You have a chronic health condition and visit your specialist for an annual check-up, but the referral’s expired. You’re told to get a new referral from the GP to claim the Medicare rebate. You take the next afternoon off to see your GP, who gives you another 12 month referral and tells you they can’t backdate it. You’re out of pocket for the specialist fee and gap payment for your GP consultation. You’ll have to do it all again next year.
Common issues like this are highlighted in a new report on the specialist referral system out today by the Deeble Institute for Health Policy Research, the research arm of the Australian Healthcare and Hospitals Association.
The report, which we co-authored, finds shortcomings in a broken referral system, plagued by poor data collection and wasted dollars.
Fixing these issues requires a better understanding of patients’ long-term needs and the health and economic consequences of the medical referral system.
Chronic illness is more common now
The rules about specialist referrals were developed in the 70s, when acute illness was more common.
Now more people each year are being diagnosed with a chronic illness, needing long-term specialist management.
They will often need multiple referrals, depending on how many specialists they see and when these referrals expire. This can be a frustrating financial and logistical burden and can even cause some patients to delay treatment.
Referrals can be too short
Different types of health-care workers can refer you to specialists or consultant physicians. The duration of the referral ultimately depends on who issues it.
GPs commonly limit their referrals to fixed terms, even though indefinite referrals are possible. Specialists can only issue referrals to other specialists for three months, and this rule poses serious challenges for many vulnerable people.
One example, taken from a review of Medicare in 2016, is of cancer patients receiving different types of therapy, where the radiation oncology treatment lasts longer than three months. When the referral expires, the patient needs to obtain a new one to continue treatment.
Issues the review identified about the three month rule included difficulties providers had in interpreting the rules, leading to improper Medicare billing practices. This echoes previous concerns.
Why are referrals stuck in the 70s?
Regardless of the burden on patients, health-care workers and Medicare, both sides of government have shown little interest in changing the referral rules.
This is largely because of the general principles that sit behind them. These include the need to keep people away from expensive specialist care and the importance of GPs as gatekeepers of the health system.