Do you know who your GP clinic is? The answer may surprise you

In the United States, it is not uncommon to see GP clinics with signs that say “No Medicaid patients” or “Insured patients only”.

It points to a troubled health care system filled with stories of uninsured patients being denied legitimate care and dire health outcomes for the uninsured.

In Australia, where GPs have long complained that drug discounts are not keeping pace with costs, the threat of “no Medicare” doctors in the telehealth space has become very real.

Medicaid is not the same as Medicare, but it is a government-subsidized health care system for low-income earners in the United States.

In the United States, doctors can opt out of Medicaid and sometimes do because of its low reimbursement rates.

In Australia, Major insurers such as Medibank Private and Bupa have been open about their moves to buy and open GP clinics, and are fast becoming major healthcare providers.

Similarly, all four major insurers now offer some free or heavily discounted GP telehealth procedures to their members.

The important thing to remember about this is that these phone health consultations are not covered by Medicare, and insurers pick up the tab entirely.

It is the result of a combination of two laws that basically make it legal.

This is why doctors are raising concerns about a possible two-tier system.

Insurers say anyone can access these phone services, and that’s true, but the problem is the price point.

By making it cheaper for members, insurers are starting to create a second tier where the privately insured have easier access to care, because it’s more affordable for them.

As Australian Medical Association Vice President Julian Wright points out, in a situation where Australia has a shortage of GPs, there is potential for these insurance-led GP services to attract GPs to their organisations, particularly if they are well paid.

With longstanding criticism that Medicare rebates aren’t keeping pace with costs, it’s easy to see how “no Medicare” doctors could become a reality in the online telehealth space.

Encourage referrals to selected insurance specialists

Along with GP clinics, Medibank buys private hospitals and offers its “hospital at home” care services through its subsidiary Amplified Health.

This has sparked concern among doctors that Australia is slowly moving towards an insurance-led healthcare system, commonly referred to as ‘managed care’.

The AMA told the ABC it was concerned that if a health insurer owns a GP clinic, it encourages it to refer patients to the insurer’s own hospitals or preferred network of specialists.

There are laws to prevent this; However, the argument is that the conflict of interest is too great and the potential for perverse incentives too high.

While patients can even get a nominal referral anywhere, most rely on their doctor to know who to go to and which hospital will suit their condition.

Insurers may try to save patients money, but what that ultimately means is that patients have little choice.

We know that when there is less choice, one thing happens: prices go up.

Health Minister Mark Butler told the ABC the government did not support a two-tier system.

This is despite obvious facts showing that it has already started to emerge.

Insurers say the system is different

Now insurers are loudly arguing that Australia’s system is too different to the US.

In many ways it is: Anyone can buy health insurance under our community rating system and it is not offered through employers.

Insurers are also tightly regulated in what they can and cannot cover through the basic gold policy system and they often have to respond to medical committees that decide what is and isn’t covered.

However, they are slowly moving into more healthful spaces and pushing the boundaries to influence care when the laws allow it.

Orthopedic surgeons with a large share of private hospital work say they’re seeing more insurance overreach: with policies that don’t cover some of the prostheses they want to use and claims for reconstruction limitations in insurance contracts with hospitals — something the industry opposes.

This was also seen in the Ombudsman’s review of Type C certificates – these are used to indicate that a procedure normally carried out in a specialist’s room is carried out in a hospital and claims private health.

So, for example, a Parkinson’s patient may need sedation to allow eye injections.

The ombudsman found that some health insurers were questioning these documents and leaving them in limbo, in effect denying claims out of sheer greed.

Some insurance efforts may be well-intentioned, such as preventive care pilots in GP clinics.

While anyone can access the one run by Medibank Private in Western Sydney, this does not change the fact that the insurer stands to profit if it can reduce hospitalizations, and thus insurance claims for its members.

While there is no suggestion that there is anything wrong with the Medibank pilot, theoretical issues arise if insured patients receive better treatment or if they are told where or when they can go for health interventions.

Australians may decide the push towards telehealth and preventative care is a good thing – but it’s important to remember there’s a much bigger picture to consider.