The consultant leading the Independent Doctors Federation (IDF) campaign to overhaul the working relationship between private doctors and insurers believes some insurers operating in market are exhibiting anti-competitive behaviour and creating massive inequality in how doctors are treated.
IDF specialist committee chairman Andy Roche has told Health & Protection he wants to create a “fair and transparent system” governing the doctor-insurer relationship.
Roche, who is a consultant and orthopaedic surgeon, highlighted several key issues which have been brought into scope following research conducted by the organisation among private practitioners.
“I’m not trying to move any market, we’re simply trying to create a system and a relationship between the insurance company, the patient, and the medical provider where there is transparency and fairness and equality for all,” he said.
“For too long there’s been a massive inequality in how certain insurance companies treat certain doctors.
“And it’s not particularly based on anything sound, and it seems to be just financially driven by the size of the market share, which is wrong.”
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 and claims raised by the IDF.
Three goals from long-running dispute
The dispute between the medical profession and some private medical insurers is a long-running one, with issues particularly around fees paid being raised for many years.
In March last year at Health & Protection’s first Health Summit, Federation of Independent Practitioner Organisations (FIPO) chairman, Dr Richard Packard, warned patients could face increased wait times for private treatment unless insurers can effectively sort out the issue of fees paid out to consultants.
And this week’s research among IDF members raised very strong feelings and many further issues which have been reflected in the organisation’s aims to change what it believes is a market power imbalance that has swung too far towards the largest insurers.
The IDF has set out three key aims to its campaign and said it intends to work in collaboration with independent doctors, insurers, regulatory bodies and the government to develop mutually agreed ways meeting those goals.
They are:
- 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 General Medical Council (GMC);
- ensuring that doctors are being fairly treated by insurers, especially on matters of representation to the policy holders and reimbursement;
- and 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.
What does that system look like to Roche compared to the current process?
“I want a fair and transparent system that governs the doctor-insurer relationship, giving the doctor the ability to treat the patient to the best of their ability to choose the level of care they feel the patient needs through evidence-based medicine, without any significant interference from the insurance companies, who tend to govern the level of care based purely on financial expense on their behalf,” he argued.
“So if a patient chooses to have a treatment and it’s discussed carefully between the doctor and the patient then they should have the ability to do that.
“And if they choose not to have that treatment for whatever reason, then they should have the ability to go and see another doctor or go down another avenue of treatment.
“So really, it’s about a fair and transparent system that is available to all of the doctors,” he added.
Regulatory intervention
The private health market is little more than a decade removed from its last regulatory intervention which focused on the provider market, including hospitals and doctors.
This led to many interventions including the creation of the Private Healthcare Information Network (PHIN) to which hospitals, clinics and medical practitioners are required to report key data such as patient outcomes to be published openly giving greater information to patients.
At the time of the enquiry there was urging from the practitioner community to focus on insurers and that demand has only grown louder over the last ten years.
Now Roche is steadfast in his belief that the insurance market needs to be examined for potential anti-competitive actions.
“Whether it’s the Competition and Markets Authority (CMA) or another regulatory body, that’s something we will be looking into,” he continued.
“There is certainly an anti-competitive behaviour by some of the larger insurance companies who perhaps have garnered a more significant corner of the market, therefore potentially restricting patients access to certain specialists or to certain locations.
“In fact, for one example, there’s many reports of whole regions of certain surgeons being excluded from Bupa because these surgeons are not working with certain other types of doctors who are on the fee schedule of the same company.”
Roche said this approach was “outrageous” noting these surgeons had been “working diligently for many years but were being penalised because of who they associate themselves with”.
“This is unique to certain areas of the country and then ten minutes down the road, the same groups of doctors are working happily together,” he continued.
“It’s just not particularly transparent as to why certain big insurance companies have made these decisions, which may be penalizing certain doctors in certain parts of the country.
“And that should be investigated as to why these things happen; whether that’s through one regulatory body or another, we’ll see.”
Doctors withdrawing from insurers
In terms of next steps, Roche was unwilling to discuss the IDF’s strategic plan, but said the body would be gathering responses from its initial calls, including political bodies and from insurers.
