Health insurance: the problem with claims tied to the level education of the provider

Health insurance can be a driver for health treatment claims costs. Take this simple summary of the ear wax removal scenario sent to us by a person claiming on their health insurance. This is a common requirement for older people, and the claim situation indicates ways in which insurance may drive the wrong behaviour in procedure costs:

  • There are range of people competent to complete assessment of the need and to complete ear wax removal including, for example, registered audiologists, registered nurses and others such as enrolled nurses and presumably audiologists who, for whatever reason, might not be on the audiologist register.
  • There is a fee for the procedure. For example, Ear Health charge Gold Card superannuitants a discounted rate of $59.
  • A claim can be submitted to a major health insurer for the consultation and the procedure.
  • The amount the insurer will refund depends upon who does the consultation and procedure, up to approximately $200 for a registered audiologist, $30 for a Registered Nurse, and zero for anyone else that completes exactly the same procedure. We presume this is a cost control measure - but we suspect it is working precisely in reverse of how it is intended to operate.
  • Hence, competence is not the measure used to determine whether a claim will be admitted, and the rate of reimbursement, rather the educational / professional status of the individual doing the consultation and ear wax removal.

In our view, this leads to a perverse outcome as it appears on the face of it to be in the interests of the client to insist that an audiologist complete the procedure, even at a higher cost, if necessary, because the full cost can then almost certainly be claimed in contrast to the situation where a Registered Nurse or someone else does the work.

We think this is the worst outcome for everyone, as the audiologist spends expensive time doing menial work, the insurer pays out a higher amount, and the client presumably ends up with a risk of higher premiums or reduced discounted premiums because of claims.

One is tempted to suggest that somewhere a registered audiologist has already figured out that they could complete a very quick assessment, charge like a wounded bull, and passes the client on to someone else in-house to do the cleaning at no extra charge. Could other examples be given: of course.


Report critical of results of additional mental health spending

Newshub has details of a report critical of the results of the additional spending on mental health, highlighting findings which suggest limited increase in access. Link: https://www.newshub.co.nz/home/politics/2022/03/review-finds-no-change-in-access-to-specialist-mental-health-services-in-5-years-despite-1-9-billion-funding-boost.html


Health services failures criticised

The mental health foundation has criticised the health service for failures which in cases related to five homicides. Link. Tara Shaskey of the New Zealand Herald reports:

"Heartbreaking" and "absolutely avoidable".

Those are the words an unmistakably frustrated Shaun Robinson, Mental Health Foundation chief executive, used to describe five unconnected but equally tragic homicides by five mentally-ill people.

"What makes me most angry is that this is total system failure in terms of responding to people's mental health needs," Robinson told Open Justice.

For more, read the whole article.


Quality Product Research: Medical - Major review process commenced for UCR Limit

Introduction

Medical insurance is one of the most hotly contested areas of product comparison. Adjustments are made frequently to our Research to keep up with changes, however it’s still a complex and difficult product to compare. Following a challenge by a rated company to our methodology for assessing UCR/EMP/network limits, it’s time we reviewed the method of how insurers apply UCR Limits and have therefore started the process of a major review of this item.

Theme of review

We would like to begin by renaming the item from “UCR Limits” to "Network or market price limits/UCR"

Our review seeks to categorise and evaluate the impact of the following:

1) No requirement to use specified providers/network and no UCR/EMP

2) Requirement to use specified providers/network

3) UCR/EMP applied to all costs (including specified providers /network)

4) UCR/EMP applied to only non-network costs

5) UCR/EMP applied only specific sets of costs (e.g., overseas)

Review process

We will begin by alerting insurers of our plan to review, including the five points above anticipating they will respond with which applies to their product with appropriate references to their policy document.

Once all required information has been collected, we will make the appropriate changes to our database and share our new rating on our social platforms for further feedback.

Your feedback

We value getting your feedback on how these wordings are being applied to claims you may be aware of. Please email us with details of any recent claims to help us update our understanding.

Doreen Dutt, Research Manager, Quality Product Research Limited, researcher@qpresearch.co.nz


MAS sponsors Wellington children's programme, and more daily news

MAS was a sponsor of Nuku Ora’s Run and Become programme in Wellington for the second year running. The programme is designed to encourage children to become more physically active. The programme is a lead up to the Brendan Foot Supersite Round the Bays that will be held next month. This sponsorship has allowed 750 children and their family to have free entries and transport to the event.

“MAS has sponsored the Run and Become programme, that seeks to encourage physical activity among children and whanau in Wellington, in preparation for Brendan Foot Supersite Round the Bays run in February.

This is the second year the mutual insurer has sponsored the programme, which is run by not-for-profit organisation Nuku Ora to encourage kids to become more active and healthier.

Run and Become’s objective is to make physical activity fun and accessible for tamariki from predominantly low-decile schools in Wellington. The programme will offer free entry and transport to Brendan Foot Supersite Round the Bays for children and their parents or caregivers, as well as t-shirts to run in and a healthy breakfast for the big day.

One of the programme’s first activities was a workshop for students from Avalon Intermediate in Lower Hutt. The students took part in games to help them stay active over the summer holidays, without the need for any special equipment.

