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Bupa policy shift labelled move toward ‘managed care’

07/03/2018By Matthew Woodley • Staff Journalist
A plan from Australia’s largest private health insurer, Bupa, to restrict gap cover only to procedures performed on patients within its network of approved hospitals and medical centres has been met with dismay by the country’s peak medical bodies.

The policy update, which will commence on August 1, has been described as a stepping-stone towards ‘managed care’ by Australian Society Ophthalmologists (ASO) president Dr Peter Sumich, who believes it would be a fundamental and philosophical change in the way private health insurance has been delivered in Australia.

“From that date on, if you have a Bupa patient and you’re not at a Bupa centre, which is 30% of day surgeries, that patient will have to make a decision on whether they stay with you and risk substantial out-of-pocket expense, or find another surgeon,” Sumich said.

“The alternative is the surgeon ends up going to a hospital that does have a Bupa contract. It will certainly affect a lot of ophthalmic day surgeries.”

According to The Australian, Bupa has justified its move by saying that there were many cases in which customers had not been told when booking that the facility was not contracted with Bupa.

“When this is combined with ad hoc use of the Medical Gap Scheme, customers have been left with large out-of-pocket costs without full, informed financial consent up¬front,” the spokesperson said.

“This change only impacts a very small portion of Bupa claims, with more than 96% of all Bupa claims for same-day and overnight admissions currently going through contracted facilities.”

However, Sumich told Insight aside from the effect the change would have on restricting choice for surgeons and Bupa patients, there could be larger ramifications if other health insurers adopt similar policies.

“If the other funds follow suit, the whole problem gets magnified. They’re setting a precedent and it is a huge, tectonic shift in the way private health has traditionally been managed in Australia – and people don’t understand it,” he said.

“We’ve spoken to the minister and informed him of our concerns. The Australian Medical Association will be running a campaign and we’ll be assisting the AMA, and the council of procedural specialists will be also involved.”

The president of the AMA, Dr Michael Gannon, has already spoken out against the policy shift, both publicly and in a letter sent to members on Monday.

“These changes are bad news for the profession and our patients. They are bad for the reputation of private health insurance. They are bad news for the contribution that the private system makes to the Australian healthcare system,” Gannon wrote.


“I have raised our concerns directly with Minister Hunt and his office, highlighting that in addition to heading down a managed care pathway, Bupa’s change undermines a lot of the work performed by the Private Health Ministerial Advisory Committee over the past 12 months.”

“We have requested the government urgently seek advice from the Department of Health and the Private Health Insurance Ombudsman as to the legality of Bupa’s actions,” he added.


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