Mind the Gap: Part 4 - Private Health Insurance

This is Part 4 of a series outlining the Australian Health Insurance industry from the perspective of a health provider.

4. Private Health Insurance Companies

Unlike overseas insurance companies, Australian Private Health Insurance Companies do not usually set an anual dollar limit on benefits, or directly dictate medical care to their members like US Health Maintenance Organisations (HMOs).

The unique structure of Medicare extends to all Australians, including those who have Private Health Insurance. What this means is that Australian Health Insurers can depend on the Federal Government continuing to pay the bulk, or at least a known minimum, of health care costs for their members. Therefore, they are only responsible for meeting the difference between what the CMBS pays and what the provider charges (the Gap Fee). This includes the 25% of the CMBS fee which Medicare will not pay.

In actual fact, Private Health Insurers in Australia generally have policies which will:

• only pay for inpatient services (i.e. services rendered in a hospital)
• only pay for the 25% difference between the CMBS fee and the Government Rebate (i.e. not any gap fees on top of this)
• pay for costs incurred by the hospital during that period of hospitalistion
• pay for approved consumables and surgical implants used during operative procedures

As explained later, hospitals also receive money from state and territory governments for these services, so Private Health Insurers basically pay a standard fee intended to bridge the difference between the hospital's costs and the state or territory funding.


On top of this, Private Health Insurers in Australia benefit from a Federal Government drive to promote Private Health Insurance via a 30% Government rebate for Health Insurance Premiums. All in all, they have it pretty easy, and are raking in cash hand over fist, though they refuse to admit it when it is time to raise premiums. Instead, they employ specialists to help them think of hare-brained schemes to waste money and hide their profits.

The largest health insurer in Australia is Medibank Private which is currently privately owned by the Federal Government. Unfortunately for the ordinary taxpayer, Medibank Private has done such a good job of hiding its profits that the Federal Government thinks it would be better off privatising the company rather than keeping the income stream.

Medibank sale details to be decided
Medibank: In sickness and in health
AMA maintains Medibank premiums will rise
AM: Medibank privatisation good for consumers: Abbott
AM:Labor rejects claims of benefit from Medibank sale
The World Today: Govt set to confirm sale of Medibank Private
PM: Govt to sell Medibank Private
No guarantee on premiums
$50m private health ads 'planned'
Shakeup for medical insurance
Labour to target doctors over fees

More on this series next week.

Who am I?

Dr Michelle Tempest started a discussion on her blog about anonymity amongst medical bloggers, and I couldn't help but to post a lengthy diatribe.

Thanks for the mention - my readership has suddenly increased about 20 fold (i.e. from 2 to 40 in the last day).

There is always an altruistic purpose to anonymity - as a doctor I don't want to risk exposing or identifying my patients or colleagues, and once my identity is out it is an order of magnitude easier to pinpoint specific people.

Then there is the CYA purpose to anonymity - I don't want to be sued, fired, or otherwise publicly shamed for saying something controversial on my blog.

I think, however, that the biggest reason is that it allows me to be a different person. It frees me of my real-life inhibitions. There are many fewer consequences to saying something offensive, inflammatory, or downright mean on an anonymous blog. I can adopt a different personality, say something that I haven't really thought through, or which I am still deciding upon.

As Barb once said to me - "I'm not my blog. That is not the whole me. It's just part of me that I like to express sometimes."

Inevitably, it's a pretty thin veil of anonymity. It's very easy if you are in the right (or wrong) circles to work out who is who. It's probably only a matter of time before a real identity is revealed - unless the blog is stopped, deleted and/or abandoned beforehand.

While you might not have your name tattooed on your forehead while scrubbed, if people spend enough time looking at or talking to you in the OR, they learn to recognise you outside the OR.

In fact, trying to hide behind an anonymous blog is like... wearing a Paper Mask.

OK, maybe that last line was a bit corny. Enough posts for the moment, more from Mind the Gap next week.

I love LUSCS?

Doctors told to reduce caesarean births

The New South Wales Health Department has issued a new directive aimed at trying to reduce the number of unnecessary caesarean deliveries in state public hospitals.

The new policy says a request from a mother to have a caesarean section is no longer a justifiable reason for performing the procedure, if there is no medical reason.

Dr Andrew Child from the Health Department says under the changes a doctor must fully explain to a woman all of the risks associated with a caesarean section before one can be performed.

"It will change the attitude of the staff," he said.

"At the moment the staff are tending to just give it a quick tick whereas this will enforce the need to make sure that all the risks and dangers are very clearly put on the table."

Firstly, does the NSW Department of Health seriously believe that anybody performs Caesarean Sections on a whim, without due consideration for the indication, benefits and risks? Or that women agree to a Caesarean Section without appropriate consultation, advice and consideration?

Secondly, like any surgical procedure, it is normal practise to explain to the patient the risks associated with the procedure that is planned. The only exception to this rule is where the patient is incapacitated (and therefore the explanation goes to the person who is most responsible for the patient), or in the setting of a life or limb-threatening emergency where the patient is unable to understand or comprehend the situation, or time is so critical that there is no option (these usually all happen together). Though obviously in the Health Minister's mind, a Caesarean Section is not like any other operation. Perhaps the only "change in attitude" should start at the top. A Caesarean Section is an operation. A Caesarean Section is an operation. A Caesarean Section is an operation...

Lastly, perhaps there should be a similar edict warning mothers of the risks of not proceeding with a Caesarean Section when recommended, the risks or home birthing, or the risks of getting pregnant in the first place!

