Insurance Networks and Ophthalmology

Both BUPA and AXA PPP have attempted since 2006 to enforce preferred provider networks in ophthalmology. This is an ongoing issue and recent and previous statements about this can be accessed here.

see updates 5th May 2009
see updates 5th December 2007
see updates 6th August 2007
see updates 16th July 2007
see updates 8th April 2007
see updates 12th December 2006
see updates 5th November 2006
see updates 2nd October 2006
see updates 19th July 2006
see updates 29th June 2006

Bupa Insurance Ophthalmology Approved Network
June 10th 2006

Background

BUPA Insurance has recently implemented a new strategy of setting up its own networks for clinical services in the independent sector. This began earlier this year with a tender for MRI scans (Magnetic Resonance Imaging). As a consequence of this a number of leading hospitals and their consultant staff have not been recognised. This has affected patient care and interrupted the normal working relationships between referring clinicians and radiologists.

In May 2006 BUPA Insurance introduced the first of its clinical projects with a preferred provider list of hospitals and consultants in ophthalmology. This will be followed by further similar plans in other clinical specialties such as orthopaedics. The Chief Executive Officer of BUPA spoke recently on the 18th May 2006 at the BUPA AGM and said; “On the insurance side, we are working with doctors and hospitals to develop accredited networks of healthcare partners in the main clinical specialties and we will see these expand over the next few years. A network for MRI scanning services is a recent example and an ophthalmology network is being launched shortly”.

BUPA Insurance is currently trying to implement the Ophthalmology Approved Network in two phases and all relevant consultants and hospitals will have received information about this. Phase 1 requires private hospitals or other facilities to combine with local consultant ophthalmologists and anaesthetists to form “teams” and then to submit detailed documentation about their services.

In the case of consultants this document is extremely complex and involves professional issues that have never been requested before by any insurance company. It also requires consultants to sign a declaration (in essence a contract) which is one sided and totally biased in favour of the Insurer. As an example, it would allow BUPA Insurance to de-list consultants on the basis of complaints (number and content unspecified) by BUPA personnel or patients without any independent appeals process.

If hospitals and their consultants do in fact agree to apply together for this BUPA Insurance “Approval” they will move in to Phase 2 of the process which will involve the agreement of a price for their combined services with BUPA Insurance. Those hospitals not recognised will be unable to treat BUPA subscribers and similarly with consultants (although there may be just a few patients that can be seen by so called “BUPA Recognised consultants”).

The impact of this tendering process, if completed nationally, would be a limited number of preferred providers, restriction of choice for the patients, loss of independence for the profession and BUPA control of the referral patterns of patients. There are also clinical “guidelines” suggested by BUPA for the care of patients. This is a Managed Care Scenario (although this is denied by BUPA).

The Response by the Profession

A) National Responses to the BUPA Proposed Network

Apart from various Roadshows around the UK BUPA Insurance has held three major meetings with the profession. These involved the BMA, FIPO, the London Consultants’ Association, the Royal College of Ophthalmology and the various associations in both of these specialties (the Association of Ophthalmologists, the United Kingdom and Ireland Society of Cataract and Refractive Surgeons and the Association of Anaesthetists).

Attempts have been made by the profession to address the BUPA Insurance concerns about quality and costs in ophthalmology services and more generally. The profession believes that there are high standards of care in ophthalmology in the UK but nevertheless is intent on further audits through the Royal College of Ophthalmology and governance reviews to promote continuous improvements. Other points were made to BUPA about the costs of services. The profession agreed to do what it could to improve cost efficiency and to work with hospitals in the streamlining of services although the profession does not control hospital charges. With this strong quality programme the profession asked BUPA Insurance to withdraw its network proposals but despite these strong assurances BUPA Insurance has continued with its initiatives and deadline.

As a consequence all the relevant main professional bodies are agreed that the BUPA Network proposals for ophthalmology services are unacceptable and are recommending that consultants do not sign up to the BUPA network. The profession rejects the roles that BUPA Insurance has tried to assume. As an insurance company BUPA is not a regulator of hospitals (a role which belongs to the Healthcare Commission). BUPA Insurance is not an accreditor of consultants (a role which belongs to the Royal Colleges, Post-Graduate Deaneries and the GMC) and it is not an arbiter of clinical care plans or audit (a role which belongs to the profession working within well recognised governance and other regulatory controls).

The various national professional bodies have made their views known in a series of letters to consultants and to BUPA Insurance. The theme in all of these is to advise ophthalmologists and anaesthetists not to sign up to the BUPA Network.

