Health Insurance Amendment (Pathology Requests) Bill 2010
Reference
1.1
On 24 February 2010, the Senate, on the recommendation of the Selection
of Bills Committee (Report No. 2 of 2010), referred the provisions of the Health
Insurance Amendment (Pathology Requests) Bill 2010 (the bill) to the Community
Affairs Legislation Committee for inquiry and report by 12 May 2010.[1]
The following issues were identified for consideration during the inquiry:
- the onus being placed on patients to choose the pathology practitioner;
- problems which may arise between unknown referring doctors and
pathology providers and which may result in delays;
- problems which may arise as a result of the inconsistent
reference ranges and measurement series used by different pathology providers;
and
- possible effects upon arrangements between general medical
practitioners and pathology providers relating to emergency and out-of-hours
contacts.[2]
Conduct of the inquiry
1.2
The committee called for submissions to be received by 9 April 2010.
Nine submissions were received and are listed at Appendix 1. These can also be
viewed on the committee's webpage, available at:
https://www.aph.gov.au/Senate/committee/clac_ctte/health_ins_pathology_requests/submissions.htm
1.3
A public hearing was held in Canberra on 30 April 2010. The Hansard
transcript from the hearing has been tabled for the information of the Senate
and can also be accessed via the committee's website at:
https://www.aph.gov.au/Senate/committee/clac_ctte/completed_inquiries/index.htm
1.4
The committee is grateful to all those who contributed to the inquiry
through written submissions and oral evidence.
1.5
References in this report are to individual submissions as received by
the committee, not to a bound volume. References to the committee Hansard
relate to the proof Hansard. Please note that page numbers may vary between the
proof and the official Hansard transcript.
Background to the bill
1.6
In the 2009-10 Budget, the government proposed changes to the pathology
provider referral system. The changes are intended to provide patients with
more choice regarding providers of pathology services, leading to improved
quality of service and increased price competition among providers as well as
more convenience for patients.[3]
These changes were based upon an interdepartmental review of pathology services
and funding which received over 30 submissions from peak professional bodies
and other stakeholders.[4]
1.7
Currently, for a Medicare benefit to be payable, the Health Insurance Act 1973
(the HIA) requires that a referring doctor designate a particular pathology
provider on the pathology request form. This requirement limits the patient's
choice of pathology providers. Many doctors use 'branded' request forms which
specify a particular provider and often indicate the provider's company logo
and address.[5]
1.8
This is different from the way in which patients can choose general
medical practitioners (GPs) or providers of other medical services such as
diagnostic imaging. The government believes that patients should be free to
choose their pathology providers just as they are free to choose providers of
other medical services.[6]
Provisions of the bill
1.9
The effect of the bill is that patients will be able to present requests
for Medicare-eligible pathology services to any approved pathology providers.
The proposed amendments to the HIA remove the requirement for a referring
doctor to designate a particular pathology provider on the request form. The
provisions of the bill amend the wording of the HIA to specify that the
provider of a pathology service should be in receipt of a referral for that
service in order for the service to be eligible for a Medicare benefit. This
replaces the current wording specifying that a provider of pathology services should
be in receipt of a referral which designates that particular
provider.
1.10
The new arrangements are to take effect from 1 July 2010.
Changes to regulations
1.11
The government will also amend the current regulations, before
1 July 2011, to require the inclusion of a clear and prominent
statement on pathology request forms informing patients of their right to
present request forms at pathology providers of their choice. The requirement
for inclusion of such a statement on pathology request forms has been delayed
by 12 months to allow for consultation with relevant stakeholders such as
pathology providers and medical practitioners as well as patients about the
exact form this statement should take. Following the changes to regulations,
pathology providers may continue to provide medical practitioners with branded
request forms but such forms must indicate that patients can choose any
pathology provider.[7]
Purpose of the bill
1.12
The Minister for Health and Ageing has stated that the government
supports a patient's right to choose pathology providers. She further explained
the government's position by stating that:
[w]e believe informed patient choice is a key element of
quality health care. This amendment will ensure that patients have a right to
choose their pathology provider and are made aware of that fact, leading to
increased competition and better service among providers.[8]
1.13
In addition, the government's amendments are aimed at increasing
convenience for patients.[9]
Issues
1.14
A number of issues have been raised by stakeholders regarding the
government's proposed amendments, both prior to and during the committee's
inquiry. These include:
- the introduction of the legislation prior to completion of a
consultation process;
- the risks associated with patients choosing pathology providers;
- measures designed to increase competition in the pathology
sector;
- the differences between pathology and diagnostic imaging
services; and
-
contact between pathology providers and referring doctors after
business hours.
Consultation process
1.15
The Department of Health and Ageing released a discussion paper in
January 2010, seeking feedback from relevant stakeholders including
patients, pathology providers and GPs regarding the proposed changes to
pathology request forms. The department explained at the time that the purpose
of the discussion paper was to 'ensure that the implementation and management
of this measure is sensitive to the interests' of such stakeholders.[10]
1.16
In response to the discussion paper, the Royal College of Pathologists
of Australasia (RCPA) complained that the legislation was being introduced too
hastily and before the deadline for responses to the discussion paper had been
reached.[11]
The president of the college, Associate Professor Paul McKenzie, cautioned
against presenting the legislation prior to appropriate consultation as this
risked alienating stakeholders whose support was central to the successful
implementation of the proposed changes.[12]
1.17
Concerns regarding the timing of the consultation process were also
raised by the Australian Association of Pathology Practices (AAPP).[13]
The association warned the government against introducing the legislative
changes without 'an understanding of the risks of this change for the patient'.[14]
1.18
However, representatives from the Department of Health and Ageing
clarified that the consultation process related only to the implementation of
the proposed changes. Mr Richard Bartlett of the department told the committee
that:
[c]ertainly talking to people, there was an awareness of when
the bill went into parliament. There was also an awareness that a decision had
been made as part of the budget and legislation needed to be introduced by [a] particular
time if it was to take effect in the time frame given. The consultation was
about issues of implementation and subsequent issues regarding the forms and
the format of the forms. People were having a discussion in that context. It
was not about whether we revisited the decision...
