A health insurer's viewpoint
The GP referral system... and those alleged commissions
Why do you want me to go to a general practitioner before I see a specialist? Why don't you accept my form if my GP signs it after I go to a specialist? What are you doing to keep my premium from escalating? These are just a few of the questions patients ask us and more recently they are adding another. What are you doing about these alleged commissions? Why rely on GPs when they could be sending me for tests or to certain specialists because of some vested interest?
Clients of ours hate being 'piggy in the middle' and want insurers and doctors to make life easier for them so that they don't get to know about the 'money' side of private healthcare. On the other hand, as we all know, a great many factors are contributing to increase the cost of private healthcare.
As well as the rising costs of pharmaceuticals and consumables, new facilities in the market such as the new cardiac unit opened recently in a private hospital as well as the rising number of cancer cases being treated in the private sector have created serious problems in our industry and we feel that more awareness of the issues which face us is crucial.
The importance of good primary care
Insurers strongly believe that good primary care is the cornerstone of good community healthcare. Primary care may be described as the care provided by the health professional who the patient sees first when he or she first has a health problem. In different countries the primary care system is organised in many diverse ways but general country comparisons show that structures where there is a comprehensive recognised and strong general practice (ie based on general practitioners) go hand with hand with lower overall national spending on health care.
This is true in the United Kingdom, Norway, Italy, Netherlands, Canada, New Zealand and Australia as opposed to systems such as those of the United States, Germany, France, Sweden and Austria where the GDP share for health expenditures tends to be far higher. References for these studies may be accessed for those who are interested at www.cfps.org.sg/ sreenivasan/articles/1997.html. In Malta, although specialist outpatient charges tend to be far lower than in most European or North American countries, health insurers do observe that self referral often leads to patients having to repeat consultations with different specialists since the specialist that they self referred themselves to was not the correct specialist for their medical condition.
The fact that the specialist is related to you, solved your auntie's problem or that you met him at a party does not mean that he can give the best medical advice for your medical condition! The general practitioner should be seen as a care manager who will help to keep your records and refer you to the correct specialist for your particular medical condition. It is his or her duty to keep up to date with new specialists and should give the best advice.
Referral and rumours of commissions
But insured patients are not always convinced! In December 2004 the Medical Council of Malta issued a circular to medical practitioners, dental surgeons, laboratories and clinics stating that "certain medical practitioners and dental surgeons may have accepted commissions from other practitioners and/or business concerns". The Medical Council reminded doctors and laboratories and clinics that this goes against headings 30 Commissions and 31 Dichotomy (fee splitting/sharing) of the General Notice for the Guidance of Practitioners. The Medical Council felt it necessary to emphasise that this provision also applies to commissions that may be offered to doctors by private laboratories, x-ray clinics, etc., in respect of patients referred for their investigations.
On October 23, 2005, Albert Cilia Vincenti, writing in The Sunday Times, again brought up this subject and referred to 'very ethically dubious professional conduct' where commissions were rumoured to be being paid for referral of patients to labs and even to hotel staff for referral of tourists. Unfortunately such rumours do not help and patients come up with these arguments when insurers state the advantages of having a GP as a care manager.
Unfortunately the Medical Council states that it can do little to solve this problem as their position is that it is not illegal for providers to pay commissions. The Medical Council has been empowered by recent changes in legislation to set up committees for the purpose of enforcing professional and ethical standards. The health insurance industry wrote to the Medical Council in July and requested it to consider setting up various committees including one relating to the payment of commissions to medical practitioners - and lobby the government to make it illegal for providers to pay such commissions.
Insurers see doctors as a very important part of their business. Although some doctors feel that their relationship is solely with clients and that insurers just create bureaucracy for them, most of the medical profession today understands that good cooperation and communication with insurers can only help the private healthcare market to grow. Insurers would welcome associations such as MAM, the Association of Private Family Doctors and the College of Family Doctors taking a strong public stand against such practices.
In a comment made in an article published in The Times on November 9, 2006 (Vanessa Macdonald, Health Insurers Fight Medical Commissions), we were pleased to note that the Association of Private Family Doctors "has an internal disciplinary board to consider instances of unethical practices brought to its attention". The Association of Private Family Doctors is doing much to improve the standard of primary care in Malta and we note that they are doing all they can to promote and improve record keeping and professionalism. We hope that they will continue to vociferously oppose commissions, fee splitting and other such dubious practices as this will further enhance their reputation.
Health insurers have always pushed GP referral and literally spend large sums on staff time to explain and reinforce the concept of the importance of continuity of care and the advantages of having one 'care manager' with clients who often cannot understand why we cannot pay a claim for something as trivial as conjunctivitis or ear ache which has not been GP referred. Sometimes insurers feel that GPs are not always so supportive in return!
