A dispute has erupted between BUPA and consultants over the insurers’ move to introduce a new system of prior approval for surgery.
BUPA is asking orthopaedic surgeons to complete an assessment form which must be approved before they can proceed with any new knee arthroscopy operations. If there are any questions about funding a procedure the surgeon’s decision will be reviewed by an external medical assessor appointed by BUPA.
The private medical insurer has introduced the system following a review of the 19,000 knee arthroscopies it funds a year. It claims that the procedure rate was double that carried out in the NHS, and that some surgeons were three times more likely to operate than others.
The Federation of Independent Practitioner Organisations (FIPO), the British Orthopaedic Association and the British Association for Surgery of the Knee say the move undermines consultants, devalues the clinical and personal relationship between consultants and their patients and undermines the GP to consultant referral pathway.
They fear the bureaucracy will lead to delays in patient treatment and reduce patient choice.
They also accuse BUPA of attempting to influence clinical decisions. “Any second assessment of the need for surgery made without seeing and examining patients and without taking in to careful consideration the clinical findings, co-morbidity, lifestyle, activity and patients’ aspirations could only lead to some inappropriate decisions,” said FIPO vice chairman Richard Packard.
FIPO claims that many consultant orthopaedic surgeons, including those who work at the five main specialist tertiary orthopaedic hospitals, have refused to sign the forms which has resulted in BUPA diverting patients to other surgeons.
But Dr Annabel Bentley, medical director of Bupa Health and Wellbeing, accuses FIPO of making inaccurate and misleading statements about their new process and claims the vast majority of orthopaedic surgeons are filling in the forms. In the handful of cases where they refuse patients are being offered a choice of seeing an alternative consultant and in most cases are agreeing to the switch.
“Bupa has introduced this system because we are responsible for our members’ funds and we need to ensure that funding is provided for clinically appropriate, evidence based treatments.
“We reviewed the evidence on knee arthroscopies to make sure we understand the best use of this procedure. We already know that knee arthroscopy doesn’t work for the treatment of common knee conditions like osteoarthritis. If treatment is not suitable and goes against best practice it won’t be funded. That is in line with our standard terms and conditions across all procedures,” she said.
Bentley rejects the claim that they are intervening in clinical decision making. “What BUPA is doing is making a decision whether treatment is eligible for funding under the terms of our policies. Our new process will not delay treatment for any patient if it is correctly followed.”
Bentley says neither the GMC or the Royal College of Surgeons have raised any objections to their medical review process.
Last year FIPO fell out with BUPA over the introduction of fixed fee contracts for new consultants which also require them to provide information about their clinical practice including appraisals, audits and outcome data.
Tags: Private practice
