Why your patient can’t see you now

A previously healthy 72-year old woman, Clare*, requests an increased dose of the opioids first prescribed by another GP via a telephone call. She has become housebound during the pandemic with severe right hip osteoarthritis, aggravated by immobility, weight gain and depression. The longer Clare waits for hip replacement, the more complex will be her recovery and the more likely she will permanently lose her independence. She has recently downgraded her private health insurance to “bronze” and she cannot afford specialist gap payments. The local public outpatients are closed. What are her options?

THIS common scenario illustrates the pandemic’s negative impact on patient access to our public and private health systems for non-coronavirus disease 2019 (COVID-19) conditions. We are yet to quantify the full extent of fragmentation of GP care and disruption of specialist referral pathways. However, the familiar story of patients like Clare is warning us of the emergence of major health inequities due to patient financial hardship.

Will our current health system, like the economy, soon fall off a cliff? Over the next few months, unless we take positive action, more Australians are likely to drop or downgrade their private health insurance if financial hardship becomes more widespread after the inevitable withdrawal of governments’ general financial support in September in the context of an ongoing recession. If this occurs, it may precipitate a crisis in public hospitals, whose resources are already stretched trying to enforce social distancing and infection control in overcrowded public accident and emergency departments, as well as managing blow outs in waiting lists for outpatient departments and elective surgery.

Although these issues require urgent attention, many of our medical leaders are too swamped by the risk of a second wave of COVID-19 to consider the underlying flaws in our current public and private health systems exposed by the pandemic.

Here are a few examples:

Some dismiss the current underutilisation and non-viability of many traditional private GP and other specialist clinics as temporary.

What cannot be ignored is that corporates are using their scale to recruit additional GPs and effectively market efficient 24/7 e-triage and online booking systems, generalist and subspecialist telehealth directories and bulk-billed telehealth services to the whole population, across state boundaries, including regional and rural Australia (Access Specialist, HealthShare, MindTheGap, SeekMedi, whitecoat). There has also been concern that some pharmacies have been promoting such national telehealth services, where patients can access prescription medications without consulting their local GP.

If our patients continue to switch allegiance from the cottage industry of small private GP practices to corporates, should we be surprised when specialist referral pathways are also disrupted?

Before the pandemic, it was widely predicted that artificial intelligence would soon disrupt traditional health care. The international best-selling book The patient will see you now explored ways new e-health technologies will empower consumers to be more assertive in their health care choices. “Your patient can’t see you now” is the current reality as many patients do not wish to sit in traditional medical waiting rooms, not only because of the risk of COVID-19 spread but because it is inconvenient.

For all these reasons, unless traditional private GP and other specialist clinics proactively respond to patient feedback and embrace change, the landscape of medical practice will be irrevocably shaped by corporatisation and new e-technologies.

As an example of the way health consumers are driving change, patients facing financial hardship are, in my experience, requesting transparency of specialist gap fees before a GP pens a referral. Early in 2020, before the pandemic, the federal Health Minister’s push to provide clear sight of out-of-pocket costs was met with resistance from some medical organisations representing surgeons. Only a few months later, surgeons are considering providing visibility of their fees to referrers or on online specialist directories to mitigate the risk of being underutilised in the future.

Hospitals are also being disrupted by the pandemic. In the past few months, public patients have been admitted to private hospitals under government viability contracts and private patients are continuing to be encouraged to use their insurance in public hospitals, giving health consumers an opportunity to see first-hand the pros and cons of each sector. In the future, health consumers are more likely to make assertive choices across both the public and private health systems, including self-pay options.

Private hospitals are currently focusing on the recent lifting of elective surgery restrictions, which has resulted in a flood of private hospital theatre bookings. Beyond this initial rush, there is no guarantee private hospital activity will return to pre-pandemic levels, as many private specialists are concerned about falling private health insurance membership and a drop-off in the pipeline of new GP referrals. When the government viability contracts and JobKeeper allowances for practice staff expire in September, many private hospitals and specialists may find themselves under financial strain. Investing more time now into nurturing new relationships with referrers, rather than simply bombarding general practices with ineffective paper marketing and social media publicity, may cushion the impact.

Private health insurers also risk underestimating the negative impact of the pandemic on their members’ ability to continue to pay the high cost of premiums. A number of insurers have contributed part of their savings from the recent bans and restrictions on elective surgery to set up info-lines, telehealth services for psychology and physiotherapy, and temporary hardship provisions. However, it is unlikely that these strategies along with the deferral of premium rate rises, will slow the tide of young people abandoning or downgrading their private health insurance unless radical steps are taken to reform our flawed private health funding model.

In February 2020, unrelated to the pandemic, the Australian Prudential Regulation Authority attributed a poor prognosis to private health insurance and called for “difficult conversations and even tougher decisions involving all the industry‘s major stakeholders, including Government, insurers, regulators, medical practitioners, hospital groups, as well as device manufacturers, pharmaceutical companies and … health fund members”. There was also a foreshadowing of consolidation of the industry from 37 top heavy funds to three.

However, instead of dealing with the underlying issues raised by APRA, many private health insurers have focused on cutting costs by pressuring private hospitals to accept poor indexation rates below the consumer price index and well below medical inflation. As it is common for these difficult negotiations to break down forcing private hospitals to accept unfavourable second tier rates, the Commonwealth Ombudsman released guidelines on termination and transition last month to protect health consumers from being subjected to additional gap payments during contract disputes. Unfortunately, private health insurers and private hospitals appear to be engaged in a time-consuming cold war, rather than a constructive alliance in the best interests of members such as our hypothetical patient, Clare*.

The reality is that there will be no new funding for significant public health reform in the foreseeable future as our governments are preoccupied with the massive blow-outs of their deficits. However, there is a need to debate the best way to use existing government funding to improve patient access to both the public and private health systems.

Meanwhile, the scale of the blow-out in public elective surgery is currently hidden by prolonged waits or closure of public outpatient clinics. In response, public hospitals are considering outsourcing part of their massive elective surgery lists to private hospitals at cost-efficient prices.

To deliver affordable and quality health care, the system must find ways to eliminate waste and reduce cost without negatively impacting the level of care for patients.  No one party unilaterally deliver this outcome.  This will require a concerted effort of collaboration to examine procurement models, prostheses costs, use of consumables and length of stay. In many countries, high acuity surgical care is provided in day or short stay hospitals using advances in virtual hospital and rehabilitation in the home, resulting in quality patient outcomes at a significantly lower cost. It’s never been a better time for public and private Australian hospitals to invest in new remote e-monitoring technologies and virtual hospitals in the home or nursing home, particularly while the risk of COVID-19 spread in traditional hospitals is real.

In the current environment, it is incumbent on the leaders of medical and other peak organisations to collaborate and to advocate for better patient access to both the public and private health sectors (here and here). Just as we have seen pandemic plans emerge rapidly to keep vulnerable populations from being hit hardest by COVID-19, we can apply the same agile thinking to prevent the predicted increases in morbidity and mortality due to non-COVID-19 conditions.

For patients like Clare*, it is important to find solutions fast. The status quo is not an option.

Clinical Professor Leanne Rowe AM is a GP and current Chairman of Nexus Hospitals. In the past, she was Chairman of the RACGP and served on the boards of three private health insurers.

All the views expressed in this article are those of the author not of the organisations she works with.

(*Not her real name)

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.