BUPA Physiotherapy Tender Process

[Wendy Emberson]

Fair point Jill. But the only way we are going to have any recognition for the work we do is by proving that we are clinically effective. That is why the research project with Ann Moore at Brighton University, funded by PhysioFirst/PPEF is so essential. For years now Physio First has been trying to set up new research protocols that raise the perceived value of physiotherapy by PhysioFirst members. With PPEF, we now have the funding to be able to do this.
I was in Lloyds chemists the other day and in their book on back pain, by Michael Grayson, physiotherapists apparently offer massage and gentle exercises - why do we need a BSc Hons to do that?!
This is one area where we have all allowed our professional image to sink even further than it has been for the last 105 years. The issues are complex and include the level of education of our students as much as the lack of marketing and PR. This is not something that a small band of physios is going to achieve. The other problem is our NHS colleagues. They think that eveyone who goes into the independent sector is providing poor standards of physio for vast amounts of money. Having been to 7 ARC conferences, I can assure you of their attitude! We are on our own - which is why Physio First needs as much support as we can give them. They have been working for years on all fronts. The first 2 treasurers of CSP have been Physiofirst members; the Chairman of the Professional Practice committee is a PhysioFirst member for the second year running. There is a huge amount of work and history to PhysioFirst and few people seem to understand or appreciate it. This is very much the case of Identify the Battle.

[physiobob]

I tend to partly agree with the above comments. However in a democracy the way to change things is to get the public on side. The government will bend to the wants of the people. We should not be spending more time lobbying government than we do promoting the profession to the public. Research is useful, but again that has been primarily done to feed the needs and wants of the insurance companies and the government. The reality is that is it a stalling process to coral us into something they can later decide to back or withdraw support from. Don't be mistaken.

The way to improve the physiotherapy profession at large is to promote it's benefits to the public. The public who come and see a physio by and large understand and reap the benefits having done so. The more we get in the doors the larger the public opinion. That includes getting gov. ministers in as patients!! 99% of people who have seen a physio would promote the profession.

So let's make sure our activities are looking at the wider picture and are no pandering to government lead, insurance company provoked, initiatives.

[RLStov]

As you have so rightly said physiotherapists need to think very carefully before agreeing to BUPA's tender agreement.
The idea of a PMI calling the shots on how we treat our patients is a very worrying prospect.
We fought to stop the medics from telling us how to treat patients more than 20 years ago! This is huge backward step if not even more concerning as I doubt if the decisions will made by exeprienced clinicians.
I am baffled as to why the CSP and or Physiofirst aren't more interested in this issue, I understand why they can't discuss costs and pricing but this is about the errosion of our professional autonomy.
I have friend who runs a practice in the USA and if you want to see where this is heading look no further.
She is told by the insurance company, to treat a patient so many times for a particular condition and no more.

[Bupabear]

In this world Bupa divide and rule. Having been told by Bupa that I could only charge patients at the agreed discounted rate, I then find out at a recent course that other physios have been allowed to charge their patients for the shortfall in the Bupa agreed rate compared to their normal rate. Just like Bupa allow the top surgeons to do.

It all boils down to this: we are clinicians not technicians. We are worth more than a 75p wage rise over four years.

75p is the key in the pricing argument in this campaign. 75p, that's all your skills are worth in the world according to Bupa.

[alithephysio]

I have read everyone's views on the BUPA tender with great interest. This may be quite naive, but what is wrong with submitting a tender but not reducing our current fees? Surely if we all did this then they would have to accept that we will not be financially undervalued?

[Wendy Emberson]

One of the emerging big issues here is not just the price, but the incidious removal of our clinical autonomy. We need to think very carefully about giving them enough information about how we treat patients with specific conditions as they may well intend to nail us down on cost per condition and treatment. ie they will only pay for previously agreed treatments in the same way that the dentists have to get pre authorisation for any procedure. We all know that every patient is different and requires subtle, and even not so subtle changes to a treatment plan depending on a very wide variety of variables.my feeling is that people who do tender, at whatever price, are digging themselves a hole that they will find very difficult to climb out of. It is all about control.