The discussion paper followed up consultation and attempted
to look at ways in which issues that had been raised could be addressed. The
consultation period went beyond the submission of the legislation because in a
sense it is a flow-on from that rather than part of that.[15]
Patient choice
1.19
The Department of Health and Ageing noted in its submission to this
inquiry that, according to the National Health and Hospitals Reform Commission,
'the health system should be empowering consumers to make fully informed
decisions'. Further, the department stated that:
[t]here are no compelling reasons for restricting patient
choice and the Health Insurance Amendment (Pathology Requests) Bill 2010
(the Bill) removes this unwarranted legislative impediment.[16]
1.20
Consumers Health Forum of Australia (CHF) welcomed the government's
proposed amendments because they would deliver more choice for patients,
enabling them to take a more effective role in their own health care.[17]
Patients' opinions regarding pathology services were surveyed nationwide by
CHF. A representative of CHF told the committee that:
[t]hroughout that process it became
very clear to us that consumers want the choice of the pathology provider that
they choose to use. They believed that that was a very good thing in terms of
being able to source the most cost effective provider...[18]
1.21
Patients have indicated to CHF that they value choice but also want to
receive sound advice and information from their doctors during consultations.
CHF summarised consumers' opinions gathered through the forum's nationwide
consultations by noting that:
[t]hroughout CHF's consultations, consumers have argued that
they want increased, high quality communication and advice on their rights and
responsibilities around pathology testing. Most consumers [who were] consulted
identified that they were unaware that they would have any choice about which
pathology provider they attended under new legislation. Choice is something
consumers value...[but] appropriate and thorough communication between the
requesting practitioner and the consumer at the time of the consultation is
imperative. CHF considers it important that the requesting practitioner should
have a comprehensive discussion with the consumer about their right to attend a
pathology provider of their choosing. This is also an opportunity to discuss
the benefits of the consumer informing the practitioner of their choice of
provider. Informed consent is an important part of quality healthcare.[19]
1.22
The RCPA, in response to the announcement of measures in the May 2009
Budget relating to pathology services, pointed out that patient choice should
not come at the expense of quality health outcomes. The college commented that:
...the loss of the referrers' (i.e. usually GP's) right to
select the pathologist they wish to refer to [is a major concern to the
college]. Pathology is a medical specialty like any other area of medicine and
requesting doctors should have the professional right to determine who they
refer their patients to, if quality is not to be compromised.[20]
1.23
The AAPP noted that the core issue was 'how to give the patient choice
without impacting patient safety'.[21]
While agreeing that patients should have the right to choose their pathology
providers, the RCPA pointed out that this right is already available to
patients during consultations with their medical practitioners. The president
of the RCPA, Associate Professor Paul McKenzie, argued that this consultative
approach was the safest and most effective method of choosing a pathology
provider as it ensured that patients understood the medical and other reasons
for choosing particular providers and doctors were aware of their patients'
preferences.[22]
1.24
In response to questions from the committee regarding whether patients
were aware that they could discuss the selection of pathology providers with
their doctors now, CHF commented that:
...it certainly was not something that our members were aware
of—and our members are quite informed. They are people that use the health
system. They use pathology services frequently and they did not raise that with
us as something that they were aware of. Certainly, when this legislation was
announced we made them aware of that and they welcomed that, embraced that and
said that they would value having that option for choice.
...We were surprised. We thought that
we would not necessarily get a lot of interest in these consultations but we
were swamped with interest. That is because people are having these sorts of
experiences and feel that there does need to be some improvement to the way
things operate.
...it is up to consumers to have the
conversation with their doctor and we would like to think that that is a
two-way communication process, that the reasons for them being referred to a
particular provider are clear to them and given to them, and that reasons for
them similarly choosing to go to a different provider would be explained to the
doctor. This legislation creates more of an option for consumers to have the
conversation, which is a good thing.[23]
1.25
The Department of Health and Ageing pointed out that the proposed
changes do not remove the requirement for pathology requests to be made by
suitably qualified medical practitioners.[24]
The department also commented that:
...part of what this bill does is reflect an acknowledgement
that the key decision maker about a patient’s treatment is the patient. It
gives them some capacity to exercise choice, and we hope [that] will be
informed choice.[25]
Clinical reasons for nominating
pathology providers
1.26
The AMA and the Royal Australian College of General Practitioners
(RACGP) informed the committee that doctors may, at times, feel it necessary to
nominate particular pathology providers. In the majority of cases, it would be
acceptable for patients to present pathology request forms to providers of
their choice. However, in a small number of cases, doctors may need to specify
particular pathology providers for clinical reasons. Both these organisations
suggested that doctors should therefore have the option of specifying that a
pathology request must be presented only to the nominated provider.[26]
A representative of the AMA who appeared before the committee, Dr Paul Jones,
stated that:
...there are a few situations where I specifically say to [patients],
‘I’d like you to go to pathologist X.’
