Medical Association (AMA) warns Australia could be heading towards a US-style managed care health system.

It said private health insurers' push for vertical integration – where they pay for and provide health services – was forcing patients to receive treatment which may not be in their best interests, such as psychiatric care without the involvement of the treating psychiatrist or general practitioner.

The AMA's report also raised concerns about patients' ability to access out-of-hospital care because health insurance companies often refuse to pay for these services if they are provided by a private hospital.

APHA CEO Michael Roff said private hospitals were willing and able to offer innovative programs for out-of-hospital care, but not all patients had access to them because they were often only funded by one insurer.

"The AMA report suggests about 40 percent of patients are missing out on access to these services, in large part because the funding models don't support the innovation we know exists in the private hospital sector," he said.

"It also highlights the danger that the vertical integration push is leading to outcomes that are not in patients' best interests.

"There is also a genuine threat to clinical autonomy that could have further adverse consequences for patients."

Mr Roff said the report supported APHA's longstanding call to introduce contestability into the market with a minimum guaranteed payment scheme that ensures private health insurers pay for any out-of-hospital service chosen by the medical practitioner.

"We agree that this is an important measure to allow private hospital patients to access services no matter who their insurer is. The APHA called for this change in its submission to the Government's review of default benefits," he said.

"It is quite obvious that if a private hospital is allowed to provide out-of-hospital services to patients following an episode of hospital care, then continuity of care, quality of outcomes and patient satisfaction will improve.

"Unfortunately, some health insurance companies appear more focused on their own bottom line than meeting the needs of their members."

The AMA said expanding access to out-of-hospitalcare would benefit both patients and the healthcare system. It estimated that opening uprehabilitation services to all clinically-eligible private patients having a total kneereplacement in 2024 would save around 47,000 to 94,000 bed days and $31.3million to $62.7 million.

Mr Roff said the report also highlighted the need to introduce important principles around quality and safety, patient protection, patient choice and clinical autonomy.

"APHA welcomes this report and looks forward to further discussion about some of the important issues raised within it," he said.

Read more: Private health insurers profit while cost of care increases

Read more: Do we want US-style managed care in Australia?

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