[physiobob]

I have read everyone's views on the BUPA tender with great interest. This may be quite naive, but what is wrong with submitting a tender but not reducing our current fees? Surely if we all did this then they would have to accept that we will not be financially undervalued?

Firstly I must agree with Wendy's comments above. This is more about a much larger issue, much more than $$.

If it were just a pricing issue then your thoughts might be fine in some respects. However if you consider the amount of extra work BUPA are asking you to do then you should tender to them for MORE than your fees to other clients. Also they are holding onto those fees for at least 30days post receipt of your invoices. If you only invoice for a client at the end of a treatment this could be months.

Then if you add in your own rate increases as a yearly increase well that is not permitted. You are tendering for 4 years really as you are agreeing to one small increase in yrs 3 and 4. So you should factor that into you current pricing now to account for it now should that small future increase not be enough. After all those considerations you probably would fail their tender process.

That said there are a lot of legal aspects to the contract that actually require you to be at least an insurance broker to agree to. As we do not have those legal skills, by law we cannot agree to any document in the current form.

[physiobob]

Here's an interesting report I found online about this issue with the MRI professionals

Hospital files complaint on Bupa as it fails tender process

Bupa could be probed by the Office of Fair Trading (OFT) following a complaint from a hospital about the insurer's new network arrangements, writes Kirstie Redford.
St Anthony's Hospital in Surrey filed the complaint after Bupa conducted a national tender of routine elective out-patient MRI scans earlier this year. The hospital failed the tender process meaning that patients have to go elsewhere for scans, despite receiving the rest of their treatment at the hospital and listing St Anthony's as their preferred provider.

Brian Clarke, hospital director at St Anthony's, said altering network arrangements undermined the whole concept of private medical insurance (PMI). "The move by Bupa goes against the heart of PMI, which is that patients have the choice of where, when and by who they get treated," he said.

Clarke added that narrowing the choice of radiologists could put the quality of treatment in jeopardy. "Operating surgeons choose radiologists very carefully and often work closely with them so that they can speak the same language when interpreting results. Separating reporting radiologists from surgeons has already led to requests for repeat scans," he said.

Lara Gorman, spokesperson for the OFT, confirmed it had received a complaint from St Anthony's saying it had been unfairly prevented from joining Bupa's preferred provider network for MRI scans. "The OFT is currently still considering the substance of this complaint," she said.

Natalie-Jane Macdonald, medical director of Bupa UK Health Insurance, said the objective of the tender was to ensure consistent quality of service, together with fair pricing. She said: "St Anthony's was unsuccessful because it was too expensive. The hospital was given the opportunity to improve its pricing during the tender process but chose not to do so."

[Bupabear]

Are "Blooper" intending to impose a similar tender process on orthopaedic surgeons? Anyone know? They might be useful allies for us: imagine a surgeon not been able to refer to a physio they trust.

One very interesting point in the letter we received from Bupa is when they say they would only be able to guarantee pre-authorisation to physios in the network. Reading between the lines, does this say:

"If you are a corporate member, we don't want to upset your company so we will allow authorisation in this case."

or

"Don't shout at us and threaten to withdraw your membership, we will allow pre-authorisation in this case."

Any thoughts on this ambiguity?

[markphysio]

Spoke with Roger Hint Customer Relations Officer (0207 306 6695) from the CSP, and Chris Hammacott (0207 314 7839). Both men were very helpful, firstly Chris pointed out the standard line that the CSP could not be seen to directing members as to what to do, etc. as we have heard before.

Later in the afternoon I spoke with Roger who said that due to the large volume of calls received regarding this matter the CSP in conjuction with the OCCCP (check the website this evening for further news I was informed) were now considering a media campaign to highlight our issues and even examining legal alternatives as to what can be done to protect THEIR/OUR membership, which I think they initially failed to take into full consideration. The CSP is our governing body, and it is up to us to continue the pressure so that our collective voices are heard.

I think all the issues that have been raised in this forum and the physiosvoice.co.uk, are excellent ones and their is no need to re-hash them, but I emplore you all to be passionate about this matter and continue to keep fighting the good fight.

cheers mark

[thephysiosvoice]

Good work.