Perhaps it might have kept this poor couple out of trouble: Twins' home birth risk 'downplayed'

I am sure that Dr Crippen would have plenty to say, given his Campaign Against Reckless Midwives (or "Madwives", as he prefers). Perhaps we are inevitably heading towards the NHS model of perinatal care - though not if this article from The Times has anything to do about it.

Personally, having just been through the whole business recently, we had a fantastic obstetrician and some excellent midwives in the delivery suite, though once we left for the post-natal ward the quality and empathy of the ward midwives left a great deal to be desired. You get the whole range from the uncaring to the overbearing. Nevertheless, we have each other. And now two little boys.

We Need to Talk...

Milk & Two Sugars writes in regards to underperforming medical students and interns:

My opinion is this: that most people, when they fail to meet a certain expectation, are unaware that they're doing so. Unless we're told, we can't ever be expected to realise our shortcomings. So why - when an intern or student is lazy, ineffective, or otherwise failing to meet an important expectation - are junior docs reluctant to tell them to pull their socks up?

I must say that there are a few things to point out, M&TS:

1. Medical Staff in a hospital are like people on an escalator. At some point all of us had to step on, and started at the back, and then we moved up the line. We all remember what it was like being chastised, embarrassed and humiliated by the person in front, rare as those occasions might have been. We don't like doing it to those behind us unless things get really bad, and often by that stage it is a bit too late.
   

   Maxwell Smart's Cone of Silence The only way to have a private conversation in a hospital.

2. It is unprofessional to criticise a colleague (even a junior is a colleague) in public. Unfortunately, it is rare to find a private moment to have these discussions in a hectic day at the hospital. There is always somebody around - nurses, patients, other doctors.
   
3. Often the junior knows what is coming and will actively avoid situations where they have to confront their senior. This may happen deliberately or unconsciously.
   
4. Most of us have not had adequate training on how to deal with these situations, teaching modalities, and conflict resolution. Even when you can manage to sit down in private with this person, it is very easy to say the wrong thing, or to get so emotionally wound up about it yourself that you cannot be professional, courteous and objective in your feedback.
   
5. Not uncommonly, procrastination on your half may lead to avoidance behaviour by yourself as well. This may take the form of ignoring the problem, completing the tasks yourself, delegating the criticism or feedback to someone else (like a senior), or excusing the junior's behaviour. This may be rationalised away: "It's too hard to change them", "They're untrainable", "It's not worth the trouble", "It's faster if I do it", "It should be the Head of Unit that talks to them", "They've got a lot on their plate" etc.
   
6. Lastly, part of the journey is to learn some natural self-awareness. Usually I believe that the junior staff member is aware of their own faults - they just need gentle encouragement to improve their behaviour. Don't underestimate the power of the subtle look of disappointment, or the probing question which shows that both you and they know what the problem is but escapes everyone else. There comes a time when you will not always have someone else to pull you aside and talk to you - you have to keep an eye out for yourself.

There is a bit of an art to apprenticeship-style training. And while the quiet talk in private has its place, one should be judicious about when and how to use it. Unfortunately, most of us are not very good at this side of medicine. Not all of us are born managers, but it is inevitable that at some stage we have to manage someone who is not very good, and those skills come with time and practise.

As for advice for you, M&TS? Be proactive about your training and your faults. Our training system is intended to encourage medical students and HMOs to have enquiring minds, and to seek out answers. Your seniors may know the answers, but not be very good at teaching you. If you sit back and let it all happen to you, then you don't get the full benefit of the opportunities that are available to you.

Out of the Closet... and into the Frying Pan

Oh dear. It looks like Barb has been outed by a major print newspaper. I see little point in linking to the article, I am sure that Barb will have a copy soon if she hasn't already. In any case, she assures me that she will be back at work soon and can dish out as good as she gets.

Mind the Gap: Part 3 - Estimates of Costs

This is Part 3 of a series outlining the Australian Health Insurance industry from the perspective of a health provider. Dr Dork has prompted me to add an extra section to my series.

3. Estimates of Costs

Dr Dork said:

What disturbs me is when there is not financial disclosure prior to a procedure. I personally outline costs with every patient, and believe this is always necessary.

As a patient, I've also had some surgeons send me large unexpected bills. The bills don't piss me off. The fact that it is unexpected does.

Precedents demonstrate that lack of financial consent excuses the patient from paying, if they so choose.

Of course patients should expect an indication of the costs involved in their care - but just like when you contract a builder or any other tradesperson, the initial quote can balloon out if there are unexpected issues that need to be addressed.

As the "point man" (or "woman", or "person" etc...) the surgeon is often put under the spot to supply quotes or cost estimates from the private hospital, the assistant, the anaesthetist, the visiting physician, orthotics, physiotherapy etc. As things stand today, it is impossible for one doctor to presume to know what everyone else will charge.

Ultimately, such cost estimates are only indications of likely cost, and the failure is in the practitioner's ability to explain that to the patient. Usually this is because the patient is so worried about what the "gap fee" will be!

Things are somewhat easier for a physician (for the benefit of our US readers, internist) treating a patient as an outpatient - a set fee is charged per visit. Imagine giving the patient a quote for their hospital admission for, say, community acquired pneumonia? Who is to say how long they will be in hospital and how many inpatient visits or procedures you may be involved with? Should the patient refuse to pay anything beyond the first week because you said they would probably only be in hospital for that long?

Obviously the patient has the right to walk out of the hospital after a week, just as you have the right to fire your builder - but that's not very productive when you've got a half-built house. At the end of the day, if the builder fixed an unexpected major problem that had you been there you would have agreed to anyway (possibly because there is little or no choice) then would you deny payment just because they didn't talk to you first? Perhaps that is an issue of principle over pragmatism.

More on this series next week.