Private specialist practice: the forgotten sector in health care reform

The current health care reform process is remarkable for its lack of attention to private non-general practice (non-GP) specialist services. About 23 million ambulatory visits are made to non-GP specialists each year, and $1.6 billion of the Medicare budget flows to these services. For the patient, effective collaboration between his or her various health care providers is essential for safe, high-quality care. This is particularly so when the patient is consulting more than one non-GP specialist. An individual with type 2 diabetes, for example, might be seeing an endocrinologist, a nephrologist, a cardiologist and perhaps others, in addition to his or her general practitioner and allied health providers.1 The final report of the National Health and Hospitals Reform Commission (NHHRC) noted the key role of non-GP specialists in the shared management of care for patients with complex and chronic health needs, and recommended improving access to a more comprehensive and multidisciplinary range of primary health care and specialist services in the community through the establishment of Comprehensive Primary Health Care Centres and Services, available for extended hours.2 However, the current reforms are concerned almost exclusively with public hospital, general practice, community and primary care services. While GP Super Clinics may provide consulting facilities for visiting medical specialists, there are currently only 64 implemented or planned across Australia, and there is no formal requirement or policy incentive for functional integration between non-GP specialists and members of the primary health care team working in the same GP Super Clinic.3

So is there a problem? Potentially, yes. The vast majority of non-GP specialists in private practice are highly skilled, committed practitioners. Nevertheless, the lack of a comprehensive policy framework means that access to private specialist services is determined largely by market forces. This is most apparent in the geographical maldistribution of the medical workforce, with relatively few non-GP specialists choosing to work outside metropolitan areas. Moreover, almost no improvement in specialist–population ratios in remote and rural areas is expected over at least the next 8 years.4 Even in metropolitan areas, there is a tendency for private specialists to practice in affluent areas, limiting the choice available to patients in more deprived areas, whose mobility may be reduced by poverty or disability. And yet it is in socioeconomically deprived areas that patients are more likely to suffer multiple chronic diseases.5

It is striking that about 80% of general practice consultations but only 27% of non-GP specialist appointments for ambulatory care are bulk billed.6 The average gap between the fee charged by a non-GP specialist and the Medicare benefit received by a patient who is not bulk billed is $46.12. A recent Australian Bureau of Statistics (ABS) survey found that about 10% of Australians referred to a non-GP specialist delayed or did not keep the specialist appointment because of cost.7 Unlike in general practice, there are no Medicare incentives for non-GP specialists to bulk bill for most consultations. The Medicare Safety Net helps, but it is clear from the ABS data quoted above that up-front billing can exceed the cash reserves of many patients.

A further potential problem with the lack of a policy framework for private non-GP specialist services is the risk of lapses in quality and safety. All medical practitioners in Australia are required to provide evidence of participation in continuing professional development at the time of annual registration but, unlike the accreditation process for general practices, there is no requirement for the quality review of non-GP private specialist practices, with the exception of imaging providers and laboratories. Lapses in the quality of non-GP specialist care are likely to be rare, although few rigorous data exist, but when they occur the implications can be disastrous.8

A more common threat to quality and safety may be lack of timely communication with the patient’s general practitioner following every consultation by another specialist.9 This can have major ramifications for a patient with complex care needs. There is very little point in a doctor seeing and advising a patient without communicating with the other health practitioners involved in his or her care. Radiologists, pathologists and non-medical health practitioners who provide Medicare-rebateable services following referral are required to supply a report to the referring doctor, and it seems reasonable for such reporting to be universally expected of all referred services. No systematic data exist, but general practitioners report frequent frustration at the lack of timely communication from other medical colleagues.10

These difficulties are further compounded by failure to implement the NHHRC’s recommendation of strategies to assist patients living with complex health problems to adopt a single general practice as their “health care home” responsible for continuity and coordination of care.2

So what is required to address these problems? Medicare Locals are currently being rolled out across Australia, replacing Divisions of General Practice, and will be required to work with local clinicians — including Lead Clinician Groups and presumably individual specialists — “to identify and remedy service gaps and breakdowns in service integration and coordination”.11 However, their ability to bring about change at regional level will be limited without a national policy framework that includes provisions relating to non-GP private specialist practice.

General practitioners receive incentive payments for bulk-billing concession card holders and children. For reasons that are not clear, other specialists only receive bulk-billing incentives for telehealth consultations. A Medicare incentive for non-GP specialists to bulk bill consultations and other services for concession card holders and children would help to address the financial barrier faced by many patients. Such an incentive would also help redress the potential differential in revenue for specialist practices between affluent and deprived communities. A bulk-billing incentive would be more socially just than the current Extended Medicare Safety Net (EMSN) which, on the ABS evidence cited above, fails 10% of referred patients. A review published in 2011 found that some 53% of EMSN benefits were distributed to the 20% of the population living in Australia’s most socioeconomically advantaged areas, whereas the 20% living in the most disadvantaged areas received only 3.7% of benefits.12

Medicare rebates should be contingent on a report being provided for all referred medical services, not only pathology and imaging services. It will become easier to ensure that such reports are accessible to all treating health professionals once the impediments to a national personally controlled electronic health record are overcome. Incentives are required for all health practices, not just general practices, imaging providers and laboratories, to undergo regular accreditation.

The present Australian health reform process provides a window of opportunity to develop and implement policy changes relating to private non-GP specialist practice, ensuring that the considerable public funding flowing to this sector of the health system achieves the most effective and equitable contribution to the nation’s health.