... These are not frequent occurrences but we believe we need
to have the option of doing that with those particular patients [who we feel
need to attend specific pathology providers]. For the vast majority of cases I
think that most doctors will say to the patient, ‘It doesn’t matter where you
have the test done.’ But there are some specific circumstances where we think
it is important.[27]
1.27
CHF informed the committee that patients are generally willing to accept
their referring doctors' reasons for nominating particular pathology providers.
Miss Anna Wise of CHF reported to the committee that:
[i]f there is a legitimate reason why
the doctor wants them to go to a particular pathology provider, they will take
it on board and make that decision accordingly. Some machines are calibrated
differently from one lab to another, which can affect the results. Consumers
are very open to recognising the impact that that can have.[28]
Acceptance of responsibility
1.28
The president of the RCPA questioned who would ultimately be
responsible, if the legislation were to be introduced, in situations where
patients attended different pathology providers against medical advice.[29]
In relation to this question, the AAPP clearly stated that the responsibility
should rest with the patient. The association declared that:
[w]hen patients change the advice of the referring doctor and
make judgements about the suitability of a particular pathology practice to
perform their test, then they must assume responsibility for the consequences
that flow from the choice.[30]
1.29
To address this problem, the AAPP and RCPA recommended that patients be
required to document acceptance of responsibility in such situations on the
request forms, similar to the way that patients sign themselves out when
leaving hospital against medical advice. Furthermore, they recommended that
warnings be included on the request forms informing patients of the risks
associated with changing providers against medical advice.[31]
1.30
However, the committee was informed by a representative from the
Department of Health and Ageing that patients’ signatures on pathology request
forms would not necessarily alter the burden of legal responsibility. Mr Chris
Reid of the department explained that, in this situation, the law of negligence
was based upon the ‘reasonableness’ of doctors’ actions in following up
pathology results. Mr Reid stated that:
I would have thought, from a legal
perspective that whether they had signed the form or not, would make no
difference. If there is a problem and the matter gets to court it will become
apparent how the facts have unravelled. If the fact of the matter is that the
patient has taken the referral somewhere else and not told the doctor about it
and the doctor has been unable to follow up on it, then it is difficult to see
how a court could find that the doctor was liable. There is no cast-iron rule
that says that doctors are legally obliged to follow up. The whole law of
negligence revolves around the principle of reasonableness. They have to take
reasonable steps. If the patient has somehow made it impossible to follow up on
the referral then it is, in my view, quite unlikely that the doctor would be
sheeted home with liability as a result of that.[32]
Onus of choice upon patient
1.31
Some organisations have expressed concern about a patient's ability to
choose the most suitable pathology provider for that patient's particular
circumstances. The AMA pointed out that there may be 'good clinical reasons'
for choosing a particular laboratory for certain tests or the decision may be
based upon the expertise held by a particular pathologist.[33]
Patients would not be ideally placed to make such judgements. Similarly, the
AAPP commented that:
[p]atient choice is a desirable goal but, in practice,
assumes the patient has the knowledge and expertise to understand the complex
process of pathology testing and the key elements that are necessary for a
provider to be able to ensure a quality outcome for the patient.
Diagnosis of disease is a complex process requiring
professional medical expertise from a team of medical specialists to understand
the symptoms and test results that are essential to an accurate diagnosis. The
medical team comprised of GPs, pathologists, radiologists and specialists work
together in a way that is not visible to the patient. Because this interaction
between treating doctors is not visible to patients, we believe they are not
equipped to make an informed decision in the selection of pathology provider.
Importantly, price and location are not the only determinants of the best
pathologist for a patient.[34]
1.32
The RCPA cautioned that patients should not be exercising such choice
without access to professional advice and 'potentially without realising that
such advice could be beneficial to them'.[35]
1.33
CHF found that, while choice of pathology providers was valued by
patients, they also wanted sound advice from their referring doctors. This
highlighted the need for effective communication during consultations to
establish the patient's preferences but also to inform the patient of the
medical or other reasons for the doctor's recommendations. CHF stated that:
[c]onsumers reported they would be more likely to follow
advice from their practitioner about what pathology provider to attend if
the reason for their practitioners' preference were effectively communicated to
them.[36]
1.34
The Department of Health and Ageing emphasised to the committee that the
proposed changes did not indicate that the onus of choice rested with the
patient but, rather, that 'the onus remains on the treating doctor to advise
patients of the most appropriate choice'. A doctor should prepare a pathology
request form following discussion of pathology services with the patient. The
department also informed the committee that it is expected that most patients
will follow the recommendations of their doctors regarding providers of
pathology services.[37]
Pathology collection
1.35
More than half of all pathology collection procedures are conducted by
pathology service providers at their collection centres. Pathology samples can
also be taken at a GP's surgery and later collected for analysis by a pathology
provider with which the GP has an agreement. Less commonly, pathology specimens
may be collected at hospitals by providers nominated by the hospitals.[38]
1.36
The Department of Health and Ageing indicated in its 2010 discussion
paper that a patient's choice of pathology provider could be restricted when a
sample is collected in a doctor's surgery and later forwarded to the surgery's
usual pathology provider. However, the department argued that, by accepting the
request form citing a particular pathology provider, the patient is therefore
accepting the surgery's existing arrangements for pathology services and
accepting the particular provider normally used by the surgery. Similarly, it
