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Wondering about the value of PHI?

22 March 2017

Between last week’s Senate Inquiry* and the current focus on renewing annual private health insurance [PHI] policies, the value of PHI is under the spotlight. So how is value really delivered?

We believe it comes down to ‘choice and access’. PHI provides consumers control and choice over the timing of treatment, clinician and services – compared with accessing healthcare through the public system. For HCPs, the PL arrangements provide a wide range of clinically effective medical technology with certainty of costs for all parties.

Only HCPs – in partnership with their patients – should have the right to choose the most appropriate medical technology or treatment option. In a Galaxy Research poll[1], it was almost universally acknowledged that implantable medical devices are important in promoting better health [99 per cent] and quality of life [100 per cent]. In Australia there is considerable confidence in the ability of doctors to choose a device suitable for the needs of the patient; as many as 82 per cent of respondents believe that the doctor should be responsible for the selection of the medical technology that is implanted.

Any significant restriction in the ability for clinicians to choose the best device for their patient diminishes the value of PHI for the consumer. So what happens when a medical device isn’t included on the PL because the PL in its current form has failed to keep up with medical evolution?

Health funds are not required to reimburse non-implantable medical technologies used in hospital procedures, which often leads to limited or no funding for these devices. Technologies that do not meet the criteria of the PL include:

  • Catheters used for ablation of Atrial Fibrillation [AF] [one of the most common reasons for emergency room visits in Australia],
  • Drug Coated Balloons for a range of vascular blockages [which can replace stents that remain in the body and are currently covered on the PL]; and,
  • Ablation Catheters to treat Barrett’s Oesophagus [which can lead to cancer, radical surgery to remove the oesophagus and death].

These are just three examples – there are more, with the potential to benefit large numbers of Australians. And it’s not just the patient numbers that are large. Consider AF – AF is a leading cause of stroke. Stroke costs the Australian community more than $5 billion each year. The total PL is significantly less than half of this… and that’s just one unfunded technology. Imagine the potential, the patients and their families we could help through reform of the PL and greater access to currently ‘unfunded’ technology.

The PL arrangements should be expanded to incorporate non-implantable technologies [including diagnostic and monitoring technology] that that provide improved health outcomes, cost savings and / or efficiency gains and are aligned with best clinical practice. This would support the use of medical technology based on the most appropriate treatment option rather than the availability of PHI coverage.

As part of the PL reform activities, there is now opportunity to address this anomaly to improve patient outcomes, reduce health system cost, and enhance value to privately insured patients. We hope this is achieved so that the right product gets to the right patient, at the right time.

In the meantime, if you take out PHI, it’s important to be assured you are covered for all appropriate treatment options and to discuss the best option with your doctor.

Note: *The title of the Inquiry is “Price Regulation Associated with the Prostheses List Framework” The title includes reference to ‘Price Regulation’, but when we talk about the PL it isn’t actually a ‘price’, it is a benefit for PHI members when they go to a hospital to receive lifesaving and/or enhancing medical devices.

[1] Galaxy Research. Medical Devices Study. Prepared for Medtronic Australasia. May 2015 eive lifesaving and/or enhancing medical devices.

 

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