Pathology gap fees

• If taking your referral to a different provider than the one your GP suggests, you should get phone approval from your GP.
• Legislation has been proposed to formalise full consumer choice of a provider, with this made clear on referral forms.
• Public and private providers have told CHOICE about problems that can occur with patient choice. Your GP may want a specific provider with expertise in checking a skin tissue sample for cancer, or may want just one provider testing blood for tumour markers so they know for certain that any changes are not being caused by different machines or testing protocols.

The reality? GPs almost never discuss with you the choice of provider, the costs involved and/or your ability to pay. A compromise is consumer choice, but with the option to lock in a provider on specific clinical grounds.

Private providers

They claim to be operating in a challenging commercial environment, must compete with the bulk-billing public sector and bulk bill about 90% of services. While staff and technology costs are rising, Medicare pathology rebates have been static for many years, and are only paid on the three most expensive item numbers on a request form (this is called “coning”); the others must be done at no charge when bulk billed.

In last year’s Federal Budget, the specimen collection fee that the government pays for licensed collection centres was reduced from $14.80 to $5.10. The federal government cited automation efficiencies and operating profit margins of 18.5% to justify Medicare rebate reductions.

Service refusal can happen

Be aware that your GP can overrule your choice of provider.

An employee of the public provider, Western Pathology Cluster in rural NSW, told CHOICE they had received private referral forms where the GP refused permission for the pathology to proceed, insisting instead on a particular private provider being used. This was not for good clinical reasons, but purely because of a pre-existing relationship between the GP and the private provider. It meant the consumer had to pay more for pathology because their GP overruled their choice.

Northern Territory

All providers in the NT bulk bill. Darwin-based public provider, Northern Territory Government Pathology Service, runs a small number of regional labs providing equity of access to medical services in situations where private providers would not make a profit. Profits from private referrals help fund the retention of experienced staff and pathologist training.

Tasmania

Pathology is very much private sector-based in Tassie, with public-provided services currently limited to public hospital clinics. However, the public provider, Centrepath, is set to open three collection centres in Hobart over the next two years. Any profit from increased private referral work can be retained by the government pathology service for service improvement.

ACT

The ACT is well served by a large network of public and private collection centres. The public provider, ACT Pathology, relies on both the money and work volume it gets from private referrals to support the comprehensive service it provides.

Western Australia

There is a large network of public and private providers in WA. Public provider, PathWest, has about 100 collection centres and 24 labs that serve all significant population centres. PathWest uses the Medicare income from GP referrals to reduce the amount of taxpayer funding for pathology services.

Queensland

The public provider, Pathology Queensland, has 33 labs and many hospital and health centre collection points, but only four shop-front collection centres – one in each of Townsville and Toowoomba, and two in metropolitan Brisbane. Private providers are also widely represented throughout Queensland in hospitals, medical centres and shop fronts.

South Australia

The Institute of Medical and Veterinary Science (IMVS), part of SA Pathology, is the public provider in SA, with many shop-front collection centres. SA is also well served by an extensive private network, with many shop fronts and private medical centre collection points.

New South Wales

Public pathology in NSW is regionally based and each service is independent. Access to the bulk-billing public provider is often good in the country but poor in greater Sydney (given traffic congestion) where public services are often provided through hospitals. There are some places where service is better, such as in the north of Sydney, where Pathology North has six metropolitan and 12 country community collection centres.

Victoria

Victoria is largely a private pathology state. Several public providers exist in greater Melbourne, based in major public hospitals, with limited collection centres, often in a hospital. They will do GP- and specialist-referred pathology, but convenience may be an issue. St Vincent’s is the exception, with 32 collection centres. Most regional centres rely on private pathology, with smaller rural hospitals contracting out pathology to private providers.

Professor Ruth Salom is executive director of SA Pathology, a government-owned enterprise that provides pathology services to all South Australian public hospitals and to the public through “IMVS”-branded outlets. Income is derived from Medicare in the form of the bulk bill rebate for community pathology, and the public hospitals also pay SA Pathology for work at the Medicare rebate rate.

SA Pathology receives no money from state general revenue for provision of pathology services. The company is expected to provide high-quality 24-hour service to hospitals and doctors across the whole state, maintain a full complement of trained staff and provide a surplus to fund medical research within SA Pathology at the Centre of Cancer Biology. Direct funding of research amounts to about $9 million from a turnover of about $250 million. This model for a public enterprise is not without risk, given the significant reliance on private work. SA Pathology does about 40% of all private pathology in SA.