was claimed in the discussion paper that:
[b]y choosing the services of a particular hospital, it could
be argued that the patient has made a choice to accept the arrangements in
place in that hospital for the provision of pathology services.[39]
1.37
The president of the RCPA pointed to inconsistencies in this argument,
noting that if such an assumption could be applied to the collection of samples
in hospitals or in GP surgeries, the same assumption could be applied when a
patient chooses a particular GP or surgery. By choosing that GP, the patient
could also be said to be accepting the GP's usual pathology provider. Such an
assumption would negate the need for the current legislative changes allowing
patients to choose pathology providers as they can exercise such a choice by
choosing a GP.[40]
1.38
Collection of pathology samples from operating theatres also raised
difficult questions regarding patient choice. The present system allows for
identification of errors because the form indicates to which laboratory the
sample should be taken. It would be more difficult to identify errors as well
as to determine the patient's choice of provider if this was not specified on
the form.[41]
Informing patients
1.39
In order to address these difficulties, the RCPA has suggested that the
legislation be based upon the requirement that doctors inform patients of their
right to exercise choice in the provision of pathology services.[42]
The AAPP also recommended that a referring doctor discuss with the patient at
the time that the pathology request form is generated not only the patient's
right to choose a pathology provider but also the doctor's reasons for
recommending a specific pathology provider.[43]
1.40
Representatives from the Department of Health and Ageing informed the
committee that they expect that doctors and patients to discuss during
consultations the reasons for choosing particular pathology providers. Mr David
Learmonth stated that:
I think what we are talking about is the kind of discussion
that might reasonably go on when there is a treatment, accessing that treatment
or some other aspect of what the clinician is proposing that deserves full and
proper discussion and a clear informed choice on behalf of the patient.[44]
1.41
Similarly, Dr Megan Keaney of the department declared that:
[i]n that particular circumstance [where a doctor recommends
a particular pathology provider for clinical reasons], those matters would be
part of the discussion between the doctor and the patient. A patient would be
guided by their doctor’s advice as to the need to have some consistency in that
situation, and for that reason a particular pathology provider would be the
preferred provider. As I said, I think this measure is about informed choice,
and that is only addressed if the discussion addresses all the issues that are
relevant to the patient’s decision making. So, in the ordinary course of
events, we have an expectation that in that circumstance a patient would be
guided by their general practitioner or specialist and would in fact follow
that advice about the preferred provider.[45]
1.42
In response to the suggestion that doctors do not currently discuss with
patients the need to attend particular pathology providers, Dr Brian Richards
of the department explained from his own experience that:
I would say to my patients, ‘Although I normally send my
pathology to pathology laboratory X, I would like you to go and get your toenail
scraping at pathology company Y because there is a particular pathologist
there.’ I would name him and say ‘I suggest you go there for this reason.’ This
was years ago. I would give that patient that advice so that they understood
the reason that I was referring them to a particular laboratory. I do not think
that is a new practice. It is simply respecting the autonomy of the patient and
part of the normal patient-doctor relationship. For the majority of patients
and pathology samples such a conversation would not be necessary because, in
the majority of cases, it would not matter where they went. Where it does
matter, I think it is good practice for the referring doctor to explain. I do
not see that that is a great imposition on a medical practitioner.[46]
1.43
Similarly, Mr Richard Bartlett pointed out that discussions between
doctor and patient regarding the benefits of particular pathology providers
would seem to be occurring already, as evidenced by the fact that the majority
of GPs used several different pathology providers. Mr Bartlett stated that:
...if somebody needs a particular sort of test, there will be a
discussion that will get you to the point of saying, ‘You need a pathology
test.’ At the moment, it is filling out a form, but equally there can be a
discussion about, ‘This is the pathologist that is nearer and this is the
pathologist that bulk-bills or does not bulk-bill.’ Again, these are
discussions that in some cases happen now.
...The GP generally does have that knowledge. Certainly, we are
seeing at the moment that 60 per cent of GPs are referring to two or more
pathology companies for similar tests, so clearly there is a choice happening
now. One assumes that there is a degree of collaboration between the doctor and
the patient in terms of making that choice. Rather than the GP saying, ‘I’ll
send this person to this one; I’ll send that person to that one,’ we have to
assume that these conversations are happening now. Similarly, if you are
telling someone to go and get pathology, you need to convince them that they
need the pathology. They do have a very clear choice at the moment between
either getting it or not getting it, and there are clearly cases where people
do not. Again, if you want them to use a particular pathologist, it is a
logical step in that conversation, and, again, I think it is happening now.[47]
Established relationships and
standardised reporting
1.44
Working relationships established between GPs (or other referring
doctors) and providers of pathology services are important in the provision of
quality pathology services and in ensuring quality patient care.[48]
An example of this was included in the Department of Health and Ageing's
discussion paper where it was noted that urgent pathology results can be
expedited through established communication channels or procedures.[49]
The RACGP informed the committee that some pathology providers and referring
doctors have agreed that 'certain bands of significantly abnormal results' will
be telephoned through to the doctor, in addition to the usual reporting
methods, ensuring that the doctor's attention is drawn to results which may
require an urgent response.[50]
1.45
The AAPP presented a number of case studies to the committee
illustrating the need for established relationships between referring doctors
and pathology providers.[51]
The AAPP explained that these relationships lead to the development of familiar
protocols regarding reporting, collection, logistics and computer systems.
