Prevention May Be The Best Insurance
Sydney Morning Herald
Thursday April 10, 2003
Health insurance funds are starting to help their members eat properly, exercise and live better.
Why? Because it's becoming obvious that the health system won't be able to cope with a large ageing population and an increase in chronic conditions such as heart disease and diabetes.
Several years ago, the Australian Health Management Group , whose brands include the Government Employees Health Fund , concluded that if it only kept paying benefits on sickness claims and ignored disease prevention, demand on the medical system would become unmanageable.
In 1997, the group established CareLink , a service which assigns people into programs to help them lose weight, exercise more or stop smoking.
Today, 17,500 Australian health insurance policy holders covered under 18, mostly small, private funds have been ``case managed" as high, medium and low health risks for enrolment in CareLink programs.
For some fund holders, it means better management of their heart disease or diabetes. For others, case management can be about arresting disease before it develops or arming pregnant women with greater knowledge.
The benefit for the health funds is as utilitarian as it is feel-good.
``We need to manage risk, like any other company in the financial services environment," says Dale Cairney , CareLink's general manager of clinical services.
Those 17,500 Australians managed by CareLink represent about 50 per cent of the case management market in Australia, giving the company the leading market share in what they term ``population health management".
Private health fund-backed population programs are still in their infancy: most of the 9.2 million Australians with private health insurance have not yet been assigned to one.
Two of the biggest health funds are now showing interest in CareLink programs, says Cairney, although he declines to name the funds.
Part of the problem is the negative press that case management practices in the United States have attracted, where companies have been criticised for restricting doctor access and even dictating to patients who they can see.
CareLink's customer relations manager, Graham Hill , denies any similarity between Australian and US case management. ``We're not saying you can't go to doctor X or Y," he says. ``We're against that."
On the contrary, says Hill, patients are encouraged to visit the doctor of their choice and ask thorough questions.
For example, simply asking whether blood pressure or cholesterol levels are ``OK" is insufficient. Patients are taught instead how to understand specific measurements.
Cairney says the company's diabetes program improving diet, exercise, medication and self-management has been particularly successful. Some patients had a poor understanding of their condition. Now, with help from case management, they know their glucose levels inside out.
Information and support for families is also provided through CareLink's pregnancy program, which is provided from before conception until the child turns one.
There is also a broad-based men's health program which provides information on a range of health issues such as how to recognise heart problems to the sorts of check-ups needed by older men.
How committed are health funds to preventive health once the cost starts affecting the bottom line?
Last year, health funds announced they would dump rebates for gym memberships and sports shoes. Consumers argued that these promoted healthiness, while others didn't think such benefits should be offered.
Australian Health Insurance Association chief executive officer Russell Schneider says that in future, policyholders should still be able to get a rebate on such items, provided the items are part of an approved program.
For example, under CareLink programs, or under health fund-linked weight-loss programs such as GutBusters , policy holders could still get their joggers or gym membership rebates if they are proven to be part of the program's structure.
But gym shoes and memberships purchased primarily for recreation, sport or entertainment will not be rebatable.
Schneider refuses to be drawn on why recreation or sport outside of structured health fund-approved programs should not be accepted by insurance funds as a preventive measure.
Tony McBride , the chief executive officer of the Health Issues Centre in Melbourne, says that, until now, health funds have been concerned largely with individual episodes of care, such as elective surgery procedures, rather than preventive health programs.
Encouraging private health funds to focus on preventive health will require a ``major reorientation of the private health sector [which] will be forced to examine its funding arrangements, its relationships with hospitals and the range of services and packages provided to customers".
More important, he says, is the question of whether private health funds can play an effective role in preventive health.
McBride says: ``One reason for the success of Medicare and the public health system has been due to its broad focus on population health, as well as funding that targets areas of disadvantage, such as indigenous health. Traditionally, these are areas that have not been [financially] attractive to private health funds."
McBride says it was always questionable whether the taxpayer, through the 30 per cent health insurance tax rebate, should have been subsidising gym shoes and memberships. The ``effectiveness of such measures in improving health is unknown".
He says one of the health system's great problems is its emphasis on acute or hospital health, at the expense of a stronger focus on preventive health and health promotion.
© 2003 Sydney Morning Herald