He also noted some insurers had tried to pre-empt the IDF’s findings and change their behaviour, but added “in some ways, it seems like they’re just trying to paper over cracks rather than do anything more meaningful”.
Given the strength of feeling among the practitioner body coming from the research and the apparent gulf in views between parties, there seems a long road to cover in this issue.
And the prospect of practitioners withdrawing from private work is a very real one with some already doing so.
“That’s already happening up and down the country; there’s lots of doctors who are not working with certain insurance companies,” Roche said.
“There’s no collective action, but certainly there’s lots of doctors individually who have taken the decision already to distance themselves from certain insured patients, which in its own way is distorting the market, but this is being driven completely by the actions of the insurance company.
“Now, these patients are being perfectly well looked after by other doctors, I’m sure, but it shouldn’t happen,” he added.
Fees unchanged
Perhaps the most high-profile subject raised by doctors is the level of fees paid by insurers, which they argue for some treatments could in-effect be loss making given the time and resources needed to perform them.
Roche argued that remuneration through some insurers had not changed since the 1990s and that they had actually gone down.
“Would you stay in your current role if you were getting paid less than your colleagues did nearly 30 years ago? Arguably, you probably wouldn’t,” he said.
But he added that pay for doctors was not the key subject in this dispute.
“One thing I want to make very clear is that this isn’t all about doctors trying to get paid more money,” Roche continued.
“This is about doctors trying to work in a fair and equitable system, and to be able to have the freedom and independence to treat their patients how they want and how the patient agrees.
“But yes, there are procedures out there that could be more time consuming and for some reason they’re much less remunerated by the insurance companies.”
Transparency for derecognition
Derecognition of doctors by private medical insurers meaning they will not make them available on lists was a particularly prickly subject raised from the research.
Doctors raised significant concerns about how the process was handled and argued that while they regularly saw derecognition decisions based on meeting fee levels, insurers flagged their lists as based on quality of care.
As a result, doctors argued they risked damage to their reputation if patients thought they had been delisted for care quality issues when it was because of fees.
“There are reports up and down the country of doctors being de-recognised by insurance companies for absolutely no reason,” Roche argued.
“When the insurance companies are challenged, doctors are told that administrative errors were made and they could be reinstated immediately.
“There were reports that doctors have been de-recognised for not abiding by the fee structure, but these are doctors who are technically fee assured, so therefore they have signed contracts with insurers to say they will abide by the fee structure.
“Yet these doctors are being taken off certain networks, certain referral pathways with insurers, even though they are completely fee assured and the reasons being given are very unclear.”
Roche said reasons typically centred around the charges for facilities the doctor is working in being too high, but argued doctors had no control over these, aside from not working there any more.
However he added that doctors within the same hospital maybe retained on insurers’ books.
“For some reason, insurance companies have just taken this on a whim to remove doctors from certain referral networks, which is completely unexplained, and it’s happening a lot.”
Chronic conditions and treatment control
A further problem raised by the research is insurer control of medical treatment offered to patients.
There appears to be a particular pinch point around the definition of chronic conditions and what care should be allowed for these treatments, while Roche noted following NICE-approved care typically used in the NHS could also be problematic.
“The treatment pathway is almost invariably exactly the same as on the NHS and following NICE guidance you can get these sorts of treatments through the NHS,” he continued.
“However, through the insurance company it seems that can be much more challenging.
“The insurers can put up blocks to say, for example, you’re not allowed to have another injection because it deems the problem chronic, therefore, it does not cover the problem under the policy.
“You could argue this is down to the patient understanding what their policy enables them to do, but most patients would take out a policy saying it’s covering X condition and that would be covered irrespective of the treatment offered by the doctor.”
He added: “It may say in small print we will not cover chronic conditions, but how do you define chronicity? There’s no worldwide definition of chronicity in a medical condition.”
Tackling such significant differences between practitioners and insurers suggests the prospect of a quick conclusion seems unlikely.
Roche and the IDF are prepared to play the long game if they can make progress.
“There’s no timeline set for making progress, but obviously you would imagine that the sooner the better,” he concluded.