"Partnering with MAS means that we're able to help more tamariki participate in physical activity by providing free entries and transport to the 2022 event for 750 children and their family members,” said Nuku Ora event manager Paddy Pierce. “Kicking off with a workshop means Nuku Ora's Healthy Active Learning team can give kids some great physical activity resources, so they can go home and train with their family in the leadup to the event.” Click here to read more

In other news

MAS: MAS will be sponsoring the Brendan Foot Supersite Round the Bays run on 20 February

MAS: MAS members being offered 10% discount on Round the Bays registration fee


New Year, new research: expanded and updated research database and product range details...

The Quotemonster team is back on deck for the new year and ready to support your quoting and Research needs.

On our last day of business, we uploaded database version 14.7 to Quotemonster which contained the following changes:

> Fidelity’s range of enhancements effective 15 November 2021  

  • Updated policy wording, brochures, and application forms are also available in the “Documents” tab within your Research comparison screen   
  • Funeral Fund was withdrawn from this date however a static Research rating for this can be found in your "Research Tools" tab 
  • More information on these enhancements can be found here 

> Updates to our Research include:

Within Trauma:

  • Chronic Lung Disease
  • HIV Medically Acquired renamed to HIV

Within Medical:

  • Specialist Consultation – (minor correction to guide score)
  • Imaging
  • Mental Health
  • Physiotherapist (applies to Southern Cross Wellbeing 2)

> Updates to our website include:

  • Research for Life Income/Family Protection has been enabled for AIA, Cigna, Fidelity, and Partners Life

And the biggest upgrade will be an entire site refresh scheduled for early 2022!

Happy Crunching!  


Obesity and the burden of non-communicable diseases

A recent study of the cost of excess weight in New Zealand finds that the extent of obesity here costs us about $2b a year: The cost of excess weight in NZ | Newsroom It is well worth a read. Obesity is a known driver for a variety of non-communicable diseases such as heart disease, stroke, and cancer. The disease burden is large and the costs - both direct and in-direct were always going to be large too. To put that $2bn into perspective, it is about 8% of the total health budget. Cutting this figure would substantially reduce the number of early deaths we experience - by hundreds each year. 

We should be interested in how to get from here to there. Our obesity rate at just over 30% is not so far behind the USA at 36% and is significantly larger than the UK's at about 27%. Our goal should be to get down to a level more in line with, say, France, at just over 20%. Given the estimated costs of obesity, that drop could save us $700m a year. It would extend the lives of hundreds of thousands of people, improving, in turn, the lives of their families and communities. 

But we cannot win this prize by blaming or shaming people who are obese. It does no good. It also fails to address the context of the problem. I spent a substantial part of my life being overweight - people that dared point it out got the cold shoulder. In the end, I decided to change, but it takes a lot of effort to push against the dominant context which is that eating and drinking too many calories is normal. More than anything else that affects our behaviour, it is what people around us do that matters most. That is a complicated project which may take decades. 


Telehealth services predicted to be essential in 2022, and more daily news

CareHQ clinical director Dr. Reza Jarral has said that virtual services similar to CareHQ are useful in dealing with non-Covid-related GP appointments. CareHQ is a ProCare service offered in partnership with Southern Cross to help patients via online consultations seven days a week. Dr. Jarral notes that telehealth services are becoming common practice and can help offer treatment to people unable to see their regular GP in person. Dr. Jarral describes telehealth services as valuable and predicts that they will become even more essential in 2022.

 "CareHQ clinical director Dr Reza Jarral says telehealth services like CareHQ can step up to fulfil non-Covid-related appointments that might otherwise be pushed back days or even weeks.

 “The ways in which New Zealanders access healthcare have gone through significant changes since Covid-19 first reached our shores last year,” Dr Jarral says.

 “While health officials juggle existing Covid cases, more and more families are self-isolating at home in their bubbles with numbers expected to rise in the coming months."

Dr Jarral says as we learn to live with Covid in the community, there is potential for GP capacity to become stretched as the monitoring needs of housebound Covid patients grows.

 “For many New Zealanders, consulting with a GP via telehealth is no longer an unusual concept.

 “With the traditional face-to-face GP visit not always possible during lockdown periods, a phone or video call with the doctor has been the only option available to many patients.

 “Patients are also seeing the value of telehealth services outside of lockdowns.

"An online consult means they don’t have to leave the comfort of their own home if they’re feeling unwell. It also means they can access the healthcare they need in a timelier way, particularly when geography or doctors’ busy schedules pose barriers to getting seen."

If, as expected, increased pressure does land on general practices, Dr Jarral said telehealth services can step in to provide an excellent option for all New Zealanders to receive a high-quality medical assessment from an experienced GP.

“These services can also work closely with a patient’s regular GP, to deliver continuity of care while supporting grassroots primary care.

Telehealth services have already shown themselves to be a valuable tool for the health sector in 2021. These services are set to become even more essential in 2022, as the country continues to navigate the uncertainty that this pandemic brings.” Click here to read more

In other news

World Braille Day will be on 4 January

Partners Life: Chelsea Tobin presentation

Partners Life: Chelsea Tobin webinar