'Optimising health care through specialist referral reforms' (Deeble Institute for Health Policy Research Issues Brief 38) by Samantha Prime, Christie Gardiner and Rebecca Haddock contains the following conclusion and recommendations
The regulatory requirement for patients to obtain repeat referrals when already under the care of a specialist has received limited scrutiny since the 1970s. Using referral expiration as a means of triggering GP involvement fails to optimise the skills of the health workforce and burdens patients and the health system with regulatory-led GP engagement that offers low to no clinical benefit to patients. Moving towards a health service model that places a greater emphasis on the appropriateness of the referral above the profession of the referrer is necessary to bring the referral rules in line with contemporary health needs and service structures. Achieving this requires a well-co-ordinated, effective and efficient referral system that facilitates the evidence-based and linear transfer of care from one clinician to another within a highly interoperable and collaborative healthcare system. The following recommendations are made to support improvements in the Australian referral framework:
Recommendation 1: Implement a national strategy for capturing and reporting standardised referral-related metrics
The limited data on how patients transition through the health system undermines effective service design. A national strategy for capturing and reporting standardised referral metrics is needed to inform evidence-based legislation and care. To be beneficial, this strategy needs to reflect referral trends across all sectors including public and private service providers. It should include detail on:
- the referral pathway/s taken by patients in order to access the necessary specialised care including who issued the initial and any repeat referral/s;
- the number of repeat referrals needed on an annual and lifetime basis in order to maintain affordable access to specialised care;
- the costs to the MBS associated with issuing initial and repeat referrals, and the costs to patients associated with obtaining initial and repeat referrals including full-fee referrals not subsidised through the MBS.
Including referral related metrics into the Primary Health Care Data Asset will improve knowledge gaps, however this also needs to be supported by an in-depth understanding of longitudinal trends in health service utilisation including tertiary related referral activities. A greater investment in linked data by government is therefore needed to ensure patient health service transition is adequately mapped and evaluated. Incorporating referral related indicators into the Australian Health Performance Framework will support the continuous identification of areas in need of improvement based on patients evolving health needs, and provide an avenue for service comparisons and benchmarking in order to promote high quality integrated care and patient health service throughput efficiencies (The National Health Information and Performance Principal Committee, 2017).
Recommendation 2: Conduct an independent, evidence-based review of the referral system
An in-depth independent review of the health and economic costs and benefits of the referral rules, and associated MBS billing practices should be undertaken to ensure the rules that underpin referral practices are evidence-based, patient-centred and appropriate to support the changing health needs of the nation. The review should:
- consult widely with stakeholders (especially patients);
- draw extensively on data and research from within Australia - including MBS and non-MBS sources; and
- consider ‘lessons learnt’ from other countries, such as the benefits and barriers of GP gatekeeping, and the relevance of any findings within the Australian context.
In order to avoid issues surrounding physician conflicts of interest due to the association between referral rules and remuneration, it is recommended that this review not be physician-led. The review process and all evidence used to support any recommendations, should be transparent and easily accessible to patients, service providers, and governments. Periodic review of referral legislation is recommended to ensure referral practices remain relevant and responsive to consumer needs and health workforce capabilities.
Recommendation 3: Decouple specialist billing from referral status and introduce protections against increased costs for patients under long-term specialist care
The expiration of a referral is broadly incompatible with the aims of specialist care for people with long-term illness. Indefinite referrals should be issued to ensure patients under long-term specialist care are not adversely and routinely impacted by referral expiration. There is a need to decouple specialist billing more broadly from referral status to ensure consultations are based on clinical need. In the absence of such reforms, specialists and consultant physicians should be authorised to extend a referral when clinically appropriate in order to retain the referral’s validity for MBS billing purposes. In addition, civil and criminal penalties associated with backdating of referrals should be removed in circumstances where a period of invalidity coincides with a single course of treatment to ensure patients are not financially or clinically disadvantaged by referral expiration. Should the Regulations and Act remain unchanged, introducing permanent bulk billed telehealth and on-demand referrals services for all Australians requiring repeat referrals would help protect patients from the burdens of obtaining repeat referrals for continuing care.
Recommendation 4: Optimise the health workforce by expanding referral rights and adopting a linear evidence-based model of patient transfer through the health system
All patients and especially those with complex illnesses and multimorbidity should not be financially disadvantaged or inconvenienced by the referral system based on ‘who’ identified the need for referral in the first instance. The current referral framework places a greater emphasis on processes over patients. Replacing it with one that is patient-centred, evidence-based, and adaptive to meet changing needs, is necessary to promote high quality and value-based care. Expanding the referral rights, including periods of referral validity, for current and presently non- recognised clinicians under the MBS referral rules will maximise the skills of the diverse health workforce and reduce the frequency of unnecessary referral duplication.
Recommendation 5: Establish a dedicated principles and rules function within the Department of Health to support the interpretation, implementation and routine revision of referral rules
Without a dedicated service to monitor the appropriateness of the rules, and oversee the correct interpretation and application of the referral rules, patients will continue to be negatively impacted by outdated referral pathways leading to increased costs and delayed care. A dedicated principles and rules function within the Department of Health should be established to:
- Support the widespread awareness of referral rules and responsibilities among patients to ensure they can exercise autonomy and self-determination within a patient-centred healthcare system.
- Develop public campaigns that educate patients on their referral rights, including the risk of liability for receiving specialist care under an invalid referral and what can be done to mitigate this risk.
- Support patients to effectively resolve referral related disputes and provide up to date advice on any changes to the referral system.
- Oversee the initial and ongoing training of MBS providers, administrators, practice managers and Medicare staff on the correct interpretation of the referral rules and MBS billing requirements.
- Investigate and mediate instances of the inaccurate interpretation of referral rules and improper billing practices.
Recommendation 6: Invest in health service interoperability and mandate real-time health information exchange between multidisciplinary care teams to facilitate high quality, coordinated and continuous care
Changes to the Regulation should be made to mandate timely information flow between all members of a patient’s care team. This would reduce the burden on patients, and ensure GPs remain informed irrespective of where the referral originates from; and alleviate any concerns over continuity and coordination of care raised by GPs. Making better use of current digital platforms like My Health Record is recommended to ensure clinicians have near real-time access to detail on emerging patient issues and their transition through the health system (Australian Digital Health Agency, n.d). Referral management software such as the Queensland Health (2020) Smart Referrals platform should be made interoperable with larger interfaces, such as My Health Record, that can then serve as the national repository for all referrals made, irrespective of service provider or jurisdiction. Referral platforms should facilitate a multi-way interface between all members of a patient’s care team by providing up-to-date information on when a new referral has been made and consultation taken place. These systems could be enhanced through automation and built-in notification and alert functionalities that facilitate instantaneous updates for patients and service providers on nominated fields such as ‘new referral issued’ and ‘referral expiring’. These notifications can then prompt GP follow-up if clinically necessary or facilitate a digital extension of the referral without the need for consultation.