• Ms Calleja is the chairman, health insurance sector, Malta Insurance Association.
Clients of ours hate being 'piggy in the middle' and want insurers and doctors to make life easier for them so that they don't get to know about the 'money' side of private healthcare. On the other hand, as we all know, a great many factors are contributing to increase the cost of private healthcare.
As well as the rising costs of pharmaceuticals and consumables, new facilities in the market such as the new cardiac unit opened recently in a private hospital as well as the rising number of cancer cases being treated in the private sector have created serious problems in our industry and we feel that more awareness of the issues which face us is crucial.
The importance of good primary care
Insurers strongly believe that good primary care is the cornerstone of good community healthcare. Primary care may be described as the care provided by the health professional who the patient sees first when he or she first has a health problem. In different countries the primary care system is organised in many diverse ways but general country comparisons show that structures where there is a comprehensive recognised and strong general practice (ie based on general practitioners) go hand with hand with lower overall national spending on health care.
This is true in the United Kingdom, Norway, Italy, Netherlands, Canada, New Zealand and Australia as opposed to systems such as those of the United States, Germany, France, Sweden and Austria where the GDP share for health expenditures tends to be far higher. References for these studies may be accessed for those who are interested at www.cfps.org.sg/ sreenivasan/articles/1997.html. In Malta, although specialist outpatient charges tend to be far lower than in most European or North American countries, health insurers do observe that self referral often leads to patients having to repeat consultations with different specialists since the specialist that they self referred themselves to was not the correct specialist for their medical condition.
The fact that the specialist is related to you, solved your auntie's problem or that you met him at a party does not mean that he can give the best medical advice for your medical condition! The general practitioner should be seen as a care manager who will help to keep your records and refer you to the correct specialist for your particular medical condition. It is his or her duty to keep up to date with new specialists and should give the best advice.
Referral and rumours of commissions
But insured patients are not always convinced! In December 2004 the Medical Council of Malta issued a circular to medical practitioners, dental surgeons, laboratories and clinics stating that "certain medical practitioners and dental surgeons may have accepted commissions from other practitioners and/or business concerns". The Medical Council reminded doctors and laboratories and clinics that this goes against headings 30 Commissions and 31 Dichotomy (fee splitting/sharing) of the General Notice for the Guidance of Practitioners. The Medical Council felt it necessary to emphasise that this provision also applies to commissions that may be offered to doctors by private laboratories, x-ray clinics, etc., in respect of patients referred for their investigations.
On October 23, 2005, Albert Cilia Vincenti, writing in The Sunday Times, again brought up this subject and referred to 'very ethically dubious professional conduct' where commissions were rumoured to be being paid for referral of patients to labs and even to hotel staff for referral of tourists. Unfortunately such rumours do not help and patients come up with these arguments when insurers state the advantages of having a GP as a care manager.
Unfortunately the Medical Council states that it can do little to solve this problem as their position is that it is not illegal for providers to pay commissions. The Medical Council has been empowered by recent changes in legislation to set up committees for the purpose of enforcing professional and ethical standards. The health insurance industry wrote to the Medical Council in July and requested it to consider setting up various committees including one relating to the payment of commissions to medical practitioners - and lobby the government to make it illegal for providers to pay such commissions.
Insurers see doctors as a very important part of their business. Although some doctors feel that their relationship is solely with clients and that insurers just create bureaucracy for them, most of the medical profession today understands that good cooperation and communication with insurers can only help the private healthcare market to grow. Insurers would welcome associations such as MAM, the Association of Private Family Doctors and the College of Family Doctors taking a strong public stand against such practices.
In a comment made in an article published in The Times on November 9, 2006 (Vanessa Macdonald, Health Insurers Fight Medical Commissions), we were pleased to note that the Association of Private Family Doctors "has an internal disciplinary board to consider instances of unethical practices brought to its attention". The Association of Private Family Doctors is doing much to improve the standard of primary care in Malta and we note that they are doing all they can to promote and improve record keeping and professionalism. We hope that they will continue to vociferously oppose commissions, fee splitting and other such dubious practices as this will further enhance their reputation.
Health insurers have always pushed GP referral and literally spend large sums on staff time to explain and reinforce the concept of the importance of continuity of care and the advantages of having one 'care manager' with clients who often cannot understand why we cannot pay a claim for something as trivial as conjunctivitis or ear ache which has not been GP referred. Sometimes insurers feel that GPs are not always so supportive in return!
• Ms Calleja is the chairman, health insurance sector, Malta Insurance Association.