Self-referral is becoming increasingly common in the world of PMI and private healthcare. But what impact is it having on cost – and patient choice? Sam Barrett reports
Private medical insurance (PMI) is undergoing significant change. Once requiring a GP’s rubberstamp to allow access to private healthcare, a growing number of insurers are enabling members to access some types of treatment when they feel they need it.
The process, which was first introduced in 2008 by Cigna for physiotherapy treatment as part of its Healthy Body pathway, is now also offered for musculoskeletal conditions by many of the larger insurers including Bupa, AXA PPP healthcare, Aviva and Simplyhealth. In addition, some, including Bupa and Simplyhealth, offer it for mental health while Aviva uses it for cataract operations too.
And it’s proving popular. While there’s been some resistance to insurer-driven treatment initiatives such as directed care and hospital networks, the benefits self-referral delivers for all parties has meant it’s been welcomed by all.
“The perception of self-referral is very positive,” says Richard Colver, head of healthcare at JLT Employee Benefits. “By cutting out the GP, you can get faster access to treatment, reducing the amount of time someone needs to take off work, preventing the condition getting worse, and, in many cases, reducing the cost of treatment. Everyone benefits.”
In terms of timing, the insurers couldn’t have got it more perfect. Access to GPs is getting tougher with the latest analysis by the Royal College of General Practitioners (RCGP) showing that the number of occasions when a patient will need to wait a week or more to see a GP is set to rise by four million in 2015, up from 62.4 million in 2014.
Unsurprisingly, making it easier to see a GP is on many of the politicians’ election agendas, with the Conservations promising seven day a week access by 2020 and Labour pledging to reinstate its 48 hour appointment guarantee.
But, although they promise more GPs, achieving this may be difficult. According to the RCGP an additional 8,000 new full time equivalent GPs will be required by 2020 to meet the growth of the population. In some areas, this will mean an increase in the number of GPs in excess of 50% over the next five years, with the worse shortages, in Bexley, Redbridge and Swale, requiring increases of 87%, 85% and 74% respectively.
As well as being an inconvenience, this waiting game has consequences for employers in terms of the level of absence.
Patrick Watt, corporate director at Bupa UK, explains: “We found that where an employee used self-referral the average absence was 4.1 days compared with seven days when they went to their GP. Even where an employee can get an appointment with their GP quickly, attending this will often mean taking time off work.”
Taking out the GP can also change the nature of treatment.
“Self-referral means someone is more likely to be treated quickly and in a less intrusive manner,” says Michelle Rae, product manager for medical at Cigna HealthCare Benefits. “It also avoids the risk of the condition getting worse and becoming more difficult to treat.”
While early intervention often means lighter touch treatment is possible, the triage process used by the insurers can also prevent a condition becoming medicalised. As an example, at Bupa there’s been a 30% reduction in the number of members requiring a consultation and surgery for a musculoskeletal problem since it introduced self-referral, with up to 10% able to take a self-help approach to their treatment.
“If you see a GP it’s much more common to be referred to a surgeon for a consultation,” explains Watt. “This in turn makes it more likely that surgery will be recommended.”
Nipping a problem in the bud in this way also improves the chances of making a full recovery, enabling them to be back at work faster and in full health.
Adopting self-referral isn’t an entirely altruistic move by the insurers. Although they’ve removed the GP gatekeeper, potentially increasing the number of members who claim for treatment through a pathway, insurers are able to keep tight control over the delivery of healthcare. For example both Cigna and Simplyhealth partner with Nuffield Health to provide physiotherapy to members who self-refer and Aviva has established provider networks to support its self-referral.
This control ultimately leads to savings, benefitting both the insurer and its customers. As an example, although Bupa’s seen the number of people using its musculoskeletal self-referral service increase, average treatment costs have reduced by 25% and Simplyhealth’s Rapid Access service has reduced the cost of physiotherapy claims by 37%.
Similarly, Aviva’s BacktoBetter service, which was launched in 2013 to large groups initially, has also delivered savings. Over the first year, the cost per claim reduced by an average of 15%, with some clients seeing reductions of as much as 30% when compared to unmanaged musculoskeletal claims.
“Over time, this will help to lower companies’ future medical insurance costs,” says Dr Doug Wright, medical director at Aviva UK Health.
Tackling mental health
Having achieved such strong results in musculoskeletal, insurers are looking to apply the same philosophy to other conditions too with mental health often regarded as the next target. Chris Evans, senior consultant at Buck Consultants, says the parallels between the two types of conditions make this an obvious next step.
“Both are conditions that, if caught early enough, can respond well to light touch treatment or even self-help. In addition, by removing the need to see a GP, it may mean that more people come forward with mental health problems.”
While it’s admirable that the insurers want to step into this space, it’s not an area that has traditionally been covered by medical insurance. Although some have added employee assistance programme style helplines to corporate schemes, mental health cover has tended to focus on inpatient psychiatric treatment, with a limit of 28 or so days the norm.
But stepping outside of the traditional medical insurance remit offers the potential for savings.
Colver explains: “Mental health problems often present as a spike in physical health complaints. Providing easy access to support for stress or anxiety can help to prevent claims for treatment for other problems.”
Expanding the list
Although mental health may be a common consideration for the insurers, Aviva has also introduced self-referral for cataract treatment and Dr Wright says he would be happy to roll the process out to other suitable areas too.
“The GP role is important in the management of long term conditions such as diabetes and high blood pressure or where diagnosis isn’t clear cut,” he says. “But, where diagnosis of a condition is relatively straightforward and we can put a network of healthcare practitioners in place to deliver treatment, then we’ll consider making it available through self-referral.”
But, while Dr Wright may be looking to roll out the model to more conditions, other insurers are more cautious. For example, although AXA PPP healthcare may extend its self-referral model beyond musculoskeletal and psychological health, intermediary distribution director, Paul Moulton, is concerned it doesn’t go too far.
“To operate this for a wide range of conditions we’d need to employ a vast bank of medical people,” he says. “Rather than helping to control costs, this could push premiums up.”
Communicating the change can also slow take-up of self-referral. Colver says that after years of being told to see a GP for a referral into treatment, rewriting this message isn’t easy.
“It’s become policyholder instinct to go and see a GP before they can consider private treatment,” says Colver. “It’s not easy for an employer to change this behaviour, especially if they only send out benefits communications once a year.”
With time this could get easier, especially as the reliance on the GP gatekeeper is weakening. Many private hospitals have stopped insisting on a referral letter for self-pay customers, allowing them to see one of their private GPs instead. Similarly, sidestepping the GP is the norm on cash plans, where physiotherapy is one of the most commonly claimed benefits.
While there may be some teething issues as the market adapts to the change, all predict that self-referral will play a larger role in the delivery of medical insurance benefits.
“Access to a GP is getting more and more difficult,” says Dr Wright. “It makes sense to create a model that doesn’t insist on a GP referral.”
Helping to drive this will be the arrival of more virtual GP services. For example, Evans points to his parent company Xerox’s recent investment into Healthspot. This is a virtual GP service that builds on the Skype style appointments by being delivered in a kiosk setting to enable remote diagnostics. And, as mobile network speeds increase, this type of innovation will become even more prevalent.
As this happens, Evans believes medical insurance will turn into more of a hub that facilitates not only treatment but also, and especially in the workplace, the management of health and wellbeing.
“There’s no reason why the medical insurers couldn’t take a more proactive approach in preventative health,” he explains. “Through self referral and the treatment pathways the insurers are establishing, it could even help people manage chronic conditions. It’s a new departure but, as the workforce ages, it’s one that will become increasingly relevant.”