This is what we need. We need the support of the CSP. The more we "hassle" them, the more they have to take notice. By hook, or by crook.....

Spread The Love

TPV

[physiobob]

Don't bank on the CSP doing anything. They are probably only calming the waters by saying they will assist. Any media campaign organized by them is likely to have little affect, be to soft and be to late. Afterall they continue to book and advertise BUPA in their frontline publication!

There is now a meeting scheduled for Wednesday, April 8th at 7pm in Central London. UK physio's on this forum and on our Physiobase membership will receive details with more information. We are trying to invite all local london press. Stay tuned...

[markphysio]

What about inviting representatives of other health insurance providers PPP, PRU etc.. who might be able to offer discounted membership to BUPA members who wish to continue with their choosen physio. This discounted membership could roll out till the patients BUPA membership finishes, and then the member joins the new Insurer.

Be guarenteed that BUPA will more than likely have a 'spy' in the midst of the Wed. meeting, so let them know we are prepared as a collective group know that we will be informing our patients/their members about their actions, and suggesting that might want to change providers. Just a thought.

Also note that Bupa physio's working in their own private clinics are being subjected to the same measures and are definately on our side.

cheers mark

[Wendy Emberson]

Physio First/OCPPP have been in negotiations with Bupa and all the other major insurers for many years. They have fought long and hard for us and do not deserve the comments that they are not doing anything. The difference here is that, as when Bupa first started the pilot contracts in the North East some years ago, the competition act effectively gagged them and the CSP. It does not mean that they have been doing nothing. What is also different about this scenario is that with sites like this and Icsp then physios have the opportunity to know what is going on and get active!
I spent 15 years on the committee for OCPPP, and believe me, the members of that committee work exceedingly hard - and are working physios just like the rest of us. This situation affects them as much as the rest of us and if there was a way round it they would have found it. Unfortunately it is now down to individual physio power. Let's go for it!

[ckaren]

I too am in favour of a boycott of the BUPA tender - where BUPA lead with this others will follow.

[physiobob]

Additionally here's a few dozies from their terms. I love how they as an insurance company think they are above the HPC and the CSP. Also they seem to think you need to be part of the CSP which of course we do not have to be to practice. I also like that you must bill them, not the client, something discouraged by Physio First. They say the'll pay on 30 days post invoice.

And get this, anything you tender for here in the UK, well that goes for any BUPA international schemes as well!! Unbelievable:

Read Below some more extracts:

6. Quality of Physiotherapy; You warrant that the information provided by You to Us in Your Tender Submission is, on the date that You sign this Agreement, accurate and correct. You agree with Us that each Physiotherapist and Facility shall at all times during the Term comply with:
(a) the quality standards contained within Your Physiotherapy Tender Submission; and
(b) the service standards contained within Your Physiotherapy Tender Submission.

You agree that each Physiotherapist shall be:

• a member of the Chartered Society of Physiotherapy (CSP);
• fully registered with the Health Professions Council (HPC);
• under 70 years of age;
• able to demonstrate advanced clinical skills in their chosen speciality and able to provide patient audit and outcome data for at least the previous 2 years that supports their status as a senior clinician in that speciality; and 2 of 5
• able to provide on request a copy of their physiotherapy graduation certificate (or if a qualification was obtained outside the UK, then written confirmation from UK HPC confirming that the qualification is equivalent to a UK Physiotherapy Degree/Diploma).

You also agree that:

• You will provide on request up to date documented evidence of audit reviews and professional development;
• patients will be: given printed information regarding their condition and treatment options; given the opportunity to complete a customer satisfaction survey; seen on a one to one basis; and offered an appointment for physiotherapy within 2 working days of a request;
• You will ensure that You comply with all relevant legislation relating to the confidentiality of information held about Members.

In particular, You will ensure that You comply with the Data Protection Act 1998.

[21fairy]

I agree that Bupa shouldn't be doing this etc etc - the only people who will work for peanuts is monkeys etc and lead to hopelessly unqualified people working for them etc, but

What actually can we do?

