Criteria & Procedures for the Overseas Referrals Scheme (ORS)

We are committed to:

Working in partnership with Ministries of Health in participating countries, treatment providers, visiting clinical specialists to strengthen clinical capacity, support country health systems & provide access to specialist treatment for eligible citizens

Ensuring access to specialist clinical services as identified by country

The bilateral allocation for each country is being utilised in an effective manner

3.1. Funding of Overseas Referrals

The MTS pays for the cost of agreed treatment from arrival in New Zealand, Australia, Fiji or other country in the region until departure. This includes diagnostic services, treatment and post-operative care. In some cases (where this is agreed between the MSC and the referring country) the MTS can make contributions towards living expenses for the patient and/or their companion.

The participating country funds airfares for the patient (and for a companion or medical escort where necessary and determined by the in-country ORC), internal travel and any pre-departure costs (such as passports, visas etc.). In some cases these costs may be borne by the patient or their family. Access to the scheme however must not be determined by a patient's ability to contribute to airfare and pre departure costs.

In some cases the patient's family or relatives may provide support in the form of accommodation and living expenses while overseas. Again access to the scheme must not be determined by a patient's ability to find support for accommodation and living expenses.

3.2 Overseas Referrals: Patient Eligibility

Individuals being referred for treatment under the ORS should be citizens of the referring country and normally resident in the country. Dual citizens (i.e. those with New Zealand or Australian passports) will not be eligible for treatment under the ORS. The criteria specifically excludes those citizens who: are usually resident in another country (e.g. citizen of Fiji living in Tonga) and who have not become citizens of the participating country and those who have not made provision for medical costs to be funded by insurance whilst living outside of their own country.

3.3 Overseas Referrals: Equity Criteria

In line with MFAT's goal of supporting sustainable development in developing countries, in order to reduce poverty and to contribute to a more secure, equitable and prosperous world the MTS should be accessible (within the funds available in each country) to men, women and children who meet the equity and medical criteria regardless of ethnicity, gender, ability to fund airfares or support costs or location. It is particularly important that people from outer islands and rural areas are aware of the scheme and the opportunities it provides. Those being referred should lack access to alternative means of accessing the necessary treatment. This includes (but is not necessarily limited to) personal funds, government or private insurance schemes, church or voluntary agency funds. It is the role of the ORC to assess eligibility.

3.4 Overseas Referrals: Referral Procedures

All people referred must be normally resident in the participating country and must be referred by the participating country ORC.
Procedures for participating country referrals to an ORC are the responsibility of each country but countries should ensure that MTS equity and clinical criteria are maintained.

3.5 Overseas Referrals: Clinical Criteria

All patients referred must meet the clinical criteria as assessed firstly by the participating country ORC and secondly as approved by the MSC following its own clinical assessment processes.

The following clinical criteria will be applied to all referrals:

  • Appropriate skills, expertise or facilities to treat the condition are not available in the referring country. This may include seeking referral for diagnostic purposes to determine a patient's condition and prognosis.
  • Consideration has been given to whether the condition can be treated in-country by a planned visit of a clinical specialist team within a timeframe unlikely to jeopardise clinical outcomes and the well-being of the patient. This may include sending a visiting team or specialist to treat the patient in the participating country if this is cost effective.
  • The referral has been made on appropriate specialist advice and supported by the participating country's ORC.
  • There is good prognosis for the patient living and improved quality of life for at least 5 years after treatment according to clinical evidence and advice.

The following conditions are excluded for treatment under the ORS;

  • chronic cardiac failure, chronic renal failure, chronic lung conditions, chronic neurological conditions and conditions requiring heart, renal or bone marrow transplants;
  • patients who have significant medical conditions other than that for which they are being referred (e.g. co-existing renal disease) and/or
  • conditions that will incur on-going costs that are unable to be met by partner government health funds.

Note: The intent of the clinical assessment is to determine that it is likely the condition can be treated with a good clinical prognosis for a minimum of 5 years. All assessments are expected to be undertaken considering current ‘best practice' and the context ‘in-country' for on-going treatment and support.

Referrals made directly to the MSC or New Zealand government will be forwarded to the in-country ORC to be processed through normal channels.

3.6 Overseas Referrals: Participating Country Medical Treatment Scheme Committee

All referrals for treatment under the ORS must be made by the ORC using the official ORS referral form (Annex 1) including a clinical referral letter, which should be faxed or where possible emailed (with scanned authorised signatories) to the MSC for consideration and referral to an appropriate specialist, prior to approval for funding and treatment being authorised.

