pay the doctor directly and file a claim with the PPO to get reimbursed. Because most PCPs rely on their clinical judgement rather than guidelines when making referrals, and specialist access is not the same for all patient groups, wide variation is inevitable. A referral is necessary to make sure Medicare Benefits are paid at specialist or consultant referred rates, rather than at unreferred rates. In other words, patients do not need a referral to see a specialist, but they do need one to attract the relevant Medicare rebate. All legal requirements relating to referrals can be found in section 20BA of the Health Insurance Act of 1973, and regulations 29, 30 and 31 of the Health Insurance Regulations Act of 1975. The patient’s visit to a specialist is often outside the direct control of the PCP. Most health plans do not require patients to get a referral from their PCP to obtain specialist care. This makes it even more imperative for a strong physician-patient relationship in which the PCP can guide patients towards the best treatment and specialty care, when needed. Patients who do not regularly visit
their PCP may be more likely to self-refer to specialists than patients with a chronic condition that regularly visit the PCP. From the research that I’ve completed, it appears that Switzerland makes it easier for its residents to get referrals for this specialty services that they need, and then have those referrals covered under their current coverage. Conversely, in the United States, referral can be easily made, but are frequently not covered by insurance policies unless they are deemed medically necessary by a physician. Premiums for these services can be very expensive. A2C. Pre-existing conditions The current policies in Switzerland are that healthcare companies can’t deny anybody coverage based on any pre-existing conditions. They are also not allowed to make any profit based off basic plans that are offered on a wide scale range. Instead, they’re supposed to incentivize positively by providing perks to the individuals that purchase supplementary, more comprehensive, plans. These plans generally cost more money, but conversely they will cover more treatments. In the United States it’s very similar. Insurance companies can’t deny anybody insurance based solely on the fact that they have a pre-existing condition. They also can’t intentionally charge you more money because of your pre-existing condition either. This is thanks to the Affordable Care Act. There is also a clause that states they can’t charge women more than they charge men either. The only exception to this rule is for grandfathered individual health insurance plans, which are the kind that you buy yourself and not purchased through an employer. They don’t have to cover pre-existing conditions. A3. Financial implications Switzerland is renowned for having fantastic healthcare, it just comes at a costlier price than other nations. These high costs tend to create some undesirable financial implications for its citizens. Their healthcare is paid for by the individual instead of their taxes or the employer.
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- Fall '18