Warning … AMA President Dr Brian Owler addressing the National Press Club in Canberra. Source: News Corp Australia

THE nation’s largest health fund is refusing to fund plastic surgery for burns and skin cancer victims under a new policy which doctors claim amounts to the introduction of US-style managed care.

The Government owned health fund Medibank has also refused to pay for women to have both breast implants removed after one of them burst under the controversial new policy.

The Australian Society of Plastic Surgeons said Medibank’s new policy meant a health fund clerk who may have no medical qualifications was overruling a doctor without ever seeing the patient.

Australian Medical Association president Professor Brian Owler yesterday warned the National Press Club “I fear a concerted effort on behalf of private health insurers to undermine and control the medical profession”.

“The stage is being set for a US-style managed care system in both the primary and hospital settings”.

“I am concerned that the Government is also looking towards such a system,” he said.

The peak doctors group is concerned about Medibank’s new process which requires a pre-approval of certain medical procedures.

David Nathan … warning about recent Medibank knock-backs. Source: News Corp Australia

Australia Society of Plastic Surgeons spokesman Mr David Nathan told News Corp that Medibank had knocked back rebates for a range of plastic surgery procedures in recent weeks.

These included burns victims and a person who needed reconstructive surgery after a skin cancer was removed.

When a woman needed to have a ruptured breast implant removed the fund was only prepared to pay for the removal of one implant even though the doctor believed there was a risk the intact one would rupture later.

The fund also refused cover for a woman who had extremely large breasts that were causing her back and neck pain, he said.

The society has taken up the funds’ controversial new policy with the fund and the federal health department.

“If Medicare refuses cover, the patient may opt to have the procedure in a less safe facility in Australia or overseas and if they are confronted with complications the public system will inevitably have to step in,” Mr Nathan said.

“We’re entering a new world where you are buying no more than the right to ask Medibank if you are allowed to have a procedure your doctor says you need,” he said.

Medibank says it does not cover cosmetic surgery which is purely for aesthetic purposes with no medical necessity and claims there has been no change to Medibank’s rules or policy.

However, it says it has recently strengthened its audit process “to ensure we are paying for the correct claims on behalf of our members”.

“As part of this process we have written to hospitals to verify a small percentage of claims that were in question. Some of these claims included plastic surgery procedures and some dated back a couple of years,” a spokeswoman for the fund said.

As a result of this audit process Medibank says it believes that some hospitals may have written to doctors questioning certain procedures and asking for information to support the claim. This may have included plastic surgery.

“Some hospital operators have also requested that we confirm the eligibility of upcoming plastic surgery for our members to ensure it is for medical reasons,” the spokeswoman said.

“During the implementation of this process, we made a small amount of errors when assessing claims, for which we apologise. We have contacted those affected by this and reassessed their claims. We have revised the process to ensure it is stronger and more robust,” she said..

“Medibank has no intention of weakening or interfering in the doctor-patient relationship, nor of managing care,” the spokeswoman said.

The fund is meeting with speciality groups, including the Australian Society of Plastic Surgeons and hospital groups to develop a suitable ongoing process that works for doctors and for members.

The Australian Medical Association is also concerned about a Medibank trial which is seeing it pay the gap cover on GP visits in some doctor’s surgeries.

Health Minister Peter Dutton … ‘happy to have discussion’. Source: News Corp Australia

Health funds are at present prevented by law from covering GP visits but Health Minister Peter Dutton has allowed the trial to go ahead in Queensland and Victoria.

While he says “we would never go down the path of an American system” he has argued that if insurers are prepared to spend money on patients in addition to what is spent on Medicare he’s happy to have a discussion.

This would include allowing health funds to pay for somebody with type-2 diabetes to see a podiatrist or a dietitian.

“If they want to spend that money in a preventive way, then I’m happy to have that discussion,” he said.

“This is not the healthcare system Australians voted for at the last election,” Opposition health spokeswoman Catherine King said.

“Labor has long warned that the Abbott government’s intention is to dismantle Medicare and now that warning is being realised,” she said.

Originally published as AMA warns of ‘US-style care system’