The following documentation is required:

a) The Overseas Medical Treatment Referral Form must:

  • indicate the referral is made on the basis of appropriate clinical advice supported by advice from the participating country ORC. This means that all patients referred must have undergone a clinical assessment by a senior clinician. The ORC then reviews the clinical assessment as part of the committee assessment process;
  • prove that the condition is unable to be treated in-country due to lack of available clinical expertise and/or facilities and that consideration has been given to whether the patient could be treated in-country by a planned Visiting Clinical Specialist team;
  • show the referral meets all equity and clinical criteria for the ORS;
  • indicate the patient consents to being involved in follow-up to ascertain the longer-term impact of the scheme;
  • indicate that the patient authorises and appoints a medical escort where this is considered necessary;
  • indicate that the patient support costs are authorised;
  • include all patient details: name, date of birth, occupation, gender, address (including outer island and village);
  • identify clinician responsible for follow up in-country;
  • be signed by the Chairperson of the ORC; and
  • appropriately address privacy issues.

b) Clinical referral letter completed by a senior clinician and following the accepted standard     format:

  • patient details; name, address, date of birth, hospital identification number/file number, gender, weight;
  • provisional diagnosis;
  • other conditions;
  • current medication;
  • presenting symptoms and history;
  • clinical history and treatment; and
  • tests undertaken.

Included with the clinical letter should be any recent test results, x-rays or other clinical assessments by visiting team members.

c) Patient details form including requests for accommodation, transport, living allowance and interpreter requirements.

All documentation must be received by the MSC and formal written approval notified prior to patients being organised for transfer.

Once a decision agreeing to treatment has been received from the New Zealand-based MSC, the ORC ensures the timely submission of recommendations to the appropriate authority to enable the patient to be referred and treated as soon as possible. The ORC ensures that the patient (or his/her family) is able to meet any travel documentation costs (such as passports/visas) and if not arranges for these costs to be met by the government.

The ORC also ensures that appropriate records are maintained of all referrals made under the ORS (including patient contact details, referral form and pre and post-operative reports) in order for any future review or impact assessment of the scheme to be carried out.

3.7 New Zealand-based Management of Overseas Referrals

  • This is the responsibility of the MSC. Following receipt of a referral the MSC will:
  • acknowledge receipt of referral within 48 hours;
  • ensure funds are available within the bilateral MTS allocation;
  • ensure all referrals meet ORS eligibility, equity and medical criteria and seek relevant specialised medical opinion on the treatment requested where required;
  • ensure the referral forms are accurately and fully completed (returning the form for completion if any information is omitted);
  • ensure arrangements for appropriate support are in place in the receiving country;
  • ensure that any support costs to be paid by MFAT conform to the MFAT policy;
  • request any specialist recommendations be confirmed in writing to enable peer review at a later stage as part of the accountability process;
  • seek estimates from treatment hospitals, select the appropriate one and arrange for admission of the patient at the earliest possible date (for some procedures only one provider may be available i.e. paediatric cardiac surgery is only available in New Zealand in one hospital);
  • provide an approval letter to the preferred provider including the funding limit approved;
  • notify the ORC in the participating country within 48 hours of receipt of the request of progress on the referral and the proposed next steps;
  • as soon as possible notify the ORC whether the treatment can be provided, at which hospital, the likely dates and the approximate cost of the treatment;
  • coordinate all patient appointments, accommodation, transport, interpreter, living allowance and pastoral care;
  • ensure all patient consents for follow up, photographs and sharing of clinical information are completed;
  • maintain records of all referrals including details of the estimated price and the indicated upper risk limit for the cost of treatment;
  • monitor management of the agreed course of treatment by the hospital and the medical specialist providing the treatment;
  • maintain a record of any proposal by the treatment hospital to extend or alter the treatment including the estimate of costs and approve these changes before they treatment is carried out;
  • review the service provided including the price and advise MFAT and/or the participating country (in regular reports) of any policy matter that may require addressing; and
  • review the discharge report and account rendered and if satisfied submit invoices to MFAT for approval and reimbursement on a regular basis.

When the patient arrives:

It is expected that all patients arriving are met by transport (or by relatives if previous arrangements have been made). Patients will be contacted within 24 hours to complete consent forms, have photos taken, have passports sighted and copies taken and support needs assessed and organised. Weekly contact with patients is necessary to check progress and deal with any on-going needs.

When patients are discharged:

When the clinical team advises of patient discharge, the MSC advises the participating ORC that the patient is cleared for travel. The ORC arranges for return travel and a clinical appointment with the patients participating country referral clinician.

3.8 The Treatment Provider and Clinical Specialist

The MSC will have systems in place to ensure that the treatment provider and clinical specialist will:

  • provide a high quality standard of care and treatment;
  • assist the MSC to perform its role through the provision of and access to clinical information;
  • undertake all reasonable endeavours to provide the contracted services within the agreed price;
  • contact the MSC immediately where a patient's condition changes or where complications in treatment require a review of the original cost estimate. In this situation prior approval must be given by MSC following its own internal clinical assessment procedures before additional treatment is provided. All requests to vary estimates and approvals will be accompanied by a clinical letter stating the reason for proposed variation of the treatment plan;
  • provide the MSC with a single account for all related expenses with adequate detail to enable confirmation that the fixed price component is consistent with any fees negotiated;
  • provide a clinical patient discharge report, copied to the MSC, for transmission to the referring country and inclusion in the patient medical record; and
  • provide a written monthly clinical update where patients are undergoing treatment for extended periods and where necessary initiate a clinical teleconference with the MSC.