The Independent Doctors’ Federation (IDF) has launched a campaign to address what it sees as the imbalance and lack of transparency between independent doctors and private medical insurers.
The IDF said it recognised that there are many cases where private medical insurer-doctor-patient relationships were very good and delivered high quality care and that decisions based on risk and profit would be taken.
But it said independent doctors had reported that insurer involvement in care pathways, fees and derecognition procedures were driving inequalities and sub-optimal standards in the quality of care, and limiting the free choice of professionals to provide clinically recommended care and freedom of patients to select their care provider.
The IDF represents more than 1,550 doctors working in private practice across the UK including specialists and general practitioners, and received responses from 474 members for its research that informed its campaign.
Health & Protection has contacted the three insurers named directly by medical professionals in the research, Axa Health, Bupa and Vitality, along with the Association of British Insurers (ABI) to offer the opportunity to respond fully to the issues raised by the IDF
‘Increasing power imbalance’
The IDF said: “We believe these issues result from an increasing power imbalance and lack of communication between these two groups.”
The IDF said that via its campaign it intended to work in collaboration with independent doctors, insurers, regulatory bodies and the government to develop mutually agreed ways of:
- Enabling doctors to be able to treat their patients to the best of their ability, in line with their clinical expertise and requirements of the GMC
- Ensuring that doctors are being fairly treated by PMIs, especially on matters of representation to the policy holders and reimbursement
- Addressing the grievances of patients and doctors to show the independent healthcare sector to be an attractive and effective alternative choice to NHS healthcare and position private healthcare as a viable solution to alleviating many of the problems in the NHS.
The IDF said its research had found three in four doctors claimed insurers have ignored their request to renegotiate fees, while more than half reporting they have been threatened with derecognition.
The IDF said: “PMIs are limiting the free choice of professionals to provide clinically recommended care and of patients to select their care provider.”
The IDF statement came out of research for the organisation’s campaign: ‘Make private medical insurers put patients first: Prioritise patient-doctor partnerships in independent healthcare’.
Derecognition reducing patient choice
One thorny issue is the threat or actual derecognition of doctors by the insurers, which the IDF said is reducing patient choice of specialist healthcare professionals.
But the problem goes beyond that with insurers using terms such as ‘recognised’ and ‘platinum consultant’ in conversation with their subscribers without explanation.
“These terms carry no professional weight and are not value judgements about the skill or quality of a doctor,” it added.
But the IDF noted that derecognitions also meant that independent GPs may be unable to provide nuanced referrals to preferred providers or those with specialist expertise.
“PMI policyholders are, then, not receiving the choice of surgeon, range of therapy, speed of care, or, potentially, fully covered treatment they expected from their insurance plan,” the organisation added.
In one case a vascular surgeon reported that a Bupa patient cancelled their procedure because the surgeon’s preferred anaesthetist was delisted for refusing to accept the insurer’s reimbursement levels.
The patient reported to the Federation of Independent Practitioner Organisations (FIPO) that they considered this meant the anaesthetist was ‘no good’.
And the use of the term ‘platinum’ by Bupa for some doctors was also raised as an issue.
The IDF said customers are led to believe that ‘platinum’ status is a mark of quality or rating with the Bupa website suggesting platinum consultants are ‘highly rated’, whereas it argued it was actually a measure of the business a doctor provides Bupa.
“Removal of ‘platinum’ status is therefore misleading as it appears to be a negative judgement of a clinician,” the IDF said.
Power imbalance
The IDF said another issue is the power imbalance in the insurer-doctor-patient relationship – which was weighted heavily in favour of insurers around fee-setting and contributed to by a lack of transparency.
The IDF said: “Insurers hold a disproportionate amount of power in their relationships with independent doctors and hospitals.
“This enables them to determine treatment requirements, set approved fees and derecognise doctors inconsistently and with relative impunity.”
It added that fee-schedules are not increasing in-line with practice costs.
The IDF said: “Two insurers provide funding for care for about three quarters of the private healthcare market making the insurers’ threat of derecognition, and therefore not receiving anymore patients, coercive and influential in clinical decision making.”
Meanwhile, insurer fees for treatments have not increased, in actual terms, since the 1990s – decreasing relative to inflation, the IDF alleged.
The IDF said: “Stagnation of doctor’s fees is not a result of insurers also facing financial pressures as, although the volume of care covered by insurers has increased, profits have significantly increased.”
The IDF said insurers assess the value of certain treatments by looking at the whole care pathway including the fees for doctors, anaesthetists, and also the fees paid to the hospitals.
It said that doctors and anaesthetists fees comprise between 20% and 25% of the cost of a whole surgery. For example, for the £20,000 cost of a knee replacement surgery, the surgeon and anaesthetist fees are £4,250.
“To save costs, insurers are reducing the real-term fee paid to doctors, or derecognising them when they request uplifts, rather than addressing the largest treatment cost – the privately negotiated prices paid to hospitals,” it said.
And sometimes doctors are being deregistered without a rationale being given by the insurers or based on disputed or subjective claims about a doctor’s quality and cost.
The IDF said: “Doctors who re-register have to agree to the fee-approved schedules and potentially face lower reimbursement rates than they had previously.
“Doctors’ ability to provide their preferred care is constrained by these threats and processes and they are currently without an independent advocate or appeals process to challenge derecognitions.
It added that Bupa had in some cases lowered agreed-fees without consultation of the independent doctor, and asked them to not charge the patient any shortfall.
Prioritising cost over care
Another key issue for the IDF was the belief that the insurers are prioritising cost over patient experience or care, when setting preferred care pathways.
The IDF said: “Insurers are often deciding on and providing a care pathway for their policyholders that is primarily designed to constrain costs – rather than provide the best or fastest treatment.
“Pathway decisions are not approved or regulated by independent clinical experts as insurers are only financially regulated and also often fail to account for differing levels of expertise or specialisms between professionals.
“As a result, PMI patients may be unable to access optimal treatments as part of their policy, potentially receive a lower standard of care compared to self-pay patients, can face delays to receiving the appropriate care, and may be directed to less experienced doctors or specialists. “
The IDF said many patients had reported being referred to doctors who do not specialise in their condition or had been placed on sub-optimal treatment pathways, against clinical recommendation.
It said patients were also often required to do their own research to find clinicians for their treatment or to check the appropriateness of the insurer-recommended clinician, requiring a significant amount of time and also giving treatment pathway decisions to patients without clinical expertise.
“Referral and treatment decisions should be consultant-led in partnership with the patient and potentially independently clinically regulated,” it added.