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When Australia’s largest private health insurer suggests a fundamental change to the referral system, alarm bells sound.

BUPA has asked the government to encourage GPs to use ‘open referrals’.

This is where a patient can visit more than one specialist before making their choice, without needing to return to the GP for additional referrals.

This would enable “patients to act on information regarding costs and possible consequences of various treatments,” BUPA says.

However, its definition of the word ‘open’ remains a little open.

Does the insurer envisage that this would allow the patient to go to the specialist’s colleague next door, who charges less?

If so, that is already the case.

Although most patients are unaware, a GP referral to a named specialist remains valid even if the patient books with another specialist in the same field.

In practice, this most often occurs with colleagues who share reception staff. But technically the patient can choose any doctor in Australia from that specialty, although this rarely occurs.

One can imagine occasional scenarios where this might be reasonable—if the named specialist had a long waiting list and another doctor cooperatively offered to fit them in.

Ideally, this would involve a second GP visit for a new, named referral, but sometimes that’s not possible.

However, BUPA’s ‘open referral’ suggestion seems to go further than this, implying that patients should be able to go from specialist to specialist based on a single GP referral.

 

That’s where the proposal starts to look odd.

Presumably, they are hoping that Medicare rebates will be available for each of those specialists.

After all, specialists and patients can already come to whatever financial arrangements they like outside the Medicare system.

When Australian Doctor contacted BUPA to clarify who they envisaged might pay for these multiple specialist visits (Medicare, patients or health funds?), their spokesperson replied: “We don’t propose to have all the answers but are instead asking the questions to prompt thinking in this area.”

Visiting more than one specialist without the GP’s knowledge also raises the spectre of patients choosing inappropriate services that the GP would not have requested.

There are excellent reasons why our expensive—and potentially dangerous—healthcare system requires decent GP gatekeepers. Chip away at those gates at your peril … hello America.

I wonder whether the ‘multiple specialists’ gambit is a distractor and the real issue is the ability for patients to switch specialists based on price?

There are some good arguments for enhancing the transparency for out-of-pocket costs for specialist care, and, in an ideal, world this information would already be known by the GP and patient when writing the initial referral.

So, if the end result of this brouhaha is merely that patients are made more aware of their already-existing right to see a colleague instead of the named specialist, that’s not necessarily a bad thing.

I’d just feel more comfortable if pushing the boundaries of that agenda was being advocated by health consumers, rather than health funds.

Dr Justin Coleman

Author: Dr Justin Coleman is a GP and columnist for MO.