I Just noticed this new clause in my Health Insurance conditions - "From July 1 2018, refund of 100% of shared room in public hospital, but if a private room in a public hospital, there is an additional daily out of pocket charge of $80 " In my experience the only way you get a private room is if you are contagious or immunosupressed.
This seems to make no sense as I am covered 100% for a private room in a private hospital where the rate per day would be a lot higher than in a public hospital.
I am in Top Hospital insurance with Defence Health. I doubt that they would be doing this without outside pressure.
Has this absurdity been forced upon the Health insurance by the current government in an attempt to dissuade the use of public hospitals by persons with private health insurance.?
*** later edit . I have misinterpreted the clause. See my following post with the correct interpretation.
I have contacted my Defence Health insurance and they have clarified this with a more comprehensive statement which shows that I misinterpreted the clause in their product statementâŠ
"From 1 July 2018, private patient treatment in a public hospital will attract minimum shared room benefits. We will pay a top-up benefit of $80 per day if the member is admitted to a private room. This means that if a member is admitted to a private room and the hospital charges more than the minimum shared room benefit plus $80 per day, the member will experience an out of pocket cost. "
âWhen it comes to visiting a specialist, it pays to shop aroundâ
That advice reminds me of blind Freddy at the ACCC. Reality is one has just been referred for a potentially serious illness and you need treatment. Time might be of the essence. How many of us will be in the mental state to âshop aroundâ and try to negotiate fees with a surgeon who might be able to treat us, has a good reputation such as it is possible to ferret out, and is timely?
Therein lies a problem with our parallel US-aping private medical system. It is opaque; practitioners usually defend their own; their fees can be highly variable; some have contracts with some private health funds and not others; and on it goes.
Another dimension is a surgeon with an ordinary reputation who can âsee me soonâ or that I can afford (if I chose private over public) might be a better option than a top one who could only see me in 6 months or who might drain my savings so I could recover to be on public assistance.
Having public tables of specialists and their standard fees would probably be anathema to the AMA but how good would it be for us to make initial judgements.
So many dimensions, and when one is ill what are the odds of dealing with many if any with a clear mind?
I doubt there is one simple answer here. Travelling across town to a specialist who charges less might be practical for some. It assumes that the option exists.
My experience suggests that the advice from Choice can help and should have a simple sub-header. Recommended for regular users of advanced medical services living in major urban centres. Our experience would draw a bottom line at centres the size of Newcastle in NSW.
While most of us Aussies live in an urbanised environment (89%) many regional towns and Cities have limited options. With the exception of larger centres such as Townsville in Qld you are reliant on visiting specialists or travelling. That includes the pre and post procedure visits. Add the cost of airfares, accommodation etc to getting a better deal in the city what is best? For most of the examples I am aware of the individuals have put years or decades of faith in the local practice in recommending a particular specialist. Sometimes the recommendations were local or a practical day trip in a car. Sometimes there was a âit might be best if you can ⊠Capital City âŠâ.
Some smaller cities can be a good choice. Eg Townsville is a special case for a smaller city as it has the benefit of a School of Medicine at JCU. We were able to negotiate a better outcome to have a local surgeon repair a major sporting knee injury for one of our family when living there.
A personal concern is the increasing churn of rural GPâs and the trend to medical practices which appear to be corporatised products. When the expansion of organisations such as Ramsay Health into providing core service facilities is considered, it is all too easy to see a future of two tiered health outcomes. As competition decreases out of pocket expenses will be more difficult to contain, in particular for those consumers who have limited Choice.
I like the idea of accessible schedules of fees for every provider. If competition is the tool of choice to keep costs down you need to be able to see what is on offer.
I am on a disability pension and I bend and scrape to keep up my Gold Level Private Health Insurance. I need to see a cardiac surgeon and a Urologist. My GP referred me to a good cardiologist who is bulk billing me for all the tests and the consultations. Yeah!!! I am still trying to find a Urologist who charges less than a gap of $150/ consultation. My brother just had a triple bypass on the Gold Coast and his out of pocket expenses amounted to $19,000. My nephew and his wife had a baby privately with top cover and their out of pockets amounted to $10,000. All this while we are being told there are excess specialists in most disciplines. Specialists seem to think they are entitled to $Million salaries and the rest of us can go to hell.
A report into Private Health Insurance (PHI) by the Grattan Institute looked at the benefits and costs of PHI.
It found that without reform the PHI Industry may be in a death spiral. Among the reasons it could be failing is value for money (increasing premiums and out of pocket costs), subsidies that donât work as intended, this leads to falling enrollment by young people plus increasing insurance levels by older people is causing the system to be out of balance. They called it a muddled system in the report.