Standardisation of reporting methods and format allows consistency in
measurement methods, cumulative reporting (indicating changes over time) and
reference ranges and intervals. Familiarity allows interpretative comments to
be tailored to the individual needs of doctors and easily accessible
communication methods to be established (for example, compatible computer
systems). In addition, these protocols allow the development of checks and
audits to ensure that tests are not mislaid or misdirected, that collection is
not delayed and that results are forwarded in a timely fashion and received by
the referring doctor. These agreed procedures ensure that pathology samples are
received and processed 'within strict tolerance specifications' and that
doctors receive accurate and meaningful pathology results.[52]
1.46
CHF acknowledged possible difficulties such as delayed results due to
patients attending pathology providers with whom referring doctors were
unfamiliar. However, the forum also cautioned that test results may also be
delayed under the current system ‘regardless of the relationship between the
pathology provider and referrer’. [53]
Traceability of results
1.47
The Department of Health and Ageing noted the legislative requirement
that doctors include their names and contact details upon requests for
pathology services.[54]
This allows pathology providers to contact referring doctors with ease.
However, the reverse situation is not necessarily straightforward.
1.48
Established relationships between medical practitioners and pathology
providers allow doctors to more easily identify the pathology provider or specific
laboratory at which particular tests are carried out.[55]
When doctors are aware of the pathology provider, they can more easily trace
the progress of particular tests, better understand test results (based on an
understanding of the particular analytical methods used by that provider) and
contact the pathology provider directly when necessary in order to query
findings and anomalies.
1.49
The RCPA and AAPP pointed to this issue when identifying the differences
between diagnostic imaging and pathology services. Typically, a patient is able
to physically hand imaging test results such as ultrasound films to a GP or
other medical practitioner. In these circumstances, it is a relatively easy
process to identify which imaging provider was responsible for the testing.
This is not necessarily the case with pathology test results which are
forwarded to the requesting doctor, not handed to the patient.[56]
1.50
In response to these difficulties, the AMA and the National Coalition of
Public Pathology (NCOPP) suggested that, when a patient presents a request for
service from a doctor with whom the pathology provider has not previously
dealt, the pathology provider should inform the doctor that the request has
been received. The doctor and pathology provider should, at this time,
establish procedures for reporting test results. If necessary, the various
testing methods used by the pathology provider should also be discussed.[57]
Establishing such procedures would ensure that the referring doctor is able to
trace test results and the pathology provider is able to forward test results
in a timely manner. In addition, the doctor would be aware of the ways in which
the results were established and the provider would be able to tailor reporting
of the results to the doctor's needs or expectations.
1.51
According to the Department of Health and Ageing, patients were likely
to inform their doctors during consultations of any changes in pathology
providers which were contrary to the doctors' advice.[58]
This claim was based upon the scenario where patients selected the pathology
providers following the initial consultations with their referring doctors.[59]
In response to questions from the committee, Dr Brian Richards of the
department commented that:
...the issue that you raise is, I think, mainly in relation to
when a referring practitioner wants to chase up the results... prior to them
arriving in due course. The practitioner is usually chasing up the results
because the patient has re-presented and is sicker or has rung up to inquire
about the results. In those circumstances, if the practitioner rings up the
pathology company to whom the referral was originally made and the pathology
company says, ‘We don’t know about that,’ the practitioner would presumably
ring the patient. Or, if the patient was chasing up their results, they would
say, ‘I went to such and such; can you ring them?’ So I think that simple
communication between the referring practitioner and the patient would address
those concerns. Most patients would not be unaware of the pathology laboratory
they attended.[60]
1.52
Dr Richards went on to explain that the ability of doctors to trace
pathology results was also related to an increasingly common scenario, the
patient who requires pathology tests while travelling. Dr Richards stated that:
[t]he other relevant factor is the patient who is travelling.
A lot of the grey nomads travelling around are on warfarin and they go from
place to place. Their referring practitioner is not in a position to know the
name of every pathology practitioner in every town they might call into or even
when they might be there. One of the advantages of this bill is that a patient
with a referral to a pathology laboratory can take it to any pathology
laboratory on their travels. So it is not only for patients who are in the one
place. Increasingly, patients are on the move, and this allows the patient the
choice. Clearly, then, if they are chasing up the results, they will ring up
their GP and say, ‘I’m in Broome today and I went to this pathology; I need my
INR result.[61]
Inconsistencies in reference ranges and serial measurement
1.53
The committee was informed by a number of witnesses including the AAPP
and the AMA that directly comparable methods of analysis are required in the
case of serial tests and also in the comparison of serial samples in chronic
illnesses.[62]
Difficulties may also arise from inconsistencies in equipment used by various
pathology providers.[63]
The Australasian Association of Clinical Biochemists (AACB) explained that
inconsistencies in references ranges across pathology providers can pose
particular problems in some computer-based practice management systems where
'only selected parts of the electronic result' are reproduced. In these cases,
the doctor may be unaware of the particular testing methods and units of
measurement that were used to produce the pathology results as reported. The
AACB recommended that serial measurements are carried out by the same pathology
provider in order to address this difficulty.[64]
1.54
Continuity of results comparison can be threatened when patients choose
pathology providers other than those recommended by their doctors or when
patients do not inform their doctors of changes in providers. The case studies
presented by the AAPP illustrate the difficulties that may arise from the
different methods used by different pathology providers to analyse specimens
and establish results. Case study 2, for example, introduced the scenario where
a patient was tested twice a year by a specific pathology provider. When the
patient chose a different provider, the test results were different because the
new laboratory 'used a different method with a different normal range'. The GP
was concerned by the higher reading, not realising that the patient had gone to
a different pathology provider. The GP informed the patient of the possibility
of cancer and referred the patient to a specialist medical practitioner. The
specialist carried out further tests which eventually established that there
had been no change in the patient's condition.[65]
1.55
In addition, the RACGP noted that, even where several laboratories use
the same reference ranges, differences may still be found in the ways in which
each of these laboratories prepares cumulative reports and highlights changes
in patients' conditions over time. If a different laboratory carries out the
testing (with a different method of reporting cumulative results), significant
changes in a patient's condition may not be easily or effectively identified.[66]
1.56
The Department of Health and Ageing, however, informed the committee
that pathology providers are required by current accreditation standards to
include in pathology reports 'any extra information that may be relevant for a
doctor to interpret results'.[67]
This would indicate that, along with the test results, pathology providers
should report to doctors the measurement series, reference ranges and testing
methods that were used to establish the results. This process would enable
doctors to accurately read test results.
