On behalf of the Royal Australasian College of Surgeons (RACS) we appreciate the opportunity to provide feedback as it relates to the Private health insurance reforms second wave - December 2020 Consultation Paper. RACS is the leading institution for the training of surgical practice for more than 7,000 surgeons and 1,300 surgical trainees and Specialist International Medical Graduates in Australia and New Zealand.


Out of the four consultations presented in the Consultation Paper, only three are of direct significance to our Fellows. These relate to 1. Age of Dependents, 2. Rehabilitation, and 4. Certification for Hospital Admission. The last consultation will have the more substantive impact on the surgical profession, which we will examine in greater detail.


As a disclaimer, discussion had with the Private Health Insurance Branch of the Medicare Benefits Division prior to submitting informed RACS that the Department of Health will only facilitate the established of a “clinician led” ‘self-regulated industry panel’ which will also welcome the involvement of private health insurers.


Summary of RACS position 


After careful examination, RACS has some concerns that we wish to articulate and advocate on behalf of our Fellowship and the patients they serve. In summary, here is our submission and critique of the Private health insurance reforms second wave - December 2020 Consultation Paper -

  • How is a “dependent” defined?
  • Rehabilitation criteria cannot be prescriptive but must be individualised.
  • Certification for Hospital Admission:
    • What is deemed as “inappropriate” was not clearly defined.
    • The distinction between a simple error made vs deliberate and misleading conduct was not clearly defined.
    • Increase in hospital admission vs. length of stay e.g. market competition, health fund acquisitions, change in government state and territory policies, hospital closures, rural and long distances resulting in overnight stay.
  • Self-regulated Industry Panel’:
    • Panel composition and the need for it to be clinician led majority representation including the Chair, and for this to be clearly stipulated in the Terms of Reference
    • Certification to be based upon strict clinical standards and guidelines, not shareholder expectations and profit margins.
    • The role of the insurer should be to not provide any clinical assessment as stipulated in the PHI Circular 37/7, 17 July 2017 .
    • What is the true role of the panel? Is it to mediate and pursue matters outside the more serious cases the Professional Services Review (PSR) would normally investigate? Mediation is the preferred option for RACS.
    • Does this open the floodgates towards medical colleges, societies, and private health insurers to be transformed into joint regulators with legislative powers? RACS opposes such direct punitive and compliance responsibilities to all parties mentioned.