Dear Member of the BHS,
The British Hip Society is a Specialist Society allied to our Professional organisation - the British Orthopaedic Association (BOA). The BOA is a Registered Charity whose
"objectives are the advancement for the public benefit of the science art and practice of Orthopaedic surgery".
It is our duty to promote the very best quality of care for patients in need of orthopaedic treatment. Currently there are some practices in the delivery of healthcare, whether funded by the NHS or by Private Sector Insurers, which we feel may seriously undermine the quality of care given to patients.
In order to provide the best care for patients
Unfortunately we are seeing increasing evidence that the pathway for patient care does not always follow this model whether funded within the NHS or by Private Insurers.
We are all aware of the uneven access to healthcare and the variability in quality some patients have suffered over the past decade caused by the continuing re-organisation of the NHS and fragmentation of access to musculoskeletal services. New pathways for referral of patients to Any Qualified Provider (AQP) are presently being drawn-up since the Health and Social Care Bill has passed into Law. The BOA is actively advising the Commissioners on details of the Quality Pathways which AQP should have in place before care is commissioned. The BOA has shown that a 15% capacity gap exists between available capacity and deliverability despite a 300% increase in orthopaedic efficiency. The fundamental principles for quality care, for both the patient and surgeon, are listed above and the BHS, through the BOA, will fight for these fundamental principles to be adhered to in the public sector.
Several Private Insurers have policies in place that restrict patient Choice and, in some cases, may restrict the quality of service available to them. It is important that patients are made aware of the limitations to the care, in an open, honest and transparent way that may be available to them when they opt to have treatment funded privately and that they understand fully the limitations of some policies from Healthcare Insurers.
How do patients experience dissatisfaction and limitations?
1. Empowerment and "Choice"
The patients may be restricted in their ability to see a surgeon of their choice:
a. Because the surgeon may not be "recognised" by the Insurer
b. On account of initiatives such as an "Open Referral policy". This type of policy has applied to some corporate subscribers from 1st January 2012. A patient is actively managed to see one of the surgeons on the Insurer's list who have agreed, some after the threat of de-recognition, to charge within the insurer's unilaterally imposed reimbursement levels.
2. Timely access to a surgeon with the appropriate skill set and experience
On first contact with their insurance company and, prior to any Consultation, some insurance companies will usually attempt to direct patients to a surgeon whose charges are known to conform to their preferred schedule of fees. The Insurer will not have detailed knowledge of the experience and skill set of the surgeon involved to make a recommendation based on clinical considerations such as quality and outcomes.
The most appropriate or experienced surgeon to address the patient's problem may not be available for a number of reasons.
a. The Insurer may not pay any or part of the fee and the patient will have to fund all or a proportion of the treatment episode. The insurance companies know that patients are locked in to their existing policies and if they decide to change insurance providers they will not be able to find cover as this will be treated as a pre-existing condition.
b. Some experienced, skilled surgeons have given up, or are considering giving up Private Practice since the escalating expenses of providing the service are not adequately covered by the income they are able to generate given the level of reimbursement now allowed by some insurers.
c. For several insurers the patient is required to "Pre-authorise" an investigation, procedure or operation advised by their surgeon before it can proceed. This is a vetting procedure by some companies using insurance-based clinical guidelines and external review of the case by clerical staff or doctors who have never seen or examined the patient. The BOA and the Royal College of Surgeons do not support the use of distant second opinions.
d. Some insurers have negotiated preferential contracts with certain hospitals which then form part of their hospital network. In some areas there is a greater range of expertise and services at a hospital nearby (e.g. Intensive Care service) which are only accessible to some insured patients only under exceptional circumstances.
e. Historically, the GP has usually referred to a specialist known to provide a quality service. The aim of some Insurers is to break this referral mechanism and the nature of the contract that exists between the patients and clinicians. It appears to be the ultimate aim of some Insurers to introduce a form of Managed Care in which the insurer would control all aspects of patient care from pre-authorisation of what treatment is allowable to the choice of consultant and the level of fees payable.
3. Re-imbursement Fees
Some insurers have not raised their reimbursements to cover consultants fees since 1993. BUPA has just announced a reduction in reimbursement from the 1993 levels for a number of common courses of treatment and operations across a number of medical specialties. The average cut back is nearly one third (32.25%), across 39 common operations so far declared by BUPA.
If we use, as an example, Total Hip Replacement the average reimbursement fee for the surgeon represents no more than 10% of the total inpatient cost. If we now consider cost increases in line with inflation using the Retail Price Index between 1992 and 2012, £1000 payable in 1993 would be £1526 today. However the costs of medical practice (Medical Indemnity, secretarial and other practice expenses) have increased significantly over the same time period. It is for this reason many surgeon are questioning whether they can still afford to provide a private service. Access of patients to have private treatment by the surgeon of their choice will be further limited.
A form of this letter will also be available for you to give or send to your patients.
Please also find attached a Newsletter from FIPO (Federation of Independent Practitioner Organizations) and a FIPO Patient Information sheet for your information along with a template for a request for information under the Data protection Act. FIPO set out the options that are available for you with regard your interaction with Private Insurers and what actions you may take with the aim of improve the quality of care available for your patients.
The affiliated specialist societies will be represented through the BOA and that body will continue to engage with the Healthcare Commissioners advocating the implementation of High Quality Standards for care within the NHS which should also be extrapolated and used in the private sector. We will keep our Membership informed as this issue continues to develop.