Details of the FIPO Consultant Survey - July 2010
In April 2010 BUPA Insurance announced that they would be seeking the views of consultants through a questionnaire which was directed at “quality” issues, regulations and the recognition of newly appointed consultants. To date BUPA has not published any outcomes of their questionnaire but nevertheless has gone ahead with various dramatic changes in the recognition of newly appointed consultants and with the Terms and Conditions by which they are recognised. These changes involve a fixed fee schedule and a requirement for these consultants to provide BUPA with a massive amount of clinical, administrative and personal data.
FIPO felt it important to conduct its own on line confidential survey of consultants to establish their views on these issues. This FIPO survey was carried out before BUPA announced its new Terms and Conditions for young consultants. The results are given here and have been shared with BUPA.
Methodology of the FIPO July 2010 Survey
The FIPO Consultant Survey took place in May 2010 and was closed in July. This fully confidential on-line survey was conducted using SurveyMonkey software with certain built in security controls. These results have been published in a shortened Press release which can be seen here
The more detailed results depicted here were taken from the SurveyMonkey website and were based on 330 respondents. This number of respondents has since increased to over 350 but the results and detailed analysis has not changed. These consultants came from all specialties including, anaesthetics, general surgery, ENT surgery, orthopaedics and trauma surgery, ophthalmology gastroenterology, rheumatology, cardiology, dermatology and others.
Consultant Recognition by an Insurer
88.8% of consultants believe that a CCT and a substantive NHS consultant appointment are the sole professional requirements for recognition by an insurer, with 7.6% disagreeing and 3.6% unsure (Figure 1). FIPO agrees with this traditional yardstick for whilst accepting that some specialists from abroad may be of outstanding merit and may gain hospital admission rights via Medical Advisory Committees to independent hospitals and thus they should be considered favourably for insurance recognition. This does not mean, however, that standards of care should be compromised and the suggestion that non-consultants should be engaged en masse by either hospitals or insurers to undertake unsupervised clinical work is unacceptable.
Figure 1 - Professional requirements by an insurer for recognition
Mentoring of Newly Appointed Consultants
BUPA has previously raised the question of whether newly appointed consultants should have some form of mentoring when they commence in fully independent practice outside the NHS. The results of the FIPO survey show that just over a half of the respondents (51.7%) thought that this was unnecessary, a quarter (24.9%) thought it necessary and just under a quarter (23.4%) was unsure (Figure 2). However, there was greater certainty over excluding an insurer and 96.7% saw no place for any insurer in the process of monitoring newly appointed consultants. 71.7% felt that any such monitoring should be the responsibility of the Medical Advisory Committee (MAC) and hospital governance committee whilst 19.8% disagreed, a figure which probably reflects the view that such monitoring unnecessary.
FIPO believes that all consultants should be monitored in the independent sector and in any event this will become a routine part of revalidation. Although FIPO is against any special provision for newly appointed consultants there is merit in local specialist groupings in the private sector which will allow for audits and a degree of shared responsibility and senior supervision to occur.
Figure 2 - Monitoring initial progress, appraisal and results of newly appointed consultants
The Role of an Insurer in Clinical Regulation
BUPA had indicated previously its intention of reviewing the clinical practice of newly appointed consultants. This intention has since come to fruition with a complex contract that newly appointed consultants are required to sign and which allows BUPA access to all manner of detailed clinical data, audits, complaints, incidents and multi source feedback (MSF). The FIPO survey tackled this issue with a series of questions and quite clearly the profession is against this with 90.9% of consultants saying that an insurer does not have the capability and 96.0% saying that an insurer does not have the right to act as a clinical regulator (Figure 3). There was also a massive rejection (96.9% of respondents) of the idea that the insurer has the right to disseminate any such information to outside bodies or to publish this in any format. FIPO fully endorses this consultant view and has stated publically that a financially regulated company such as BUPA has no role in clinical regulation.
