How 'inappropriate' surgeries are pushing up your health insurance premiums
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How 'inappropriate' surgeries are pushing up your health insurance premiums

Despite years of warnings, doctors are still performing thousands of inappropriate and unnecessary treatments and surgeries each year, placing patients at risk and ultimately pushing up health insurance premiums.

An analysis of HCF claims data for 21 procedures – including endoscopy in patients under 55 years of age, knee arthroscopy and spinal fusion – found up to 34 per cent of 32,900 admissions in 2016-17 were "low-value", unhelpful, and in some cases, potentially harmful.

New reserach reveals thousands of surgeries performed each year are unnecessary.

New reserach reveals thousands of surgeries performed each year are unnecessary.

Photo: Supplied

The researchers from the Menzies Centre for Health Policy at University of Sydney found the not-for-profit health insurer had paid up to $26 million in benefits for the "low-value" services in one year, which could have been better used.

"Low-value care is adding to waiting lists, to costs, and displacing high-value care," lead analyst Kelsey Chalmers said.

"Unfortunately, the insurers are legally required to pay even though it's low-value care, and these costs are ultimately felt by their members."

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The researchers used official recommendations given by medical colleges and promoted by Choosing Wisely, a campaign aiming to eliminate unnecessary procedures, to identify the most concerning ones and figure out how prevalent they are.

The most concerning low-value procedure is inpatient intravitreal injections.

The most concerning low-value procedure is inpatient intravitreal injections.

Photo: Supplied

At the top of the list is inpatient intravitreal injections – a shot of medicine into the eye to protect  vision – which experts say is a good procedure but shouldn't be performed in hospitals because it only adds "enormous cost for no clinical benefit".

They said almost all of the 5699 admissions for inpatient intravitreal injections were "low value".

"Overall, 17 per cent of the injections are happening in the inpatient setting in the private system and that's growing at 25 per cent a year," co-author Professor Adam Elshaug said.

"In other countries 1-2 per cent of these injections occur in hospitals, so it's a problem."

Australian Society of Ophthalmologists’ president Dr Peter Sumich said despite the recommendations, "a small percentage" of eye doctors were performing the injections so they and the hospitals can generate revenue.

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"We are powerless to stop them from doing it, but we can recommend publicly that these injections don't need to be done in private hospitals," he said.

"The issue also is there are some patients who want to get it done in a hospital so they can use their insurance, and I don't agree with it, but there's no rule against it."

HCF's chief executive Sheena Jack said the figures corroborated her suspicions that low-value care was being delivered to many of its members.

She said the research not only showed where the problems were heightened but also allowed them to better protect their patients, who could be receiving better, more appropriate care.

"The dollars represent people who are having unnecessary procedures that may lead to harm and other complications," she said.

The researchers were able to pinpoint which individual doctors had the highest rate of low-value admissions. While they used de-identified data, HCF will be able to identify them.

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Asked whether HCF will contact individual doctors to express concerns, Ms Jack said: "We haven't gone down that path but we feel it's our responsibility to share that information with doctors so they can see how they compare.

"Ultimately, if those procedures aren’t occurring then our claims costs is less and so that is less cost that we have to pass on in the form of premiums. It directly affects every fund member," she said.

Choosing Wisely's Robyn Lindner said its aim was to change the "culture" of how doctors deliver care, not make an intervention, and it didn't fully support the idea of confronting individual doctors.

"We want to reward people for doing the right thing rather than pointing fingers at individual doctors and health funds approaching clinicians and questioning their practices," she said.

"If there’s evidence of excessive and inappropriate practices, that should be addressed and we have systems to deal with that."

Esther Han is a health reporter at The Sydney Morning Herald. She has previously been consumer affairs editor and also covered food and wine.