Results of the FIPO Consultant Survey into Current Private Medical Insurance Trends
5th May 2010
In the private health care sector there is a contract between the patient and the consultant; consultant charge fees and patients receive reimbursement from their insurer (if they have one) to a level that may very between different companies or within different policies from any individual company. Inherent in this contract is the fact that a patient has a choice of consultant and, by and large, of hospital.
This traditional model is under threat and in response to AXA PPP’s proposed changes to its pre-authorisation and patient reimbursement policy, FIPO conducted a survey amongst consultants into the cost pressures placed on consultants and patients by private medical insurers. Other current issues of concern to FIPO are attempts by other insurers (BUPA in particular) to involve themselves in clinical issues and the attempts by some insurers to negotiate fee packages with consultants which break the consultant/patient contract and which may lead to inappropriate referrals of patients.
The recent AXA PPP proposals have built on a previous strategy of the company to only recognise newly appointed young consultants provided they adhered to a fixed fee schedule for their services. In March 2010 AXA PPP wrote to many senior consultants suggesting that they too must adhere to this fixed fee schedule but in any event saying that all patients treated by these consultants would only be reimbursed to this new low level of benefits whatever the consultant may charge. In addition AXA PPP wrote to other consultants with whom they had previously negotiated a set of fees and unilaterally declared that this was null and void and that these consultants were expected to now adhere to this new lower fixed fee schedule. As not all consultants are affected by this AXA PPP decision the end result will be that some patients will obtain lower benefits than others for the same service depending on which consultant they see.
Thus, many patients will in effect be penalised by the insurer if they attend certain consultants’ and this financial disincentive can be used by the insurer at pre-authorisation to shift patients from their consultant of first choice to an alternative consultant.
AXA PPP is also promoting a new type of specific insurance policy which means that subscribers when seeking preauthorisation for treatment will be directed to a specific hospital group (BMI) with whom the insurer has made some specific commercial arrangement. Other AXA subscribers who are not covered by this policy may also find when they are ill and in a vulnerable position that they too will be referred this way. This then means that their consultant will be selected from a very limited list by the hospital itself, thus removing all choice from the patient of both consultant and hospital.
A fully confidential on-line survey was conducted using SurveyMonkey software with certain built in security controls. Consultants were emailed through various specialist organisations. The actual number of consultants invited to participate is unclear but probably around 3,000 to 4,000 were approached.
798 consultants participated in the survey spanning a broad range of age and specialist disciplines. There were 203 comments given by respondents in the freehand section. There was a 92 percent completion of the questions (and not all parts could be answered by every consultant due to the question construction). Respondents came from all over the UK and both newly appointed and senior consultants took part. The average experience of private practice was just under 12 years. All results were analysed automatically by SurveyMonkey and reproduced without change; decimal points are rounded up or down in a conventional manner.
FIPO Survey Results
The survey shows that
- 92 percent of those surveyed think that a fixed fee schedule will remove patient choice
- 90 percent of consultants disagree with the concept of a fixed fee schedule
- 95 percent reject the concept of an insurer controlling the referral pathways of patients
- 96 percent think that an AXA PPP package deal with a hospital will restrict patient choice
Large Numbers of Consultants and Patients Affected by AXA PPP
The AXA PPP threat to limit benefits to some of its subscriber’s amounts to a serious overall problem as the survey shows that AXA PPP has capped 20 percent of senior consultants. As 77 percent of these consultants had rejected the AXA PPP proposal at the time of this survey (and 18 percent of consultants approached were unsure of their response) it means that many patients throughout the country will have an extra penalty imposed on them by AXA PPP if they persist in their desire to see one of these consultants.
Patient Reimbursement and Pressure on Clinical Standards
This highlights concerns that as the public sector is striving for more choice the actions of some medical insurers are limiting it. It means that long established relationships between GP’s and consultants are being broached and strong evidence for this comes from 25 percent of consultants in the survey who are already aware of incidents where AXA PPP has suggested to patients an alternative specialist than the one they were referred to. This number is likely to increase as the new AXA PPP policy is implemented.
AXA’s proposed plans will mean that patients who are being treated and choose to be treated by a fee capped consultant will receive less reimbursement and in essence, are being financially penalised by the insurer. If patients are unable to recover a higher proportion of their costs than previously, they will have to change consultant, in many cases destroying the relationship they have built with their own consultant. This would mean being seen by a consultant who may not have a detailed history of the patient’s condition and who, while they may be of the same generic specialty, may not be a subspecialist able to deal with patient-specific needs. With 89 percent of respondents concerned that some other insurers will take a similar line to AXA PPP, there is a real fear for consultant independence and patient choice and care.
The Consultant/Patient Contract and Direct Billing
85 percent of consultants think that AXA PPP’s plan will break the patient/consultant contract which accounts for the high rejection rate of this insurer’s proposals by the profession. It also means that increasingly consultants are prepared to bill their patients directly (70 percent in this survey)
More consultants are now starting to advise their patients to use the Ombudsman route to seek financial redress from their insurer if they feel they have a justifiable complaint of inadequate or unfair management.
Clinical Decision Making and Hospital Managerial Interference
Given the desire by some insurers to dictate clinical guidelines 96 percent of consultants opposed this concept believing that these should be developed by a professional organisation, rather than insurers with vested financial interests. 88 percent of respondents are worried that an AXA PPP package deal with hospitals will result in managers overriding clinical decisions.
Insurers Motivation - Quality versus Finance
Overall, there was a distinct lack of confidence in the abilities of private medical insurers to make decisions in the best clinical interests of the patients, with 98 percent of respondents believing that some of the current insurance strategies are being inspired primarily by commercial rather than quality considerations. Only 1 percent of consultants believe quality to be at the forefront of these insurance tactics.
The FIPO Position
More than twenty five professional medical organisations including Royal Colleges, Specialist Associations, the GMC and the Patients Association have signed the FIPO Charter for Patients and their Doctors, reaffirming their commitment to high-quality patient care. Outlined in the Charter is the ethos that governs each doctor’s duties to their patients, the patient’s rights and the principles inherent in best medical practice.
In summary the philosophy of FIPO is;
Choice in the hands of patients
Care in the hands of doctors