General practice policy
On the record
Author: Amanda Lyons
Balancing patient privacy with insurance policy requirements often creates a precarious situation for GPs.
Insurance is a funny thing; after all, nobody takes it hoping they will need to use it.
If and when that time arrives, however, it is a situation during which some of the most stressful factors of human experience – illness, injury, death, money – can collide. Consequently, the rejection of an insurance claim can be devastating.
The fact GPs are often called upon to provide supporting evidence from patients’ medical records for insurance applications means they have a vital – and often delicate – part to play in the process.
The Federal Government recently convened a hearing before the Senate Parliamentary Joint Committee on Corporations and Financial Services (the Committee) on the provision of patient information to insurance companies. RACGP Vice-President Dr Edwin Kruys spoke before the hearing, addressing GPs’ concerns regarding the potential dangers of insurance companies accessing full patient records.
‘Feedback from RACGP members is that patients withdraw consent when they know the implications of providing full health records,’ Dr Kruys said at the hearing. ‘They may be reluctant to share issues, concerns, or even seek help for fear that it will be reported to an insurance agency.
‘Doctors are thinking twice, “Should I be putting that on record?”. [This is] not good; there are continuity of care implications for patients.’
The Committee announced in June an inquiry into the life insurance industry, focusing on issues relating to patient information, with the RACGP making a submission outlining members’ concerns. The final report on the inquiry is due for release at the end of October.
Such a vital position in the insurance process can raise anxieties for GPs trying to balance medico-legal implications with patients’ needs, and raises a number of questions: How much information is too much in response to a request from an insurance company? What are the consequences of not providing enough or too much information? How should GPs balance privacy with the need for adequate proof of medical conditions?
Dr Stephen Carbone, GP and Policy, Research and Evaluation Leader at beyondblue, has something of a guarded view of the relationship between insurers and claimants – one that is anecdotally reflective of many GPs’ concerns.
‘I think doctors have to be very circumspect about the information they provide to insurance companies because, unfortunately, it’s an adversarial system; they’re trying to minimise their risk and their payouts,’ he told Good Practice.
‘Doctors have a responsibility to be honest and ethical, but also to understand the implications of what they are doing when they are providing these sorts of reports.’
When GP Dr Lisa Fraser first received requests from insurance companies for access to full patient records, she would confirm with the patient, view the notes and release them. But she later became concerned about the further implications of this process, particularly in light of limited training.
‘No one had ever said to us in training or as a practice, “If there is anything in the records that the patient or someone else might read that could be a problem, you’ll need to identify that”,’ she told Good Practice. ‘Doing that requires you to go through the whole record, which is extremely time-consuming and, in most instances, I guess that’s a bit defensive.
‘But a medical record is extremely sensitive ... to the point where records might include other people’s names, businesses, potentially references to criminal activity. All sorts of things that have a context at the time of the consult, but in another situation that information could be really damaging.’
Dr Fraser is concerned that patients may not always fully understand to what they are consenting when they authorise insurance companies to access to their medical records. Dr Sara Bird, Manager, Medico-legal and Advisory Services at MDA National, a member-based medical defence organisation, recognises the ethical dilemma this can potentially present for GPs.
‘Some patients might not even remember or be aware of what’s in their medical records,’ she told Good Practice. ‘So then is the GP obliged to say, “Do you remember you had that termination of pregnancy 20 years ago and that’s going to be released to the insurer?”’
Dr Bird, who has found this type of dilemma to be a common source of requests for advice from MDA National, provided an example.
‘Perhaps a patient signed a form from their insurance company when they had a motor vehicle accident three years before, and they suffered some soft-tissue injury of their neck,’ she said.
‘Then, further down the line, the GP gets a request from the insurer for a complete copy of the medical records and they attach to that the form that was signed by the patient three years earlier.’
When such requests are received from an insurance company, the first step for the GP is careful scrutiny of the patient authority and to understand they are not necessarily obliged to provide a complete history.
‘If you read the fine print, it often says, “I give permission for medical information relevant to my claim to be released to the insurer”,’ Dr Bird said.
‘I don’t think anyone would say a patient’s entire medical record, including Pap smears, sexual health history and so forth, would need to be sent to enable an insurer to assess a soft-tissue injury to the neck.
‘So my reading of the authority in that situation is that it doesn’t actually entitle the insurer to access an entire copy of the medical records.’
Dr Bird also cautions the vital thing for GPs to remember in such situations is that access to medical records is ultimately the patient’s right.
‘Under the Australian Privacy Principle 12, doctors are required to give patients access to their health information on request, unless an exception applies,’ she said. ‘So patients are entitled to access their medical records under that privacy legislation.’
This aspect of the privacy legislation, introduced in 2001, was designed to further protect personal privacy by giving the patient more control over their own information. But it has also had some unintended consequences.
‘With the privacy legislation, [insurance companies] can say to the patient, “You’re entitled to access your medical records. We want you to extend that authority to us, as the insurance company, to be able to assess your insurance claim”,’ Dr Bird said.
‘Somewhat counterintuitively, it has been the privacy legislation that has enabled insurers to access entire medical records.’
That said, Dr Bird suggests being mindful that the patient’s rights are always central to a request, and it is beyond a GP’s scope to second-guess a claim. It is therefore best to always go back to the patient or insurance company, especially if the GP is uncertain.
