Miscommunication and lack of communication from government to Victorian GPs has lead to undertesting and possible underdiagnosis of patients for coronavirus.


9/3/20

Dr Vyom Sharma

FRACGP, MBBS
0433152872


vyomsharma@gmai.com

@drvyom (twitter)

www.vyomsharma.com.au

Below I will

  • Lay out the thesis directly

  • Explain key terms

  • Highlight the doubts/confusion cause by miscommunication. These are both underlined and emboldened

  • give real life examples which I have permission to share – some of them are my experiences, others from other GPs I know who have been deidentified
     

A ) THESIS GPs have received mixed message about the cost of COVID19 testing that patients might have to pay OUT OF POCKET.  GPs despite their efforts receive conflicting answers.  Because patients are discouraged by the risk of very large costs, some have chosen to not get tested. This means we have possibly missed cases/diagnosis of COVID19 in Victoria right now.


B) Key Terms


DEFINING CASES

 A “suspected case” typically needs to fulfill a ‘clinical criteria’ (certain symptoms) and an epidemiological criteria (where they’ve traveled/if they’ve been close/casual contacts with


 An “edge case” is a term I am using to describe people who don’t technically fit the criteria, but come close enough that a reasonable GP might want to test them
 

STAKEHOLDERS


GPs are independent contractors. Our job is identifying “suspected cases” as per a criteria, and testing them. Sometimes though, we identify ‘edge cases’ who we want to test, so we ask for advice.

 

Hotline gives advice to public and also GPs on who is a “suspected case”.

Infectious diseases Specialists For enquiries about edge cases, hotlines have commonly referred us to speak to Infectious Disease doctors in public hospitals.


VIDRL is a government lab - the only lab in Victoria that can do the test for coronavirus. They definitely do tests for free if they fit the “suspected case” definition. But how about the ‘edge’ cases - Is there an out of pocket fee? Cause for confusion for GPs



Private pathology companies  - GPs use these when ordering typical pathology tests – companies like Melbourne pathology, S&N, Dorevitch.  But they can’t test for COVID. They don’t have equipment and/or their facilities have not yet been accredited. Currently, their only role in COVID test is that they will courier the patient test samples from the GP, take it to VIDRL, and send the test results to the GP.


Do they charge a cost for this courier/result service ? Different GPs have heard/believe different things – cause for confusion for GPs


I have heard figures quoted like $1000 out of pocket, $500 out of pocket, $60 out of pocket. I called at 10 am and was told “I can’t see any info about it here, so I imagine it’s free”.
 

Different GPs have heard different answers. We have ZERO formal communication about this. So rumors abound in hallways, facebook groups and SMSs.


The problem is that patients are not billed before, but AFTER the tests are done. So it’s too late by the time the sample is sent. GPs don’t want surprise bills being sent to patients.
 

C) Real life instances of doubt impacting testing/ causing undertesting

Example 1


1)      When we call up the hotline to ask about these edge cases, we are usually told it doesn’t fit the testing criteria, and at GPs insistence about validity of doing the test, we are referred to a senior Infectious Diseases specialists in hospitals. Many GPs had been told by these specialists that “If the patient doesn’t fit the criteria, the government might not pay for the test i.e. give a Medicare rebate. As you can see, when GPs communicate this answer to patients, it discourages them to comply with tests.

So I know a GP who communicated this to their patient. The patient was an ‘edge case’ who had been contacting hundreds of overseas travellers. The patient opted not to have the test, dissuaded by the costs.


Example 2


An overseas traveller came to a GP I know who obviously didn’t have medicare. GP said he did not have a clear answer about what costs the tests would incur. The patient opted to not have the test.
 
Example 3

Several weeks ago I personally had a patient returned from Singapore in transitwith symptoms of upper respiratory tract infection.  Singapore wasn’t on the list of high risk countries. But we intuitively understood that it is a major world hub.  He and his wife are both healthcare workers. We wanted clarification on costs -  He called up the lab VIDRL, I called the hotline. We couldn’t get a clear answer about out of pocket costs. We both agreed to not do the test given combination of mild symptoms and cost.

 

Example 4:


Direct quote from a GP who is deidentified but consents to their exact quote being shared with media:
 

‘I’ve been telling patients “Yes I can swab, but there might be an out of pocket cost. It’s nothing to do with me, and you have to self isolate until the results come through.

The guidelines don’t say the patient has to agree to this [the swab] so if the patient declines, which most do, then the swabs are not done.

This is a long weekend in Vic, no chance of getting patients to self isolate. Patients have flatly said “No, I am going on holiday”.


Example 5


To avoid the patients getting the ‘courier service’ out of pocket charge from private pathologies, a fellow GP called up VIDRL and asked if they have their own courier service. VIDRL said no. The GP can’t just send the sample in an uber… I do not know how or if the sample got to VIDRL.

 

The kicker to all this is that technically speaking there is what seems like a lawyer-written, bank-contract like clause that, contrary to advice that has PREVIOUSLY been given by the hotline (not currently), GPs can test ANYONE THEY WANT based on their suspicion. Even still, there is not explicit clarification if these tests, NOT fitting the suspected case criteria will be rebated.   One GP today said she spoke to VIDRL last Friday who said all tests will be covered. 
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