3.8 General practice financing

Medicare Australia (formerly the Health Insurance Commission)

Medicare Australia’s responsibilities include:

• ensuring Medicare benefits are paid to eligible health care consumers for services provided by eligible medical practitioners
• assessing and paying Medicare benefits for a range of medical services, whether provided in or out of hospitals, based on a schedule of
• fees (the Medicare Benefits Schedule) determined by the Australian Government Department of Health and Ageing in consultation with
• professional bodies.

The latest Medicare benefits information is available on http://www.health.gov.au/mbsonline

Medicare is available to:

• eligible Australian residents
• New Zealand citizens
• holders of permanent visas
• a number of visitors and temporary residents from countries with reciprocal health care arrangements with Australia are covered in certain
• circumstances
• holders of Temporary Protection Visas.

Some categories of Australians, such as members of the armed services and veterans, are covered by additional special arrangements, while remaining eligible for mainstream coverage by Medicare. Some injuries and illnesses are covered by other forms of financing: such as workers’ compensation insurance. Motor vehicle accidents may be covered by third person motor vehicle insurance.

In February 2004, for the first time in Australia, MBSitems were made available for the work undertaken by general practice nurses. The new items were initially for a practice nurse to provide immunisation and wound management services for and on behalf of a GP. Additional items for Pap smears (February 2005), Pap smears and Preventive Health Checks and Antenatal Care (November 2006) have since been added to the MBS. A new practice nurse MBS item for chronic disease care is to be introduced in May 2007. For more information see the “For the
employer’ section 2.3 of this resource. Other information is also available at
http://www.medicareaustralia.gov.au/providers/incentives_allowances/medicare_initiatives.htm

For more information about Medicare:

— call Medicare Australia Information Service on 132 011
— write to Medicare Australia at GPO Box 9822 in your capital city
— visit the Medicare Australian website at http://www.medicareaustralia.gov.au/

Bulk-billing

Bulk-billing is when a doctor bills Medicare directly, accepting the Medicare rebate as full payment for a service. Under this arrangement the patient signs a Medicare claim form and no additional charges relating to the service can be made. Therefore, there are no ‘out of pocket expenses’ to the patient. Bulk-billing applies at the doctor’s discretion.

On 1 February 2004, new Medicare items were introduced to pay GPs incentive payments for bulk-billed services provided to concession cardholders and children. The items provide an additional $5.15 incentive payment in urban areas and $7.65 incentive payment in rural and remote areas and in all of Tasmania.

More information is available at http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-medicare-health_pro-gp-index.htm

The gap

‘The gap’ is the difference between the fee charged by GPs for their medical services and the recommended Medicare rebate relating to those services. If the doctor’s fee is above the Medicare rebate, the patient will pay the remainder of the doctor’s fee. This is known as ‘the gap’.
For more information on fees and rebates, and ‘the gap’, visit:
http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-privatehealth-gaps-consumers-gapsexplained.htm

The Pharmaceutical Benefits Scheme

The Commonwealth Government has provided affordable access to a wide range of medicines for all Australians via a subsidy whereby the patient pays less for the medicine. This is known as the Pharmaceutical Benefits Scheme (PBS).

Information on the PBS Safety Net is available by calling free call 1800 020 613 or visit
http://www.medicareaustralia.gov.au/yourhealth/our_services/pbs.htm

Department of Veterans’ Affairs

The Department of Veterans’ Affairs funds medical services provided by GPs and specialists who are registered with DVA for eligible veterans, widowers, war widows and their dependents. Eligible veterans are issued with either a gold or white health care. A gold card entitles a veteran to a full range of services funded by DVA, while a white card provides access to the services for service related conditions.

For more information on benefits available to DVA patients, including Veterans mates program http://www.dva.gov.au

Practice Incentives Program

The Practice Incentives Program (PIP) is part of a ‘blended payments’ approach to general practice funding, that is, payments made through the program are in addition to other general practice income sources such as patient fees and Medicare rebates.

Practices must be accredited or registered for accreditation to be eligible to participate in the program, which aims to recognise general practices that provide comprehensive, quality care. It identifies areas within the general practice that contribute to quality of care rather than patient turnover and provides incentives for practices to improve these areas.