Figure 3 – Insurers as regulators; use of personal audits, multisource feedback and other personal information
Use of Clinical Audit and Outcome Data by Insurers
The profession was more or less split over whether or not the insurer might use this very detailed information involving multisource feedback, complaints, incidents and audits to develop a preferred provider system with 45% thinking that BUPA would do this and 48.3% believing the opposite (Figure 3). However, when considering just audits and outcomes, 89.4% of consultants thought that this would lead to preferred provider networks of consultants and 84.5% felt that this would lead to demands for volume discounts by the insurer (Figure 4).
When BUPA last attempted to foist a similar contract on to all consultants in 2005 they made it clear that this would allow them to rank specialists and to develop restricted networks of consultants. The overall purpose of this is type of “quality” agenda is to enforce volume discounts and consultants have clearly seen this as a commercial rather than a quality initiative by the insurers (See Figure 15 of the FIPO May 2010 Survey >>)
Figure 4 – Insurers’ use of audit and outcome data from consultants
Scope of Practice
The development of any preferred provider networks by an insurer would require the definition and control of the scope of practice of all consultants. BUPA has already introduced some networks of consultants dealing with certain cancers. In essence this is BUPA acting as a regulator but such a role is overwhelmingly rejected by the profession with 98.5% stating that this is not an insurance issue; 93% of consultants in the survey felt that scope of practice should be a matter for the hospital MAC and governance team (Figure 5)
Figure 5 – Defining scope of practice
Working with Insurers
BUPA has suggested that consultants “work with them” in an undefined manner and have floated the concept of extra payments for such “quality options and also for seniority payments based on undefined “clinical expertise”. These concepts are not popular with consultants (Figure 6) and the FIPO survey shows that
- 83.3% felt that there would be regular demands from insurers for data (4.6% believing the opposite)
- 92.4% saw this as a method of creating new fee structures (1.8% not agreeing with this)
- 86.3% saw difficulties in defining clinical expertise (6.1% feeling this was possible)
- 88.8% felt outcome measures would be hard to measure in some specialties (4.0% not agreeing with this)
Overriding these clear results was the concept that this type of insurance approach was geared towards tying consultants in to some agreed fee structure and thus breaking their contract with the patient. 91.2% saw this as BUPA’s motive with only 2.7% disagreeing and with 6.1% unsure.
FIPO has always argued that consultants should maintain their contract with the patient and not be tempted by any short term agreement or special fee structures offered by insurers.
Figure 6 – Working with insurers
Consultants Revalidation Requirements
BUPA have imposed a contract on newly appointed consultants which requires them to provide details of their clinical practice which would appear to be a replication of the data that will be needed for revalidation. Whilst the respondents to the FIPO survey were clear that they did not believe that this data was required by an insurer they fully understood (97.3%) that it would be a requirement for revalidation with only 2 respondents (0.6%) not appreciating this and 2.2% unsure (Figure 7).
Figure 7 Consultants views on the requirements for revalidation
Consultant Derecognition by Insurers
A recurring theme is the fact that some insurers (in particular AXA PPP) have delisted consultants in an excessive manner. The BUPA questionnaire results have not at this time been released but one question within this discussed various scenarios under which a consultant might be delisted by an insurer. Some were clear cut (such as being suspended from the GMC register) but mostly these questions were too vague to be answered very specifically. The FIPO survey took two of the most contentious questions and put them into its own survey. The results (Figure 8) show that only 7.3% of consultants thought that a failure to submit audit or other clinical data were grounds for delisting and 87.5% did not think this was a cause for delisting.
The question on delisting due to a failure to comply with billing procedures showed that there was a slightly higher number (13.7%) who felt that this was a reason for derecognition and perhaps this was due to the multifaceted question which included coding practices as a reason. However, three quarters of consultants (75.4%) did not think that this was a cause for delisting.
FIPO would not defend any consultant who persistently engaged in fraudulent coding or billing practices but such cases need proof and there are problems in the CCSD codes which can give rise to confusion. However, billing administration is a matter for consultants and their patients and should not be dictated by insurers.
Figure 8 – Basis for derecognition of consultants by insurers
An Appeals Process for Consultants Delisted by Insurers
One burning issue is the fact that there is no independent appeals process for consultants who have been delisted and consultants overwhelmingly felt that such a process was required with 96.7% agreeing, 1.8% disagreeing and 1.5% unsure (Figure 9).
Figure 9 – Derecognition and appeals process