We need constructive advice about how best to as a united group appeal against this.

Any ideas anyone!!!!????????

[physiobob]

I agree that Bupa shouldn't be doing this etc etc - the only people who will work for peanuts is monkeys etc and lead to hopelessly unqualified people working for them etc, but

What actually can we do?

We need constructive advice about how best to as a united group appeal against this.

Any ideas anyone!!!!????????

That will take some time, more than the BUPA tender period. Thus my opinion is that the we should ignore the tender all together as a first step. Following that we should work on getting our own house in order (CSP/OCPPP).

[Jill Wigmore-Welsh]

While I respect my colleagues views that we need to promote to our patients, and that the public will help to promote us. It is undeniably a necessity that we must bend to behave as our GP, Nurse, and Pharmacist colleagues have done, and act politically to lobby government and review the way that we, as a profession, can help them to achieve their health agenda outcomes.

A couple of years ago GP's achieved a BIG increase in salaries, with new contracts, and in return have taken on the massive job of gatekeeper to NHS health services.

In the same vein Pharmacists have worked WITH government to assist them to achieve their targets. In return they have been moved into a primary care position.

Same with nursing. Who would have thought that so many occupational health roles would now be available to occupational health nurse managers ?

Question is. How can we as a profession help the government to achieve their targets, for example of preventing heart disease, diabetes, and the other priority dis-ease groups.
If we can show Government that what we do can help them achieve their statistics, then we are in prime position to be helpful primary care folk.

The research is often already there. Many overseas Physiotherapy organisations, UK universities, and individuals have undertaken research.
What is needed is a strong collating of the global research, and strong arguing that our role in helping the government achieve their targets for the main issues of heart disease, stroke, diabetes etc, is already there.

This is the job of the CSP, if they want to be our membership organisation.
If another group want to be our main membership organisation then let them take the main mantle whether its Physiofirst, or the Physios in Independent Hospital Practice, or and other group

BUPA is just an insurance company. Although they want to pay less for Physiotherapy interventions, and it is an across the board cut for all practitioners, the bigger picture is to get our profession moved to primary care, which is where we should be.
For example...can Physio prescribed exercise prevent type 2 Diabetes?
Is there a test we can do to help identify those at risk ?
I dont know, but if we could find evidence that exercise prescribed by a Physiotherapist could help then we can help the government.

Same goes for heart disease, and all other government targeted 'diseases' that cost them money.....

Lobbying is the real World.
10 years ago I discussed this very issue with a patient of mine. A professional lobbyist, and his immediate response when I moaned about our profession, was to question how many of us there are, and how we could help government.

Its a fact of life, in the UK health industry, because we have the NHS, which is unique in the globe. We will not move ourself to a higher profile in the UK through public approbation, but via the NHS recognising and moving us to primary care posts. If we can become equal to GP's we will be equal in the eyes of the insurance industry, if not we are hand maidens.
Sad reality but fact

Jay

[physiobob]

Thanks Jill for your further comments. Whilst I tend to agree in part that this is a reality, I do also think it is a reality because of the way all those professions have reacted to the pressures put on them. Kind of if we can't beat them join them attitude or a pavlovian experiment to jump through a hoop to get a cookie. It is rather exploitive. Unfortunately that's not my mind set and though it might well be the way to work in an already dysfunctional healthcare system, I would prefer not to make it any worse.

It's a bit like everyone getting involved in ergonomics, and it's affect on occupational low back pain. The govt. loves it, industry loves it, physio's seem to love it, we spend millions every year on it. Unfortunately the stats clearly show that ergonomics does not work. That said with such intrenched pathways, product development, funding, education etc. it is unlikely to go away. I suppose we should continue to learn more about it though as it is interesting and does lead to better business processes and efficiencies. It doesn't do anything for back pain though.

Sorry if that's a bit of a digression. Looking fwd to weds meeting as it's so nice to have physio's talking together with passion.

[thephysiosvoice]

Great discussions by one and all. Validity in lots of directions, we now need to channel them in one direction. Having just been to a meeting with Phil Grey, CEO of the CSP, I believe we have made progress - and lots of it.