Currently, the PIP pays a range of incentives in the following areas:

• General Practice Immunisation Incentives Scheme (the only component where accreditation is NOT a prerequisite for participation)
• care for patients with diabetes (eg, 12 month cycle of care)
• care for patients with moderate to severe asthma (eg, asthma cycle of care)
• cervical screening
• care for patients with mental health issues (eg, mental health 3-step process)
• participation in National Prescribing Service (NPS) quality use of medicines program
• IM/IT (including using prescribing software to generate prescriptions, and electronically sending and or receiving clinical information)
• after hours (payment for ensuring patient have access to out of hours service, 24 –hour care and greater payments for greater
• participation in that care)
• teaching of medical students
• rurality (location outside of metropolitan areas, with higher loadings for areas of greater remoteness)
• financial support to employ practice nurses (this is not available in some metropolitan areas).

Each of these elements may have a number of incentive payment levels:

• a one-off ‘sign on’ payment per GP
• a Service Incentive Payment (SIP) for completing a specific service
• an outcome payment for completing a specific level of service.

Some levels of payment under the PIP are also linked to the size of a practice. The Standardised Whole Patient Equivalent (SWPE) is used to measure practice size. SWPE is a measure of practice size that is independent of the number of services provided to patients with standardisation applied for age and sex.

Practice nurses can play a pivotal role in many of the PIP incentives. For more information visit
http://www.medicareaustralia.gov.au/providers/incentives_allowances/pip.htm

The Rural, Remote and Metropolitan Areas (RRMA) classification of a practice also impacts on certain aspects of the PIP. Its structure is outlined in the table below:

Table 1: Structure of the Rural, Remote and Metropolitan Areas classification

General Practice Immunisation Incentives (GPII) Scheme

The GPII scheme provides a financial incentive to general practices that monitor, promote and provide immunisation services to children under the age of seven years. The overall aim of the GPII scheme is to encourage at least 90% of practices to achieve 90% proportions of age appropriate immunisation.

The GPII is made up of three components:

1. a Service Incentive Payment (SIP) of $18.50 each time a GP notifies the Australian Childhood Immunisation Register (ACIR) of a
—childhood vaccination that completes an immunisation schedule

2. an Outcome Payment of $3.50 per SWPE for practices that achieve 90% or greater proportions of full, age appropriate immunisations

3. immunisation infrastructure funding, which provides funds to divisions of general practice, state-based organisations and a National
— GP immunisation coordinator to improve the proportion of children who are immunised at local, state and national level.

In addition to the above GPII payments, an ACIR information (notification) payment of up to $6 can be made to immunisation
providers who administer and notify the ACIR of a vaccination that completes one of the age-based immunisation schedules
funded under the National Immunisation Program (NIP).

General practice accreditation is not necessary for a practice to participate in this incentive. For more information visit
http://www.medicareaustralia.gov.au/providers/incentives_allowances/gpii_scheme.htm and
http://www.gsedgp.com.au/appdata/File/imm-strivefor5Nov05.pdf

The Australian Childhood Immunisation Register (ACIR)

The ACIR began recording details of all immunisations provided to children less than seven years of age on 1 January 1996. It is overseen by Medicare Australia. Access to the secure ACIR website is easy to arrange. The site provides a wealth of information on children’s vaccination histories, including due and overdue details. Regular electronic reports can be requested to help improve the practice’s childhood immunisation coverage rates. Local divisions can provide assistance with access to and navigation of the ACIR website, data cleaning and managing reports including how to manage reporting.

There are four methods of submitting immunisation data to the ACIR:

1. Medicare Australia’s online claiming
2. secure website via http://www.medicareaustralia.gov.au
3. Medclaims
4. manual submissions.

Useful contacts include:

• GPII General Inquiries 1800 246 101
• http://www.medicareaustralia.gov.au/providers/programs_services/acir/info_for_imm_providers.htm
• ACIR payments, child histories and data correction 1800 653 809
• ACIR Field Officer – please call your division to obtain a name
• Immunisation Register [Online] http://www.medicareaustralia.gov.au/yourhealth/our_services/aacir.htm
• internet helpdesk 1300 650 039
• Immunisation Register fax number 08 9214 8163
• stationery order forms 1800 815 664.

Government immunisation programs

Local divisions of general practice provide support and advice to practice nurses regarding immunisation issues including vaccination schedules, data cleansing, and cold chain management.

