In the United States, it is not uncommon to see GP clinics with signs saying, “No Medicaid patients” or, “Insured patients only”.

It is indicative of a problem-plagued healthcare system littered with tales of insured patients denied legitimate care and worse health outcomes for the uninsured.

In Australia, with GPs long complaining that Medicare rebates do not keep pace with costs, the threat of “No Medicare” doctors in the telehealth space has become very real.

A sign saying 'Medicaid Accepted Here'

In the US, only some clinics accept Medicaid patients. (ABC News: Supplied)

Medicaid is not the same as Medicare, but it is the government-subsidised health care system in the US for low-income earners.

In the US, doctors can opt out of Medicaid and sometimes do because of its low reimbursement rates.

In Australia, major insurers like Medibank Private and Bupa have been open about their moves to buy up and open GP clinics and are quickly becoming major healthcare providers.

Similarly, all four major insurers are now offering some free or heavily discounted GP telehealth-style visits to their members.

The important thing to note about this is that these telehealth consultations are not covered by Medicare and insurers are picking up the tab in their entirety.

It is the result of the confluence of two laws that essentially make it legal.

That is why doctors are flagging concerns about a potential two-tier system.

The insurers say anybody can access these telehealth services, and that is true, but the problem is the price point. 

By making it cheaper for members, insurers are starting to create a second tier where the privately insured have easier access to care, because it is more affordable to them.

As Australian Medical Association vice president Julian Rait points out, in a situation where Australia has a shortage of GPs, there is potential for these insurer-led GP services to start to attract GPs to their organisations, especially if they are better paid.

With long-standing critiques that Medicare rebates do not keep pace with costs, it is easy to see how “No Medicare” doctors could become a reality in the online telehealth space. 

Incentives to refer to insurer-preferred specialists

Along with GP clinics, Medibank is buying up private hospitals and offering its own “hospital in the home” care services through subsidiary Amplar Health.

It has prompted concern among doctors that Australia is slowly moving towards an insurer-directed system of healthcare, commonly referred to as “managed care”.

Are private health insurers moving to US-style model?

Increasing partnerships among health insurers, GP centres, and telehealth services raise concerns about a potential two-tier system in which privately insured patients have more affordable access to GP consultations.

The AMA told the ABC it is worried that if a health insurer owns a GP clinic, it creates incentives to refer patients to the insurer’s own hospitals or preferred network of specialists.

There are rules preventing this; however, the argument goes that the conflict of interest is too great and the potential for perverse incentives too high.

While patients can take even a named referral anywhere, most rely on their doctor to know who to go to and what hospital will suit their condition.

Insurers may be trying to save patients money, but what it can ultimately mean is patients have less choice.

We know when there is less choice, one thing happens: prices go up.

Health Minister Mark Butler told the ABC that the government does not support a two-tier system.

“The government has no plans to allow private health insurers to move into general practice services. Any move by insurers into GP services would be a significant change to Medicare and is not being considered,” he said.

This is despite obvious facts showing that it’s already beginning to emerge.

Insurers say system is different

Now the insurers argue loudly that Australia’s system is vastly different to the US.

In many ways it is: anyone can buy health insurance under our community rating system and it’s not offered through employers.

Insurers are also tightly regulated in what they can and can’t cover through the Basic to Gold policy system and they also must mostly mirror the Medicare committees that decide what is and is not covered.

However, they are slowly creeping into more health spaces and pushing the boundaries to influence care whenever the laws allow.

Orthopaedic surgeons who do the lion’s share of private hospital work say they’re seeing more insurer encroachment: with policies not covering certain prosthesis they would like to use and claims of rehab limits in insurer contracts with hospitals — something the industry disputes.

This was also seen in Ombudsman’s review of type C certificates — these are used to allow a procedure normally done in a specialist’s rooms to be done in a hospital and claimed on private health.

So, for example, a Parkinson’s patient might need sedation to allow them to have an eye injection.

The Ombudsman found some health insurers were questioning these certificates and leaving them in limbo, in effect rejecting claims by pure inertia.

Some of the insurer’s attempts may be well-intentioned, like preventive care pilots in GP clinics.

While anyone can access the one run by Medibank Private in western Sydney, it does not change the fact that the insurer stands to benefit if it can reduce hospitalisations, and thereby insurance claims, for its members.

While there is no suggestion that there is anything wrong with Medibank’s pilot, the theoretical issue arises if the insured patients get preferential treatment or if they are told where or when they could go for health interventions.

Australians may decide a push towards telehealth and preventative care is a good thing — but it is important to remember there is a bigger picture to consider as well.