I recently had a conversation with my US family, one of whom has some health issues. Their US health insurance is fairly typical mid-range. Annual premium is about $7,000. Out of pockets are $35 to see a GP and hospital is an 80-20 where the insurance pays 80% and the insured pays 20%, usually capped at some $10,000âs out of pocket per annum. Most US policies have lifetime caps, some low enough to be reached with a single long term illness. The insurance companies also have fairly strong control over the health care one receives since they approve or decline to approve many procedures. My family member has what could be life threatening but routinely has to go against the insurance companies through his doctors and specialists. It is a sad commentary when it becomes accepted that actuaries and accountants have as much or more say in treatment as medical professionals. nb. some of our health funds seem to be there already
It would be interesting if anyone has, and I presume they have, done a study to see total costs to (not in the best order, but taken as a basket of actions)
a) fund hospitals and medicos so âelectiveâ surgery was always available and done timely
b) the subsidy for private health was diverted to fund the public system
c) increasing the Medicare levy to cope with the deficit between a and b
d) leaving private health funds and private hospitals to fend for themselves, if they were able
I expect the Liber(tarian) party and their conservative allies would choke on the thought, but for the rest of us?
As we are an ageing population it is a given we will need more medical care for a while, but population growth is slowing and will become younger, in cycles. At some point there might be an over-supply of medical care, save for the effects of immigration and a reality that âgrowthâ(of everything) has become a sacred cow in many circles.
I quite agree about the âpreferred supplierâ system. First, my experience!
My wife went to a physio ,which turned out to be on Bupaâs list. She paid $71 & got back$58.60 for a half hour session.
About 3 weeks later I needed to see a physio, & used the same one I had over many years. I paid $105 & got back $38.95. I asked the Physio why ? & she said it was Bupaâs way having & supporting these preferred suppliers. Both were for half hour sessions & we are on the same policy, & have been with them for over 40 years.
I only discovered this accidently, & there must be hundreds of thousands of Bupa customers who also donât know this.
The first thing to realise is that there are about 32,000 physios in Australia, & no doubt a majority of them are not Bupa preferred. This means that all Bupaâs customers who go to these ones get a smaller rebate than they should.
The simple issue here is that we insure with BupaâŠthey are an insurance operation. They should not play favourites for the same service. They have been getting away with this for âwho knows how longâ . It is blatant discrimination.
My take on this is that Bupa register enough operators in the health industry to be preferred suppliers, [ & they suggest these operators reduce their fees because maybe they will get extra business ] , & their customers get a higher rebate, knowing full well that most of us, Bupa customers as well 1. donât know about it, & 2. wonât go to them, for many reasons.
The wash up is that, in the physio industry, Bupa are pocketing about an extra $20 per half hour visit, for no doubt hundreds of thousands of visits. Also probably in other sections of health as well. Donât forget , they are foreign owned & a for profit business
The problem here is finding some one in authority who can explain why this was allowed in the first place. If I wasnât so polite I would call this a corporate scam.
The âexpectedâ business plan is that Bupa contracts for wholesale prices to their âin networkâ aka âpreferred providersâ. Bupa provides patients in return for preferred pricing for them. In some cases there is no out-of-pocket (OOP) and Bupa receives a discount, and when there is an OOP I could imagine Bupa getting some rebate as part of their contract.
This reflects the US health insurance industry. A family member in the US recently had âin networkâ hospitalisation and the complete bill was in the order of $USD300,000 for a few days. His insurance paid about 10% and it was accepted as payment in full by all. Such is the world of medical care, American style, that Bupa and perhaps other Australian funds seem doing their best to emulate.
I think that the ACCC needs to look at this, because it sure doesnât pass the âpub testâ . So, I am going to make contact, as they could be the last resort.
The ombudsman was useless, as they said they were independent , & did not see the problem !!
Considering health funds are businesses, what does not pass the pub test? The preferred provider system? They are up front about how their insurance works.
It means they get a smaller rebate, but it is the rebate they should get under the terms of the policy. People do need to read every policy to see what the caveats are. This is analogous to a car insurer picking who will repair your vehicle; if you then chose to go to your own repairer the most they will pay is what it would have cost them if you used their lowest cost repairer. Your out of pocket will usually be more, and often significantly more.
A supervisory or senior person would explain this is how their policy works, and they will claim this is how they keep their costs and your premium down. You do not have to believe it, but that is what you will most likely be told. Insurance is business, not altruism at the end of the day, and again, they do not keep it secret.
The Private Healthcare Australia institution has released a paper about how they would like some changes made to the way people are billed.
Their concern is what is termed Surprise Billing such as split billing all of which means you have extra amounts added after the provision of a service.
To read the exposure draft see
They are seeking comment and CHOICE if they have not already done so may wish to respond to the paper before the option to comment closes on 15 August 2021. Others who have been affected by the practice outlined in the paper may also wish to respond by that date.
