Medical Forum WA 10/14 Public Edition by Medical Forum WA

Editorial

By Ms Jan Hallam Managing Editor

One Gap too Far? Sept

Out-of-Pocket Costs Some stories uncork an army of genies, and our story last month about specialist fees, private hospitals and a consumer attempting to navigate through a headspinning array of item numbers, gaps, known gaps and possibly even tiny cracks hit nerves. Our e-Poll this month asked readers for some of their own experiences and not surprisingly, there was a flood of those as well, and high on the list were messages and phone calls resenting any perception that they were “only in it for the money”. One specialist was audibly upset that his 14-hour days should be reduced to such a simplistic notion. He was aggrieved that some health funds were making it almost impossible for him to stay afloat. One e-Poll respondent summed up the complexities: “It would be very helpful if Medical Forum ran an article on what the differing amounts different health funds pay specialists … if a surgeon wants to charge the patient a gap to account for the extra hours in theatre to do a complicated case of say $500, HBF pays nothing extra apart from the Medicare rebate to 100% of the schedule fee. They pocket the rest of the money they would pay the surgeon if the surgeon registers as a no gap provider. While Medibank Private and Bupa allow a $500 gap and the rest of the account will be paid as a no gap provider as the normal full amount.” We asked HBF to comment on this complaint with Executive General Manager of Health and Wellness, Ms Jennifer Solitario, replying that HBF’s no gap or known gap products gave members a higher level of certainty of their out-of-pocket costs and the fund achieved

The cost of private health care was under the spotlight in this month’s poll of doctors. Of the 146 respondents, 60% were GPs, 34% specialists, 2% DITs and 4% others.

Health consumers with private health insurance may face out-of-pocket expense following an episode of care in a private hospital. In your experience, where does most out-ofpocket expense come from? The hospital

14%

The specialist

24%

The laboratory

14%

The imaging provider

20%

Ancillary health (pharmacy, OT, physio, etc)

17%

Uncertain

10%

None of the above

better results than other insurers, for which WA specialists saw value. However, Ms Solitario said health funds weren’t qualified to judge the complexity of individual procedures and took their lead from Medicare. Where additional complexity resulted in a different item number it would guide the benefit funds pay. This discrepancy in the market place doesn’t make for happy camping and clearly causes deep emotions within the profession. For the consumer, who is unwell and facing surgery, it can be a totally bewildering experience. O

ll e-Po

Faced with elective ctivve surgery in a private rivate hospital, if a health consumer asks for your recommendation of hospital or specialist, is out-of-pocket cost to them usually a consideration? Yes

64%

23%

Undecided

Doesn’t apply

Comments It was a case of how long is a piece of string on the complex questions of private health insurance. As one GP put it: “No matter what your insurance policy, it is difficult to anticipate what and how much will be covered until the episode of care occurs.” It’s not straightforward for specialists either: “As a surgeon I am meant to provide informed financial consent which is now impossible because, although I, my anaesthetist and the hospital are “no gap”, the path lab, radiology, OT/Physio are not, so it is impossible to provide an estimate of fees.” “Radiology and pathology should be covered totally by a combined Medicare/private health rebate agreed fee.” One thought it could be simplified if private hospitals took on the responsibility of informing patients about out-of-pocket expenses and summarised by another: NO RULE FITS ALL O