Hope everyone can to come to the meeting tomorrow, knowing that the CSP has given it the green light.

Cheers to all, and physiobob.

Spread the Love

TPV

[ndavey]

Where is the meeting to be held and at what time? I am very keen to come along and hear a balanced debate on all the issues and to help to support any group decision.

Thank you.

[physiobob]

The email below was sent to all OCPPP members. Whilst it is nice that they are saying something, it reads as a very weak commentary and to suggested we are "frustrated" is NOT a term I would use for the feeling of the members. We are outraged and are seeking legal action, not just for this tender process but also for the Age descrimination of their 5+ yrs post graduation terms that have been in place for a long time AND for the anti-competitive pricing by making insisting we charge less than they themselves charge in their own clinics.

Here's what the OCPPP sent

Email Alert – Physio First & CSP go to Press and OFT over Bupa

Following Bupa’s formal letters to private practitioners last week requiring everyone to enter into their blind tender process, we are now able to announce that as a result of meetings that occurred between the CSP and Physio First on 1st April 2009, the long planned collaboration to raise issues in the national media and to instruct solicitors to submit a formal complaint to the Office of Fair Trading, has been agreed.

Although both Physio First and the CSP have known of Bupa’s stated intention to force members to take part in a blind tender process since we met with representatives of Bupa in October 2008 (full details of which were published in the October Update), neither we nor the CSP have been able to take any formal steps with the media or the Office of Fair Trading, until the details of Bupa’s blind tender were actually produced.

The Media Campaign

The media campaign was kicked off with Physio First and the CSP submitting the following joint press release to media channels:

Joint Statement from Physio First and The Chartered Society of Physiotherapy (CSP)

BUPA, the largest Private Medical Insurer in the UK, has recently announced to private physiotherapy practitioners that if they want to continue to treat BUPA patients, they must now participate in a “blind” tender process.

BUPA has asked 6,000 Physiotherapists to compete against each other to be allowed to continue to treat BUPA patients.

BUPA’s tender questionnaire requires practitioners to quote the lowest price that they are prepared to work for. BUPA has not made clear how much weighting will be given to each part of the tender and our presumption is that price will probably be BUPA’s main determinant.

There are indications that BUPA may significantly reduce the number of private physiotherapy practitioners who will be able to treat BUPA policyholders.

Speaking on behalf of Physio First, which represents the interests of private physiotherapy practitioners, and the CSP, Eric Lewis, Chairman of Physio First, said,

“BUPA’s approach to this tender has quite naturally caused considerable frustration amongst our members. These feelings are heightened by the fact that this process is not one that Chartered Physiotherapists have been subjected to before, nor is it one where the bargaining position, between very small and multi-million pound businesses, can be equalised through collective action, as coordinated action is prohibited by law under the Competition Act.

“Whilst Physio First and the CSP recognise that it’s entirely appropriate for BUPA to regularly review the services provided to their policy holders, we are concerned that patients may lose out if price is the primary consideration in this tender process, rather than the quality of health care provided, or the particular needs of individual patients. We hope that BUPA will ensure that their policy holders continue to have easy access to a full choice of Chartered Physiotherapists, and that patients will be able to continue to see a practitioner they have learned to trust.

“The vast majority of private physiotherapy practitioners are single-handed or small group practices. They are highly qualified, work very hard to treat patients, and they comply rigorously with professional standards. Physio First has had meetings and exchanged correspondence with BUPA and has pointed out the potential pitfalls that this tender strategy may produce”.

Commenting on the press release recently issued by BUPA about its tender to private physiotherapy practitioners, Phil Gray, Chief Executive of the Chartered Society of Physiotherapy (CSP), said:

"The CSP and Physio First are very concerned that BUPA’s press release appears to show that their primary motivation is reducing prices to a uniform level. BUPA’s quoting of price variations among Physiotherapists is unfair and inappropriate if they are not also quoting the differences in the clinical condition of the patients concerned, or the specialist expertise of the practitioner.