Click here to view these letters and statements

B) Local Consultant Responses to the BUPA Proposed Network

What is happening around the UK? FIPO, the BMA and the ophthalmic organisations and fraternity have become aware of an increasing groundswell of consultant opinion against the BUPA proposals from all around the country starting at the beginning of June 2006. It is evident that individual consultants or even local groups feel threatened by the BUPA proposal. There my also be pressure from the independent hospital providers for their consultants to sign up.

In London there have been several meetings of groups of ophthalmologists and anaesthetists to discuss the issue and agreement has been reached that they would not co-operate with BUPA at this stage. Indeed it was one such group of consultants that asked FIPO to set up this website and to publicise their names so as to encourage their colleagues.

These consultants have jointly signed a letter, and this has been sent to the BUPA CEO, Mrs. Val Gooding, CBE and to the Medical Director of BUPA Insurance, Dr Natalie J Macdonald. This is not necessarily a template that all would wish to follow and the BMA, FIPO and the other professional groups have sent out alternative templates.

Click here to see the text of these letters

What should ophthalmologists do now?

The best plan is for all ophthalmologists (and their anaesthetists) to meet locally in private and to agree a mutual policy. Some consultants may have already committed themselves but of course they may wish to reflect on that position. It is quite possible to withdraw at any stage. The advice from the centre is overwhelmingly not to sign the BUPA recognition document. Consultants working in local groups gain momentum and security and can make their views known to BUPA and the local private hospital. Clearly there may be a very few who will try and take advantage of this situation but this would be to the long-term detriment of themselves and their colleagues.

In the last few days BUPA Insurance has muddied the waters by making two suggestions to consultants, as it is clear that very few have so far signed up.

The first is that consultant fees (together with the anaesthetists) need not be packaged with the hospital charges. However, if consultants take that option they will lose their contract with the patient. They will still be under the control of the insurer who would dominate the market and all future negotiations: BUPA could play one group or person of against another. Consultants would not have true financial independence.

The second comment BUPA made recently is that consultants need only apply for “Recognition” at this stage. This may be BUPA talking from a position of weakness but unfortunately it is unclear what will follow but it is most likely that the BUPA plans would eventually proceed. Furthermore there are clauses in the Contract for Consultant Recognition which the profession have found unpalatable and which need renegotiation.

For these and many other reasons the main professional groups have advised all consultants NOT to sign the BUPA recognition document.

Essentially all ophthalmologists and their anaesthetists have two choices

Either way it is very important that we try at FIPO (working with all the other professional groups) to keep some idea of the numbers involved. Thus we would ask you to look carefully at the range of email messages listed below and to return these to FIPO as soon as possible even if you have already communicated your decision to BUPA or your local private hospital. If you are not applying or withdrawing we will pass this on to BUPA Insurance although you may also wish to do the same. Duplication is not a problem. You may write to BUPA in your own terms or use any of the template letters shown above.

Please note that a number of consultants who are withdrawing or not applying to the BUPA network have asked for their names to be placed on an open list on this website. We will collect this data and decide if we wish to put this on to the website and in to the public domain. No decision has been reached about this for the moment.

Moreover, even if we do put out this data, it is in no way obligatory for any individual to be named and we would not do this against your wishes. If you do not want to publicise your decision we will respect your wishes. Likewise we will not publicise the names of those applying to the BUPA network but we would like to see how many are taking this view.

Please send us your decisions and views as soon as possible. We will NOT divulge your position or opinions if you wish for confidentiality. Whilst we will maintain confidentiality we do need to try and keep a running total of the situation and we may wish to publicise overall numbers (without personal identification).

Please send us an email whatever your decision and note that you will have several options. We need your GMC number and name for verification purposes only so as to check on possible malicious interference. These options are laid out below.

All Ophthalmologists and their Anaesthetists

To send us your decisions and views, please select the appropriate email to FIPO. Please look at all the possible options for ophthalmologists and anaesthetists who:

Have already applied or will apply to the BUPA network

Do not wish to apply to the BUPA network

Have applied to the BUPA network and wish now to withdraw

 

News Updates

29th June

Hospital Consultants and Specialist Association

The Hospital Consultants and Specialist Association has also recommended that consultants do NOT sign up to the BUPA approved network.

Click here to read their statement

This has been reinforced by the HCSA Council and reported in the HCSA July 06 newsletter.

Click here to read this item from their newsletter

1) Current Status of the BUPA Approved Ophthalmology Network

The deadline for the applications by hospitals and consultants (ophthalmologists and anaesthetists) for the first stage of the application to the BUPA Approved Ophthalmology Network passed on the 19th June 2006. The precise numbers of applicants is unclear and BUPA Insurance has made no announcement. This probably indicates that they have not to date achieved their required number of applicants. Our information is only based on the hundreds of consultants who responded to the BMA and FIPO websites and of these 97% were completely against the process and many have withdrawn their original application.