‘You can either contact the patient and say, “They’ve asked for all your records, are you happy for those records to go to the insurer to facilitate your claim?”’ she said. ‘Or you follow plan B, which is to write to the insurer and request an up-to-date and comprehensive authority.’
Accordingly, Dr Fraser has changed her practise in order to better protect her patients’ privacy and avoid any possible dilemmas.
‘It’s going to be my practise now to call the patient in and go through the records together,’ she said.
Many sides to the coin
As Dr Bird made clear, not all insurance claims and applications require access to a patient’s full medical record. In fact, Dr Carbone believes it is almost always in the patient’s best interests for the GP to instead provide a more targeted report.
‘I know it’s difficult to do, time-wise; GPs are obviously busy and to sit down and write a comprehensive report that sticks to the issue at hand takes time,’ he said. ‘But that is absolutely a far better approach in terms of what would benefit the patient.’
Perhaps surprisingly, Nick Kirwan, a policy manager of life insurance at the Financial Services Council, which regulates the life insurance industry, agrees that targeted reports are usually better for all parties.
‘I can’t imagine any scenarios where insurers would want to know absolutely everything,’ he told Good Practice. ‘What they want is information related to the risk, not things like whether you had chicken pox as a child.’
Kirwan is keen to emphasise that GPs and insurers ultimately want the same thing – a good outcome for the patient.
‘It’s important to get the information right at the outset, so that customers can rely on the policies they have,’ Kirwan said. ‘If it goes wrong at the point of claim, it’s too late for the customer to make alternative arrangements or choose something else. It’s a process we need to treat carefully.’
Mental health is one area of insurance in which this balance is of particular concern. beyondblue refers to this phenomenon as ‘insurance discrimination’ and has been advocating for affected applicants and claimants in this area for more than a decade.
‘beyondblue was hearing from people experiencing depression and anxiety who were having difficulty accessing insurance; two main groups of products in particular – travel insurance and life insurance,’ Dr Carbone said. ‘It was also hearing stories about people who had paid for insurance, but then were having a lot of difficulty when they came to making a claim.’
On the industry side, Jesse Krncevic, also a policy manager in life insurance at the Financial Services Council, argued that mental health is simply a common condition that has to be assessed, the same as other common conditions.
‘Mental health disclosures will be underwritten based on evidence-based risk assessment,’ he told Good Practice. ‘This is the same process that’s utilised for other disclosures like diabetes or musculoskeletal issues.
‘There isn’t a different process that’s utilised in mental health.’
Kirwan added that in cases in which a mental health condition exists, it is beneficial for the patient to disclose their treatment.
‘If a GP knows about a mental health condition, then it’s likely that if it’s severe enough the patient will be receiving treatment or management,’ he said. ‘That represents a lower risk to the insurer than somebody who has not disclosed or is not receiving treatment. So it’s better to have more information around that.’
But Dr Fraser, who has had patients whose policies were declined on these grounds, is concerned about the idea of different levels of mental health issues being assessed by insurers as having the same risk.
‘I don’t think people who have mild or moderate adjustment disorders need to be placed in the same category as the more severe set of people, in terms of needing to pay high premiums or be excluded from policies,’ she said.
This situation can lead GPs to be concerned about the disclosure of this kind of information to insurance companies, and thus the temptation to leave it out of a medical report. But such a decision, however well-intentioned, can end up doing more harm than good.
‘If a past history of depression is relevant, it must be included in the report,’ Dr Bird said. ‘Otherwise, it might be found that the patient hasn’t acted in good faith in disclosing their medical history to the insurer and their policy would be void.
‘And then there’s also risk to the GP; if they have chosen to deliberately omit information that’s relevant, they’re going to be in breach of the code of conduct.’
GPs may also feel concerned about the potential impacts their diagnoses and records can have for patients’ insurance claims in the future.
‘[beyondblue has] had instances of people saying, I went to see my doctor about feeling stressed at work, he thought he was doing me a favour by giving me a Medicare-subsidised opportunity to see a psychologist. He drew up a mental health care plan that’s on my Medicare records; I was only wanting to talk about my career, and suddenly I’ve been diagnosed with a mental health condition that I don’t think I had and it is prejudicing my claim,’ Dr Carbone said.
‘Doctors have got a legal and ethical obligation to write truthful reports, but they do need to be careful. Are they sure about that diagnosis and the treatment and the prognosis?’
Dr Fraser is also concerned about such issues and wants to take care to ensure patients’ notes about mental health are accurate and properly detailed. At the same time, however, she does not want this to affect the treatment she provides – or the records she keeps.
‘I don’t want to be forced to be overly vague, or have to selectively delete things out of my notes, when my job is holistic care,’ she said. ‘Especially since I am not able to see into the future and know what insurance patients are going to apply for.’
To help prevent these kinds of concerns for GPs and their patients, Dr Carbone would like to be confident that insurance companies are basing policy decisions on accurate and up-to-date data about mental health.
‘I think that’s a step the insurance industry needs to take: really beef up its data so that it’s making decisions based on sound evidence,’ he said.
On a more day-to-day level, Dr Fraser would like to see greater education for GPs around these issues, and closer links between the industry and the medical profession.
‘I think education and collaboration, more sharing of information,’ she said. ‘And a little bit of public education, as well.’