"BUPA’s apparent desire to have a uniform, fixed price for private physiotherapy does not fit with the expectation of choice of those taking out private medical insurance, or of the operation of a competitive market. If BUPA wants a uniform service standard at a uniform price, they may be encouraging customers to choose NHS services rather than the additional costs of BUPA private medical insurance."

As with all press campaigns it is difficult to predict the level of press uptake. Our view is that there are items of sufficient interest to the public to warrant press coverage and some open public debate about Bupa’s blind tender process; we are working hard with the CSP’s Communications Department, to generate the level of interest that this issue deserves.

A joint statement by Eric Lewis, Chairman of Physio First and Liz Cavan, Chair of Council “We fully understand the anguish and frustration that this Bupa initiative has caused to private practitioners. Both organisations intend to hold this process up to public and government scrutiny”.

Reporting Bupa to the Office of Fair Trading

As with the media campaign, any possibility of launching a complaint about Bupa to the OFT has had to wait until Bupa actually announced the details of their initiative.

Now that this has occurred, solicitors have been instructed to file a complaint with the OFT.

The basis of any such complaint is described in detail in the OFT Guidance note “Abuse of a Dominant Position”. A brief extract provides a flavour:

“… the OFT is empowered to apply two substantive provisions which prohibit conduct by one or more dominant undertakings which amounts to abusive behaviour … Article 82 and the Chapter II prohibition. The Chapter II prohibition provides that: '… any conduct on the part of one or more undertakings which amounts to the abuse of a dominant position in a market is prohibited if it may affect trade within the United Kingdom.'

Both Article 82 and the Chapter II prohibition provide, in similar terms, that conduct may constitute an abuse if it consists of:

(a) Directly or indirectly imposing unfair purchase or selling prices or other unfair trading conditions

(b) Limiting production, markets or technical development to the prejudice of consumers

(c) Applying dissimilar conditions to equivalent transactions with other trading parties, thereby placing them at a competitive disadvantage

(d) Making the conclusion of contracts subject to acceptance by the other parties of supplementary obligations which, by their nature or according to commercial usage, have no connection with the subject of the contracts.

2.6 These are no more than examples, and are not exhaustive. The important issue is whether the dominant undertaking is using its dominant position in an abusive way. This may occur if it uses practices that have the effect of restricting the degree of competition which it faces, or of exploiting its market position unjustifiably.

For full details follow the link to the OFT Guidance Paper on the subject at

http://www.oft.gov.uk/shared_oft/bus...ines/oft402pdf

Conclusion

As with any legal remedy the outcome cannot be guaranteed nor is it possible to control the timescale – this will be a matter for the OFT.

Physio First with the full and welcome support of the CSP is however determined to take action to the extent that the law permits, to take Bupa to task over this new and unwelcome initiative.

This is a frustrating time for all of us and we are all in the same boat having to make our own decisions on how to navigate our practices in relation to Bupa’s blind tender; everyone on the Physio First Executive Committee, your Regional Officers and members of our Sub Committees would like to be able to make it go away, but we cannot and to pretend that there is a “silver bullet” would be irresponsible.

We are however determined to help members emerge from this trying time. Perhaps this development will be a catalyst for change that could leave Physio First members as a very large and unlooked for competitor of private medical insurers. After all they and other businesses are the middlemen, but we provide the service – something to think about as we produce and review our business plans and how we direct our marketing in the future!

[sarahhayes]

This is a great Forum that i have not come across before so thank you. We need places like this at times like this. I am pleased that CSP and OCPPP have got involved and i will be at the meeting on Wednesday. I think as many as possible should go. We need to stand united on this and fight for autonomy and our Profession as a whole. Otherwise we may as well all go and work in America!
Sarah Hayes

[tamsinmann]

Have just read through the comments here and on 'thephysiovoice' and strongly recommend physio's take a look there too, to increase their awareness of all the issues so we can all make an informed choice about how we proceed as individuals, like this website it is being updated as often as possible.

Initially I was just worried about the financial implications short term but now my clinical autonomy is head of the agenda, long term implications second and any short term loss pretty irrelevant in the big scheme.