Bupa seeks expanded primary care powers

One of Australia’s largest private health insurers is calling for legal changes which would allow the sector to fund a broader range of services outside of hospital, including chronic disease management.
 
In a new discussion paper, Bupa, which currently owns dozens of general practices, said prevention must be central to health reform as the system ‘struggles to keep pace’ with chronic disease.
 
While current laws prevent health insurance from covering out-of-hospital medical services that attract a Medicare benefit, Bupa is calling for amendments to the Private Health Insurance Act 2007 to allow insurers to fund primary care-based activities.
 
It wants to ‘permit insurers to fund preventive health programs, early intervention and non-admitted care as substantive benefits’, covering risk assessment and screening, interventions, care coordination and chronic disease management.
 
The paper says eligibility should be determined by ‘clinical effectiveness and value rather than whether care is delivered in an admitted hospital setting’.
 
But Associate Professor Rashmi Sharma, Chair of the RACGP Expert Committee – Funding and Health System Reform, has concerns about the potential impact these changes will have on GPs and patients.
 
‘We support the broader objective of shifting Australia’s health system towards prevention, early intervention and better management of chronic disease,’ she told newsGP.
 
‘However, any expansion of the role of private health insurers into primary care needs careful consideration and must protect universal access, equity and the integrity of Medicare.
 
‘Any reforms should strengthen rather than fragment the healthcare system and existing models of care.
 
‘Any new funding or care models should be GP led, transparent and patient centred, rather than the commercial interests of insurers.’
 
Bupa already operates more than 30 GP clinics across Australia and has recently announced plans to acquire 68 GP clinics and three urgent care clinics from Partnered Health. It has also recently introduced free telehealth consults and expanded operation of mental health clinics.
 
The new reform paper demonstrates plans to further embed into the primary care sector, with recommendations to allow insurers to support coordinated care ‘across the full health continuum’, encompassing prevention, early detection, treatment ongoing management, and referral pathways, and facilitating information sharing between insurers, GPs, non-GP specialists, allied health, pharmacists and hospitals.
 
Associate Professor Sharma says any reforms should make it easier for GPs to coordinate care and improve access, rather than creating multiple pathways that are difficult for patients to navigate and further fragmenting the health system.
 
‘Patients could benefit if additional investment genuinely improves access to preventive care, allied health, care coordination and early intervention,’ she said.
 
‘However, we need to ensure patients are not left navigating multiple providers, funding arrangements or care plans with unclear responsibility for their overall care by exclusion of the regular GP.
 
‘We are concerned at the risk of preferential access for private health customers to general practice services, which is likely to reduce access to care for uninsured people creating equity concerns.
 
‘The focus should ultimately be on better access to high-quality care, continuity and better health outcomes and not simply on who funds or delivers the care.’
 
The Bupa paper also details a proposal to move Medicare toward a blended funding model by expanding MyMedicare with patient-linked funding for chronic and complex care.
 
This plan would require participating practices to align ‘internal remuneration arrangements with the model’, including sharing flexible funding with GPs, remunerating clinical oversight and coordination activities.
 
Highlighting that current funding has not kept pace with healthcare needs, particularly with complex and chronic conditions, the paper says Medicare’s fee-for-service funding design is ‘poorly suited’ to prevention and coordination.
 
It also says Australia’s care model does not consistently support specialists to work at the top of their scope of practice, and GPs ‘frequently need specialist input on a discrete question’ but the MBS provides no ‘dedicated mechanism for brief specialist advice outside a formal consultation’.
 
Bupa APAC CEO Nick Stone said healthcare must become more connected, preventive, convenient and centred around patients.
 
‘Too often, the system is organised around health episodes, institutions and locations rather than the journeys, continuity of care and outcomes that people face,’ he said.
 
‘Our ambition is simple: to help Australians live longer, healthier and happier lives.
 
‘That’s why we want to work with government and key sector leaders to ensure Australia’s health system remains sustainable, accessible and fit for the future.’
 
Associate Professor Sharma warns of the risks to general practice if insurers begin directing or delivering primary care without appropriate safeguards.
 
‘There is a real risk of fragmenting care and undermining the continuity that is central to quality general practice,’ she said.
 
‘We hear from members that patients receive services from private health insurer programs that are not integrated into the services being delivered by their own GPs, causing confusion and the risk of fragmentation.
 
‘Australia’s general practice system is already under significant pressure, and introducing another payer or care coordinator could add complexity and potentially undermine continuity of care.’
 
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Bupa chronic disease management continuity of care health funding preventive health private health insurers