Australia's Healthcare - Refer Madness

Healthcare would be more heroic without its inefficiencies.

(This is a reworked piece which previously appeared on ABC Open).

It's winter 1983 in suburban Adelaide, Australia. I am ill and Mum is annoyed. She's had to rush after work to get me from school to the doctor's. It's hard finding a surgery open outside 9-5 office hours when most families don't need them. Households in the '80s still has stay-at-home housewives who can attend to these problems in the window between end-of-school and end-of work, but our family are migrants and don't play by those rules. Mum is one of that rare species called working women. 

Luckily, a family friend - also a migrant (I'm beginning to see a pattern) - consulted out of hours.

After the paddle-pop stick down my throat and some furious scribbling, he rips a note off the prescription pad and gives it to us.

A piece of f*cking paper 💊

WTF do we do with it? Do I eat it? Burn it while praying?

Apparently, after paying the irascible medical receptionist, we gotta take that scrip to a pharmacy to get it fulfilled. This means finding another store that deigns to open outside office hours, more waiting, and another transaction. When sick, or aiding someone who is sick, that extra legwork feels like punishment.

To my Australian classmates who didn't know any different, this was just the way things were.

It still is.

However, in much of Asia, your doctor consult often concludes with more than a pathetic scribble. The receptionist (equally irascible and likely related to the doctor by blood or marriage) measures out your medicine, hands it to you bagged, and you pay for everything in one go.

Seeing Stars 👩🏿‍⚕️

I endured back pain for years before I saw a specialist.

Why?

Because even though I personally knew orthopaedic surgeons and occupational physicians through my medico-legal work, I would have to get GP referrals to see them. 

That's days of waiting, dealing with recalcitrant receptionists, a superfluous consult, and paying a gap/co-pay.

Just for a piece of paper. (I'm seeing another pattern here.)

That piece of paper would simply grant me access to another round of waiting and receptionist wrangling, this time for the specialist.

Repeat that if they needed to refer me for a scan.

After all that running around no obvious problems showed up, thankfully. But while a cure remained elusive, I was thoroughly discouraged from investigating further. There is something perverse about a health system that incentivises living with pain.

The referral system used in Anglophone countries was set up to ration scarce specialist resources.

However, Japan's health system functions quite well with direct specialist consultation. 

Better, I would argue. I walked into a mid-sized hospital, was examined by an orthopaedic surgeon (整形外科医 / Seikeigeka-i), and got scanned, all in the one building, all in one visit. True to the region, medication was dispensed on-site, and included in the bill. That it helped my condition was icing on the cake.

(In fact, there are no Australian-style GPs in Japan. Even suburban doctors are specialists, and you choose who to consult based on your symptoms.)

Japan has a well deserved reputation for being bureaucratic, but its health system is positively frictionless when compared with Australia. Its sustainability hints that the savings intended by Australia's referral system are questionable, not least for requiring two consultations when one would do. That is, unless the real savings come from patients abandoning treatment because of the administrative burden. 

Malingering

Australian friends white-splain dispensary separation and specialist referrals as enlightened systemic scrutiny, minimising conflict of interest and waste. To Asians like myself, with a heritage of viewing Western adversarial systems as disharmonious and wasteful, they are instead manifestations of unnecessary distrust. The ill can't be trusted to know what ails them and doctors can't be trusted to treat them responsibly. 

Such gatekeeping, it is argued, is the price paid for subsidised, affordable healthcare. However, this glosses over the amount of resources diverted to the exercise of rationing that could be used on actual healthcare.

Furthermore, a truly superior system would not be so onerous as to incentivize relinquishing such subsidies. Its efficacy should be apparent. A Chinese acquaintance was befuddled at an Adelaide hospital rejecting his offer to pay full price for a fast-tracked MRI scan, something that would have not raised eyebrows in China, notwithstanding that he could have afforded an entire machine. One should question if a system can be considered fair and inclusive if some are willing to pay a premium to circumvent it.

My story includes 1983 for good reason: practices have not changed. While health system deliverables have advanced thanks to science, service delivery has not. 20th century procedures administer 21st century treatments. 

Consider the revolutions in retail over the last forty years, particularly those enabled by computerisation including electronic records and online transactions. It took a pandemic for the government to activate Tele-health, when surely it should have been apparent years ago that if I can troubleshoot my phone by talking to the Philippines, I should be able to get a diagnosis and sick certificate through similar means.

There is nothing nefarious going on. Australia does not learn from other industries or other countries because it does not have to. Its system does not compete internally or externally with another. Even Australia's 'private' health system is less rival than appendage, using the same pool of doctors and offering little extra beyond the public system than swankier beds. 

To their credit, Australians are not so insular as to think their healthcare model is the only one in existence, and they know that it compares favourably with those in other 'Western' countries. However, their gaze is narrow. They look upon the U.S. with reassuring pity when they could instead be looking at Singapore and Japan with envy.

Perversely, that Australian healthcare did not totally collapse during the COVID-19 pandemic will only reinforce the idea that it need not reform. Arguments will be made to increase funding to it indiscriminately, faults and all, or risk lives. Proposals to rationalize health care will be painted politically as efforts to further ration it.

This is to confuse red tape and double-handling with diligence.

The counter-factual should be to consider how many more lives could have been saved with more efficient, less labour-intensive practices, that would deliver faster care with less nurses or doctors burned out.

This rant could be dismissed as that of a disgruntled outsider. Inexperienced in the nuances of a complex system. Indeed,

Every job looks easy when you’re not the one doing it.

– Jeff Immelt

I am, however, experienced at being a patron of healthcare and it seems that the customer experience remains overlooked.

I can honestly say that no piece of paper ever cured me.