Specialists back referral reform: ditch the 3-month rule


By Andrew Bracey

16 Oct 2020

Specialists have backed calls for an overhaul of “outdated” referral pathway rules, but stopped short of supporting a push for referral status to be decoupled from specialist billing.

Last week a Deeble Institute report, Optimising health care through specialist reforms, argued that existing rules requiring patients to obtain repeat referrals in order to continue receiving specialist care are outdated and have been inadequately reviewed since their introduction in the 1970s.

The authors said that expanding referral rights for specialists and “adopting a linear evidence-based model of patient transfer” would lead to more efficient case management and reduced patient out-of-pocket costs.

The report follows recent debate about “financial toxicity” and the barriers to optimal care caused by accumulating patient medical bills.

“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 limited clinical benefit to patients,” the report’s authors wrote.

“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.”

Professor Declan Murphy, director of genitourinary oncology at Melbourne’s Peter MacCallum Cancer Centre, told the limbic that while he supported careful regulation of referrals and rebates, the resulting red tape was often “tedious” for specialists and patients.

Among specialists’ key frustrations, he said, was the 3-month validity period for referrals to specialist colleagues without the involvement of a GP.

“In a multidisciplinary cancer group like ours for example, we’re constantly referring to other specialists,” Murphy said. “As a surgeon, I often want a radiation oncologist to see my patients and have a chat or to deliver ongoing care etc – so I don’t understand why 3 months is the rule there, as inevitably cancer patients are on a long journey.”

However, Murphy warned against the complete uncoupling of referrals from GPs and rebates saying that it would likely replicate the US system which he criticised as expensive and fragmented.

“Overall if they made it more patient-directed, stratified by the patient – especially for chronic conditions like cancer, diabetes, asthma, and so on – I don’t think we would be opening up the system to abuse,” Professor Murphy said.

Megan Varlow, director of cancer control policy at Cancer Council Australia, also voiced qualified support for referral reform, saying the system had been originally designed for acute cases and was not suited to patients requiring ongoing, complex multidisciplinary care.

While strongly backing the report’s proposed review of referral pathways to steer future improvements and reforms, Ms Varlow said a broader approach was necessary while ensuring GPs retained a central role.

“Referrals are a mechanism that connects specialists, but only in an arbitrary way,” she said. “We would like to see what other mechanisms are available to really get that team-based care happening more seamlessly.”

Ms Varlow added that, while often seen as solely administrative, consultations based around updating referrals were valuable chances for opportunistic care and were vital in keeping GPs and patients connected.

Meanwhile, in a lengthy response to an article posted by the report’s authors on The Conversation, RACGP president-elect Dr Karen Price said the recommendations risked patient safety, would lead to fragmented and more expensive care, and diminished the role of GPs.

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