1.57
Where a doctor refers a patient to a particular pathology provider for
clinical reasons (such as for consistency of reference ranges in cumulative
testing), a discussion between the doctor and the patient at the time the
request form is completed would allow the doctor the opportunity to explain the
need to attend the same pathology provider over time. Dr Brian Richards of the
Department of Health and Ageing commented that:
...the bill, as I understand it, seeks to give patients a
choice in pathology provider. The implication is that that should be an
informed choice...Where it does not matter clinically and it is a matter of price
and convenience then the patient can make that choice on those grounds. Where
it does matter clinically then the patient should be advised by their referring
practitioner in relation to that.[68]
Consequences of changing providers
1.58
A number of other negative outcomes can result from patients choosing
pathology providers other than those recommended by their doctors. Resources
and time can be wasted when, for example, a test request which is received by a
particular provider is for a test that is not performed by that provider. In
this case, either the patient has to go to another provider or the specimen has
to be forwarded to another laboratory.[69]
1.59
The AAPP identified more serious consequences where patients' health
outcomes were put at risk. These included the need for further (and possibly
unnecessary) testing or treatment, delayed or incorrect diagnosis and treatment
and possible deterioration in a patient's condition due to delays, misdiagnoses
or inappropriate medical treatment. A failure in the processing of pathology
tests and reporting of pathology results also creates the potential for legal
action on the grounds of medical indemnity or negligence.[70]
1.60
The AAPP cautioned that patient choice should not come at the expense of
patient safety.[71]
When introducing the current legislation, the Minister for Health and Ageing
addressed these concerns by noting that referring doctors will retain the right
to recommend particular pathology providers where such recommendations are
thought to be in the best interests of patients. The relationship between
doctor and patient is an important one, and the minister encouraged referring
doctors to discuss the choice of pathology provider in detail with their
patients along with all other aspects of treatment. The minister also pointed
to the need for patients to discuss their preferences with their medical
practitioners. This would allow patients to understand the reasons for choosing
specific pathology providers, the risks associated with changing providers and
the need to keep their referring doctors informed of any changes.[72]
1.61
Representatives from the Department of Health and Ageing pointed out that,
where confusion exists regarding which pathology provider the patient attended,
the doctor has the option of confirming with the patient. Although patients may
not inform their GPs of changes in pathology providers, most patients know
which pathology providers they attended and can advise doctors of these
details. Furthermore, patients can advise whether they attended any pathology
providers or simply failed to have the pathology requests carried out. The
department's Dr Megan Keaney told the committee that:
...the patient may well change their
mind afterwards. If they do not choose to tell the doctor about that change of
mind, we still think that there are mechanisms in place to ensure that the
information returns from the pathologist back to the general practitioner or
specialist.
I cannot see clinically what the
difference is between going to a pathologist you do not know and a pathologist
you do know. The person who has the information as to whether they did or did
not go and the reasons is the patient themselves. It would then seem to me that
the appropriate contact would be between...the doctor, and the patient.[73]
Committee view
1.62
The committee agrees that patient choice should not be at the cost of
patient safety. It believes that both patient choice and patient safety can be
delivered through effective communication between doctor and patient at the
time that the pathology request is completed. This will ensure that the patient
is aware of the range of reasons that have led the doctor to recommend a particular
pathology provider. It will also allow the doctor the opportunity to inform the
patient of the risks of changing pathology providers and the need to inform the
doctor if such changes occur. Furthermore, it will allow the patient the
opportunity to state preferences for particular providers and the factors
influencing such preferences.
Competition in the sector
1.63
In 2008, the AAPP summarised the growing role of pathology in
preventative health care and the early identification and management of chronic
conditions when noting that pathology testing is the sole basis for more than
70% of diagnoses of serious conditions such as diabetes and high cholesterol.
Furthermore, the association pointed out that the private pathology sector is
responsible for the majority of pathology tests carried out in Australia,
whether requested by GPs, hospitals or medical specialists. The association
concluded that 'private pathology practices perform the great majority of
pathology testing for primary care in Australia'.[74]
It is therefore in the interests of the wide range of patients and medical
practitioners who make extensive use of these services to encourage competition
in this sector.
