Pathology requests under the microscope

Anna Samecki

13/05/2022 2:35:44 PM

More than 5000 GPs are about to receive a letter from the Department of Health about their pathology requests.

Female GP holding referral letter
More than 5000 GPs are about to receive a letter from the Department of Health about their pathology requests.

The latest ‘nudge’ letter will target GPs who are above the 90th percentile for rates of pathology requests through the Medicare Benefits Schedule (MBS) between 1 July 2019 and 30 June 2021.
The pathology requests under examination include thyroid stimulating hormone (TSH), thyroid function tests (TFTs), vitamin B12, iron studies and vitamin D.
Only services rendered and claimed under the MBS by a pathologist are included in the rate calculations, while letters will not be sent to GPs who practice primarily in remote or very remote areas (Modified Monash Model regions 6 or 7).
Correspondence sent from the Department of Health (DoH) to the RACGP flagging the campaign says the activity aims to ‘reduce GP requesting of combinations of MBS pathology items where there is no clinical indication of a serious illness and where pathology tests are unlikely to support diagnosis or management of the patient’s health concern’.
Practice owner and RACGP Expert Committee – Funding and Health System Reform (REC–FHSR) member Dr Cathryn Hester told newsGP that while she appreciates the need for practice improvement initiatives, the timing of the letter is not ideal.
‘My biggest concern is whether the data is genuinely representative of what GPs would normally do in their day-to-day practice, because a large proportion of the data collection period coincides with the pandemic,’ she said.
‘That may have prompted some GPs to order additional tests during a time where clinical information was rapidly evolving, and GPs were trying their best to keep up to date and do what was in the best interests of their patients.’
This is not the first time that questions have been raised about the timing of ‘nudge’ letters, and similar campaigns have attracted criticism in the past for being unnecessarily intimidating and unfairly targeting certain GPs – prompting the college to call for change in a submission to the DoH in December 2019.
In the submission, the college flagged there was a ‘growing perception that compliance activities are designed to monitor and target statistical outliers, as opposed to targeting fraudulent activity’, among a long list of other issues.
Dr Hester still shares some of these concerns and says another consideration is the sheer number of GPs included in the campaign.
‘Over 5000 GPs is a really large number, so we’re not even looking at a small number of clear outliers,’ she said.
With an estimated 31,000 practising GPs across Australia, more than 5000 letters means over 15% of the workforce will be targeted.
‘Even if it’s worded sensitively, a lot of those GPs are going to feel anxious and probably even a little bit intimidated,’ Dr Hester said.
The college has remained firm in its position that while it supports activities that preserve ‘the integrity of Medicare’ and prevent ‘wrongful and fraudulent claiming’, such activities should ‘prioritise education over punitive measures’.
RACGP advocacy has previously seen the DoH commit to adopting a more educational approach when conducting compliance campaigns, and the department has been working closely with the college and other key stakeholders more recently in the development of its new activities.
In its correspondence to the RACGP about the campaign, the DoH acknowledged that pathology requests ‘are influenced by many factors’, which is why they partnered with Wiser Healthcare and sought advice from the college and other peak healthcare groups.
It has also sought feedback from individual GPs and patient representatives in the design and development of the letters, which it describes as a ‘project’, rather than compliance activity.
‘Some RACGP members may receive a letter from the department providing feedback on their pathology requesting and information regarding supporting resources and tools,’ the DoH correspondence stated.
‘Members who receive this letter are not being contacted as part of an audit or practitioner review compliance activity and are not required to provide information to the department about their pathology requests.’
In an attempt to shift the focus towards education, the DoH letters will also provide links to a number of resources and tools, and says it is keen to ‘better understand how different ways of presenting personalised feedback and educational information’ supports GPs in reflective practice.
The college maintains it plans to continue ‘working collaboratively’ with the DoH to ‘develop, [and] improve or promote education and resources for providers regarding Medicare compliance’.
Dr Hester says she appreciates that the DoH has listened to the advice of the RACGP and other representative bodies, but still has some concerns.
‘As we enter into the next phase of pandemic management where we’re encouraging patients to reengage with their GP and to reengage with preventive and primary healthcare, we really don’t want to be sending the message that GPs should be limiting their care for patients,’ she said.
‘So while I agree with the general premise of choosing the best and most appropriate pathology tests for patients, and certainly not over-requesting, this really may not be the most ideal time for such a campaign.
‘I am concerned GPs will still find the letters very anxiety provoking.’
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Dr Mai Huynh Thi Tran   14/05/2022 7:46:09 AM

Genera Practitioners are under a lot of pressure from patients, and from Department of Health.
It would be a tremendous stress if GP miss a diagnosis. GPs need to be supported, not to be punished for ordering a test.

Dr Jitendra Natverlal Parikh   14/05/2022 10:28:56 AM

It looks to me that the Councillors are looking for work.If you ignore good chance of facing tribunal for at least 10 % of the victims

Dr A Wang   14/05/2022 11:17:32 AM

It is common for a patient to present to multiple GPs for second/third/fourth opinions of their symptoms. They can report nil previous investigation or have a false recollection of previous tests. This may also contribute to the same test being ordered a number of times by different providers which may impact on Medicare as well. Many of these people have opted out of My Health Record system too. Perhaps it is possible for the government to design a system to flag to the patient that if they are having the same test within a certain period of time then they will be privately charged?