However, BUPA Insurance continues to send messages to all independent hospital providers saying that there is still time to apply and that BUPA Insurance is having ongoing discussions with the profession about the quality issues and the results of this first stage “approval” phase. Similar email messages have gone to consultants.

It should be made clear that the medical profession has made every effort to give BUPA Insurance a “clinical quality agenda” but this has been rejected. We believe that the standards of ophthalmology in the UK are very high but this does not mean that there is no reason for further audits and reviews. This was explained to BUPA Insurance but was unacceptable to them. In fact BUPA wants to draw the profession in to its commercial agenda by involving the BMA, FIPO and other ophthalmology and anaesthetic leaders in to the “approval stage “ of its network. This approach has been firmly rejected by the profession and there should be no mistake in the minds of consultants and hospital providers that there are at present no negotiations between BUPA Insurance and the BMA or any other body.

The advice that has been given out to all relevant consultants by the BMA and others NOT to join in the BUPA Ophthalmology Network remains as strongly as ever. It is clear that hospital groups understand and, by and large, reject this type of insurance network. However, inevitably they face difficult decisions and are in a commercial dilemma, each worrying that their local rival may steal a march on them. Similar thoughts may occur to consultants but all should consider the impact of signing up which was clearly stated in the first letter from the BMA, FIPO and others. Patient choice, clinical interference by an insurer and consultant independence is at stake. Again we recommend that consultants talk to each other in all localities and remember that those that think they can gain some “advantage” will very soon see this dissipate as control of their practice moves in to the hands of BUPA Insurance.

2) BUPA Insurance Continues with its Plans for Approved Networks

BUPA Insurance has made it clear that they intend to continue with their plans for more specialist tendering and in a recent article in Post (noted on 20th June) Dr Franklin the Deputy Medical Director of BUPA Insurance makes this clear despite the opposition from ophthalmologists. More information about this will appear soon.

19th June

The deadline for the application for hospitals and consultants to join the BUPA Approved Ophthalmology network was at 5.00pm today 19th June 2006. It seems clear that the vast majority of consultants who responded to the FIPO and BMA Websites have voted against going in to the network. They may be a self selected group but they are a large number. The Moorfields Hospital consultants and management have likewise notified BUPA that they do not intend to apply. For details of the Moorfields letter to BUPA click here...

The results of the Ophthalmology tender will probably not be made public by BUPA. We strongly suspect that all over the country consultants have been declaring their intention to stay out of the Network whilst stating their intention of retaining their right to treat all patients referred to them, whether BUPA subscribers or not.

BUPA Insurance has responded today by contacting consultants with a confused message about the situation. This suggests that the take up on the tender is very poor. There is also the erroneous point made in this message from BUPA that they are continuing to work with the BMA, FIPO and the profession about the quality agenda but in fact they have rejected all of our proposals.

It seems likely that BUPA Insurance will now engage in a series of local visits to "persuade" consultants to sign up. FIPO agrees entirely with the previous and current advice from the BMA (which we countersigned) that consultants should stand firm and NOT sign up to any BUPA Insurance proposals at this time.

Media Responses

The story of the BUPA Approved Network has been picked up by the various media agencies. See:

www.hospitaldr.co.uk/hd_news/hd_news_article.asp?ID=16854&Section=News

news.bbc.co.uk/1/hi/health/5079024.stm

www.timesonline.co.uk/article/0,,2-2224803.html

Hospital & Provider Responses

The BMI and HCA groups have now announced their intention not to apply to the BUPA Approved Network. FIPO understands that both groups are considering their position along with other stand-alone hospitals. The reasons for hospitals not applying to the BUPA Approved Network may be in part due to the total lack of support by consultants for the network and partly also for commercial reasons.

Professional Reponses

To date there has been a very strong response to the BMA and FIPO by consultants. 97% of those consultants are not applying to the BUPA Network for Approval. This is despite a threatening email sent by BUPA Insurance to each individual. We again advise all consultants to stand firm and to note the advice given in the letters sent out by the BMA, FIPO and the ophthalmic and anaesthetic groups (see above.)

The FIPO Open Forum

If you wish to make any Website comment about the situation (either anonymously or under your name) then we will put this on to the website but we reserve the right of editorial control. If you have questions then send them in and we may be able to answer some on the website. We hope that letters you have sent to BUPA and their responses are sent on to us by email but as we do not have permission to print BUPA replies or documentation we will do our best in all fairness to paraphrase the BUPA answers.

Submit a comment to the open forum