1.64
In evidence to the committee, the RCPA suggested that the bill could be
a 'disincentive to invest in strategies' to improve quality in the pathology
sector.[75]
The committee noted that the focus of the bill is patient choice and questioned
the RCPA as to the link between patient choice and negative consequences for
the pathology sector in the legislation. The President of the RCPA responded
that:
[i]t comes a little bit from the comment in the minister's
speech, and I believe also in the department’s submission relating to bulk
billing, that this was conceived as a way of enforcing bulk-billing
arrangements. To an extent, we view this as something that might have been more
appropriately dealt with during the pathology funding review, which is underway
at the moment. So it is something which has been raised by them. We are
concerned that the drivers for competition in pathology should be quality and
service based, because we feel that that promotes excellence within the
profession rather than having the opposite effect, which can occur if the
primary concern is cost rather than quality.[76]
1.65
When pressed by the committee to explain how the provisions of the
current bill would adversely affect the sector, the President of the RCPA
stated that 'it is not in the legislation; it is from the conversation around
the legislation'.[77]
Drivers of choice
1.66
According to the RCPA, the current drivers of patient choice in the
sector are quality of service and testing and the reliability of results.[78]
Medical expertise is an extremely important consideration which should not be
forgotten in the push for competition. The college complained that 'primary
competition on price and convenience devalues the [specialised] role of the
pathologist'.[79]
1.67
Similarly, the AAPP found that 'price is not the only nor is it the most
important determinant of the best pathology provider for a patient'.[80]
The association pointed to the importance of the working relationships
developed between referring doctors and pathology providers over time, leading
to standardised reporting and procedures.[81]
1.68
A representative of the AMA reported to the committee that patients
often choose pathology providers on the basis of the expertise of the person
collecting the pathology sample. This is judged by 'how big a bruise' the
patient has following collection of, for example, a blood sample.[82]
1.69
The committee was informed by the NCOPP that competition in the
pathology sector has historically been based upon service rather than price.
However, the NCOPP warned of possible 'unintended consequences' in the event
that pathology providers begin marketing services to patients rather than
referring doctors. The coalition cautioned that giving patients choice is
'meaningless unless it is informed patient choice'; in order to make informed
choices, patients require information from their doctors regarding the benefits
of various pathology providers. Without this information, patients can change
pathology providers, remaining unaware of the risks of doing so. Patients may
even decide not to proceed with pathology testing at all but fail to inform
their doctors of this.[83]
1.70
The NCOPP also pointed out that patients' choices of pathology providers
will be influenced by a range of factors which may differ over time and
according to individual circumstances. These factors include the advice or
preference of the referring doctor as well as the patient's socio-economic
status, health condition and place of residence. Furthermore, each patient does
not have the same range of available options when choosing a pathology
provider; patients may be limited, for example, by the number of providers in
their local areas or by the range of providers that conduct a particular type
of test.[84]
1.71
In its discussion paper, the Department of Health and Ageing identified
convenience and cost as two important factors in a patient's choice of
pathology providers. In addition, familiarity of provider or setting may be
important for frequent users. However, frequent users who had a preference for
one provider may consider going to other providers if there was a significant
change in the original provider's billing practices. The department argued
that:
...[even] regular users may be persuaded to change providers if
significant changes in billing practices occur. While pathology has
historically had a high rate of bulk billing and many patients are unaccustomed
to having out of pockets costs, should the billing practices of their regular
provider change, it could provide a catalyst to seek another provider.[85]
1.72
In support of the department's argument, CHF found that cost was a major
driver in the choice of pathology provider. The forum concluded that:
[p]roviders that offer bulk billing or testing at a lower
cost are considerably more popular among consumers than providers who charge
high out of pocket costs...Increased choice of provider will enable consumers
to find a collection centre that suits their needs and preferences.[86]
1.73
CHF identified other factors which may influence the choice of pathology
provider to a lesser extent. These comprised convenience (location,
availability of parking etc.) expertise and courteousness of staff, waiting
times, familiarity of provider, the (medical testing) equipment used by
different pathology providers as well as the interoperability of the doctor's
and pathology provider's computer systems (for electronic transfer of requests
and results).[87]
Ms Carol Bennett of CHF stated that:
[i]n terms of convenience for consumers, some of them talked
about being referred to providers who were a long way from where they lived.
Transport for some consumers, particularly consumers with chronic conditions or
who are ill, is quite a challenge, so that is an important consideration, as is
disability access for premises. Those sorts of things—convenience to consumers
as opposed to providers—were considered important.[88]
1.74
CHF also pointed out that valuable feedback for pathology providers
could be gathered by doctors during consultations regarding the reasons that
patients chose particular pathology providers. CHF explained that:
[e]ffective and collaborative relationships between
requesters and providers could be assisted by communication between them about
why consumers choose to use or not to use the provider. This could in turn
encourage providers to change their practices to attract consumers, for example
by offering bulk billing.[89]
1.75
The Department of Health and Ageing concluded its submission to the
committee with the observation that:
[a]llowing patients to exercise their right to choose will
encourage pathology providers to compete on the basis of price, service and
convenience for patients, ensuring that all Australians have access to
affordable, high quality pathology services. These [proposed] changes will put
downward pressure on out of pocket costs to patients and pressure providers to
maintain a high rate of bulk billing.[90]
Committee view
1.76
The committee concludes that competition based upon price and
convenience is an important goal but one which must not be achieved at the
expense of a decrease in the quality of testing and service provided by
pathologists. Effective communication between doctor and patient at the time
that a pathology request is generated will ensure that both parties are fully
aware of the (doctor's and patient's) reasons for choosing a particular
pathology provider, the patient's right to choose pathology providers and the risks
of acting against medical advice in choosing a different provider.