Dr Angela Catanzariti   14/05/2022 12:56:29 PM

How many bowel cancers are picked up from an incidental low ferritin on routine bloods?
Department of Health should be supporting GPs in this difficult time post pandemic!

SD   14/05/2022 1:08:56 PM

If a test is not eligible for Medicare then pathology company needs to charge privately or decline the test. They are the ones claiming from Medicare. GP’s are not claiming from Medicare for tests. They will be dragged to court by pathology company or pressurised politically if they touch them. So next comes powerless GP’s. It is sad that GP’s are made easy targets for something they are not even claiming from Medicare.

Dr Bethany Reynolds   14/05/2022 1:28:30 PM

Education about both medical need and mbs funding for tests is needed (because unfortunately they are not the same thing). Doing this post pandemic is unfair and inaccurate- being encouraged to limit f2f face so unfortunately we may be relying only bloods over clinical examination too often

Dr Bethany Reynolds   14/05/2022 1:37:34 PM

Cruel to do this based on pandemic data when so many of us were relying on telehealth and pathology over clinical examination. Education about the difference between mbs funding vs clinically indicated (which unfortunately often are not the same thing) would be helpful over targeted letters…

Dr Rob Hills   14/05/2022 3:56:17 PM

Here's a different way of going about things that I personally would welcome:

What if Medicare funded Pathology providers to send GPs regular (say annual) "reviews" of their Pathology ordering pattern that shows:
1. Numbers of individual tests ordered, compared with average for peers;
2. Proportion of abnormal results for each test, compared with average for peers;

Information like that would provide me with very useful feedback about the effectiveness of my testing.

Dr David Lap Yan Lee   14/05/2022 4:55:52 PM

Good. I’ll put on a frame next to my cert. Some patients really demanding 3 monthly iron and vit D tests as they say it’s their right. Now they can pay for that. Also no more naturopath referred patients for free tests. Thanks

Dr Greg Saville   14/05/2022 8:33:08 PM

The purpose of these letters, as near as I can tell, is not punitive. It is to improve practice. The fact they are seen to be "unnecessarily intimidating", means that the letters are being misunderstood. Nudges are meant to be used for good not evil (this is according to Thaler and Sunstein, who coined the term nudge for those interventions whose purpose is to change behaviours for the better). I suggest that Dr Hester and the author of this article both read the following books: Nudge, Inside the Nudge Unit and Think Small. All are excellent.

Dr Jo   14/05/2022 8:43:35 PM

There are many patients who unnecessarily pressurise GPs for Fe, Vit B12, Vit D , Mg, Zn etc blood tests because they read some thing rubbish on internet or seen the crystal lady/naturopath .
One way would be to make patients pay for non essential tests so the ball is out of GPs court. When they have to pay then their enthusiasm will be watered down.

Dr Bahman Ranjbar   14/05/2022 10:23:02 PM

Genera Practitioners are under a lot of pressure from patients, and from Department of Health.
If we miss a diagnosis, then patient's lawyer will sue us that why we did not request the pathology tests for diagnosis.
Majority of patients have complain about tiredness with no specific history which needs a series of blood test.
Dose department of health support us against patients complain?
Or they leave us alone with AHPRA !!!!!!!

Dr Arlene Nicol Suttar   16/05/2022 6:52:40 AM

With so many especially young people now vegetarians and vegans there is a natural increase in the proportion of people with iron def anaemia. Of course they present with tiredness. And often have low B 12. At the same time we have been taught to look out for osteoporosis and treat osteopenia early . ie check vitamin D and calcium not just bone density study. And before giving prolia I check serum calcium levels ie 2x year . Down here in Tassie vitamin D cannot be made from March til Oct naturally ( proven by Menzie Centre) . Our job is to find things early when easy to treat. Yes obsene overordering is poor practice but I feel DOH is not looking at the general public lifestyle.

Dr Dharminder Jit Singh   16/05/2022 12:17:07 PM

The intention of letters is to change the way GP practice medicine and also to save money.
GP’s should be allowed to either use these letters as a reason for missed diagnosis in court of law for example missed bowel cancer in a patient with iron deficiency or morbid obesity patient due to thyroid issues.
Or the better option is if patient wishes to have the tests and they are not eligible for Medicare then patient pays privately. It’s a choice that should be given to patients rather than denying tests.

Dr Greg Saville   16/05/2022 2:21:15 PM

Everyone should just settle down. Has anyone who has read the article, or commented received a letter? If not, why the hysteria? If they are “nudge” letters as the article author suggests, and they are true to the principals of nudging, they will not be punitive. I think it is helpful to receive feedback on how I prescribe or order tests. I like to know what my colleagues are doing too.
I think some investigations are over-ordered and one does hear apocryphal stories of patients, for example, getting more than 10 vitamin D tests a year.

Dr Babak Afshar Ebrahimi   16/05/2022 5:29:24 PM

No wonder there is less than 15% of new graduates are interested to become a GP !
Pressure from EVERY where , underpaid by Medicare and the community, etc.
They do not seem to realize GP career is going to extinct in the near future in Australia if the politicians carry on like this.

Dr Cyril Gabriel Fernandez   21/05/2022 4:32:49 AM

Patient’s Doctor shopping for repeated tests or seeing multiple Drs in a 3 month or 12 months period, few different Pathology centres and lack of a centralised results sent to or seen by the GP doctor including tests done at Hospital are limiting factors and most importantly not to miss crucial diagnosis as these parameters could be the reflection of underlying relevant Pathology. Numbers of ECG restrictions was the previous one