Private insurance and elective breast surgery: is it worth it?
November 7, 2023
December 7, 2021
By Dr. Andrew Campbell-Lloyd

Private insurance and elective breast surgery: is it worth it?

Over time, I am seeing fewer and fewer women with private health insurance.

Frankly, I am not surprised.

As a surgeon whose entire practice is built on the provision of "medically necessary" breast surgery (that is to say, procedures covered, at least in part, by an item number) I am seeing the progressive erosion of choice for women who need these operations.

Let me explain.

In the last couple of weeks, I (like other plastic surgeons) have been confronted by the discriminatory reality of how some private hospitals function. I have had operating space taken away because I offer procedures, to women, that don't "make the hospital enough money".

Evidently, for reasons that have nothing to do with me, or my patients, hospitals make more money from things like hip and knee replacements...which is incentivising them to prioritise those services over others. Across Adelaide, there is an obvious preference in all private hospitals to chase this work. Now, this isn't new. Historically, there have always been some procedures (notably orthopaedic procedures) which are more lucrative to private hospitals. There are often perverse reasons for this, including the negotiated funding agreements between hospitals and insurers, various interest groups' lobbying activities, prosthesis list distortions in private, and the way hospital income is derived based on "coding systems" (in Australia, this means the DRG coding system mainly). But in the past, private hospitals understood that it was a balancing act - some things "make" money, some things "cost" money, but at the end of the day, an insured patient only derived value from their insurance on the understanding that one patient's insurance was worth the same as another's, and that if they needed healthcare, the basic premise of private insurance was that you could access it.

That basic premise is being eroded, and this leads to certain questions.

What is the point of private insurance if some privately insured patients cannot access surgery, by the surgeon of their choice, for the procedure they need?

What is the point of private insurance if certain patients and certain conditions are prioritised over others?

The question has to be asked whether this is because insurers and hospitals consider women to be less deserving of breast surgery than, for example, patients who need knee replacements? Do they consider breast reduction surgery, and correcting breast implant complications (both of which may be covered by insurance, and Medicare) not deserving of care? Is this systemic discrimination deeply embedded in our health care model?

Fundamentally, private health insurance is being devalued for a certain section of the population, despite them paying the same premiums as any other equally insured person. That is unconscionable, unethical, and discriminatory.


The really troubling aspect to all of this, as a specialist plastic surgeon, is the fact that the behaviour of private hospitals totally undermines the recent efforts by RACS, AHPRA and ASPS/ASAPS to ensure patient safety by differentiating between qualified Plastic Surgeons, and unqualified cosmetic practitioners (who often operate out of poorly regulated or unlicenced facilities).

It all seems bleakly ironic that in encouraging a patient to see a plastic surgeon, that patient may not be able to access the surgery they are after, because private hospitals aren’t prepared to offer operating space to plastic surgeons.