Imaging and pathology services
1.77
The Minister for Health and Ageing noted that the provisions of this
bill will align the referral practices for pathology services with those that currently
apply to other diagnostic services such as imaging. At present, a patient who
is referred for medical imaging services may present the request form to any
provider of diagnostic imaging services.[91]
Risk of errors
1.78
The committee was informed by the AAPP that a patient typically has
fewer imaging tests per 'encounter' (i.e. appointment with the imaging
provider) but the number of tests was typically higher per visit to a pathology
provider. This meant that the risk of errors was also higher for pathology
services.[92]
1.79
As previously discussed, errors can be limited through well-developed
relationships between referring doctors and pathology providers, using familiar
reporting standards and procedures. However, the most important factor in
limiting the potential for errors is the need for information – on the part of
the doctor, who is kept informed of the patient's preferences and any changes
in pathology provider; and on the part of the patient, who is informed of the
right to choose pathology providers but also of the reasons for using a
particular provider and the risks associated with changing pathology providers.
Different specialties, similar
funding
1.80
The RCPA argued that diagnostic imaging and pathology services are
fundamentally different medical specialties and cited two examples of these
differences – the form of the results and the use of this type of testing to
manage chronic conditions. Firstly, a patient can usually pass imaging results
to the referring doctor or other medical specialists in the form of, for
example, an x-ray or an ultrasound film.[93]
As pointed out by the AAPP, this is not possible with pathology results which
are forwarded directly to the requesting doctor.[94]
This difference can lead to difficulties in tracing the pathology provider who
carried out the testing.
1.81
In addition, diagnostic imaging is not commonly used in the ongoing
management of chronic conditions (or long-term use of medications) whereas this
is a common reason for the use of pathology tests. In such cumulative testing,
it is important that testing procedures and measurement methods as well as
reference ranges and intervals remain consistent.[95]
1.82
The RCPA concluded that, although funding of these two specialties has
historically been similar, they are used by medical practitioners for very
different purposes. There is, therefore, no valid need to align the ways in
which doctors refer patients for imaging and pathology services.[96]
1.83
However, it was identified by CHF that consumers have serious concerns
regarding pathology and diagnostic imaging services in terms of quality,
accessibility and affordability. CHF concluded that offering consumers the
right to choose pathology (and imaging) providers 'has the potential to reduce
many of these concerns'.[97]
Addressing these concerns does provide a valid argument for aligning the
referral procedures for pathology and diagnostic imaging services.
Committee view
1.84
The committee agrees that allowing patients the right to choose
pathology providers can reduce concerns relating to the accessibility and
affordability of pathology services. In addition, the committee believes that
quality can be ensured if patients, doctors and providers are well informed.
Effective communication between doctor and patient at the time that the pathology
request is completed will allow negotiation in the choice of provider. This
will ensure doctor and patient are aware of the reasons for choosing a
particular provider and the risks associated with changing providers and will
minimise those instances where patients change their minds after the
consultations. When patients do change their minds, they must accept
responsibility for acting against medical advice and should be informed of the
need to make their doctors aware of the changes.
Emergency and out-of-hours contact
1.85
The RACGP and AMA pointed out that the benefits provided by established
relationships between doctors and pathology providers are even more important
in emergency situations.[98]
In urgent medical situations, doctors need to be familiar with the reporting
format (to read results quickly but accurately) and be aware of which pathology
providers have received which pathology requests (for ease of tracing results
when necessary). When sending urgent pathology requests, it is helpful for doctors
to have knowledge of the kinds of tests that can be carried out at specific
laboratories and awareness of the expertise of particular pathology providers.
The AMA also warned that the current communication channels between doctors and
pathology providers will need to be expanded in response to the government's
proposed changes, especially in emergency situations.[99]
1.86
A pathology provider is more likely to be aware of a referring doctor's
emergency contact details when the doctor and pathology provider have an
established relationship and agreed procedures. The RCPA informed the committee
that it is common practice that GPs do not provide out-of-hours contact details
and the inability on the part of pathologists to report results that were of
serious concern or, in extreme cases, life threatening would be 'exacerbated in
after hours situations'.[100]
Similarly, the AAPP commented that urgent test results may not be forwarded
after hours when the pathology provider holds no emergency contact details for
the referring doctor.[101]
1.87
To resolve this difficulty, organisations such as the NCOPP recommended
that agreed procedures be established between a referring doctor and pathology
provider (where a previous working relationship does not exist) when a patient
presents the request for service to the pathology provider. These procedures
should include notification by the pathology provider that a request from that
referring doctor has been received and identification of the channels for
reporting results as well as information such as the doctor's emergency contact
details.[102]
1.88
Dr Brian Richards, a representative of the Department of Health and
Ageing, disagreed with the claim that the inability of pathology providers to
report urgent pathology results would be exacerbated after business hours. In
response to a question from the committee regarding the extra administrative
burden which may be placed upon pathology providers attempting to contact
doctors after business hours, Dr Richards commented that:
[t]hat is no different from the
current situation where an urgent request comes in. If the evidence is that
most pathologists do not have the after-hours contact of most of their doctors
then that would be no different whether or not the patient went to the [usual] provider.
In 17 years I spent in general
practice I do not think I ever received an out-of-hours phone call from a
pathology provider.[103]
Conclusion
1.89
The committee believes that the issues which have been raised by GPs,
pathologists and other stakeholders can largely be addressed by effective
discussions between referring doctors and patients regarding pathology
providers and services. Difficulties such as reporting urgent results to
doctors after hours already exist and will not be significantly altered by the proposed
legislative changes. Importantly, the primary focus of this bill is more choice
for patients. The committee acknowledges that patients should be given the
opportunity to play a central role in their own healthcare. Accordingly, the
committee recommends that the bill be passed.
Recommendation 1
1.90
The committee recommends that the bill be passed.
Senator
Claire Moore
Chair
May 2010
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