State/territory health departments and the Australian Government Department of Health and Ageing provide a wealth of immunisation information most of which is available via their respective websites. Immunisation coordinators at Public Health Units can also assist practice nurses with immunisation information and resources.

Public Health Units employ immunisation coordinators, infectious disease surveillance staff, Environmental Health Officers and epidemiologists. The immunisation coordinators can advise practice nurses and GPs on all aspects of vaccination, including vaccine delivery, cold chain, catch up schedules and other technical vaccine information. Surveillance officers take notifications of diseases and can advise on
control and treatment/prophylaxis of specific diseases. The environmental health officers work with water quality, smoking
legislation and exhumations. The epidemiologist can provide statistical data for research and planning.

Other useful sources of information include:

• the ‘Immunise Australia program – resources for providers and parents’ website http://www.immunise.health.gov.au or telephone
• Immunisation Australia 1800 671 811.
• the RACGP guidelines at http://www.racgp.org.au/guidelines/vaccination
• the NHMRC The Australian Immunisation Handbook (8th Edition). http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/content/handbook03.

Contact your division of general practice for a list of teaching organisations that provide training for accreditation as vaccinators. http://www.adgp.com.au/site/index.cfm?module=DIVISION

The National Centre for Immunisation Research and Surveillance (www.ncirs.usyd.edu.au) also contains useful fact sheets and
questions and answers.

Enhanced Primary Care

The Enhanced Primary Care (EPC) initiative was introduced by the Commonwealth Government in 1999 to support:

• improved coordination of care for people with chronic conditions and complex care needs
• increased preventive care for older Australians
• a framework for a multidisciplinary clinical approach to health care through a more flexible, efficient and responsive match between
• services and the patient’s needs.

The EPC ‘package’ has grown since 1999 and now comprises a number of Medicare items for:

• annual Health Assessments for people aged 75 years and over
• annual Health Assessments for Aboriginal and Torres Strait Islander (ATS I) people 55 years and over in recognition of their specific health
• needs
• two-yearly adult ATS I health check for 15 to 54 year olds
• a Comprehensive Medical Assessment — ‘health assessments’ for permanent residents of Residential Aged Care Facilities regardless of age
• multidisciplinary case conferencing requiring participation by the patient’s usual GP and at least two other health care providers
• a GP Management Plan for patients of any age with chronic conditions
• Team Care Arrangements (GPMP/TC A) for patients of any age with chronic conditions and complex care needs.

Practice nurses can play an important role in providing many elements of EPC. For more information visit:

http://www.health.gov.au/internet/wcms/publishing.nsf/Content/Enhanced+Primary+Care+Program-1
http://www.health.gov.au/internet/wcms/publishing.nsf/Content/2EFFC8A13814C180CA2570680020866C/$File/qau.pdf
(Q&As including the role of Practice Nurses)
http://www.health.gov.au/internet/wcms/Publishing.nsf/Content/health-epc-index.htm

Allied health and dental services

Patients with chronic conditions and complex care needs who are being managed by their usual GP under both a GP Management Plan and Team Care Arrangement are eligible for Medicare rebates for certain allied health and dental services.

The need for allied health care must be identified in the patient’s management plan. The list of allied health professionals who may provide a service are:

• Aboriginal Health Worker
• credentialed diabetes educator
• audiologist
• dietitian
• mental health worker
• occupational therapist
• physiotherapist
• podiatrist or chiropractor
• osteopath
• psychologist
• speech pathologist
• exercise physiologist.

Fore more information visit http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-medicare-health_pro-gp-pdf-allied-cnt.htm

Patients with private health cover may also be eligible for rebates for allied health and dental services from their fund. The government does not control the amount of benefit that may be provided to patients by private health funds for allied health and dental services. In some circumstances the health fund will cover the cost of treatment for services and in other cases they will not and the patient will have out of pocket expenses. A patient’s health fund will provide details of their arrangements.

More Allied Health Services (MAHS) Program

The MAHS program commenced in 2001 and aims to improve the health of people living in rural areas by providing more allied health care to the community through general practice.

Funding for the program is managed by eligible rural divisions of general practice and recognises the important role divisions have in improving the health of communities.

The MAHS program emphasises a multidisciplinary approach to the provision of health care to key groups within the rural community.

For more information visit: http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-pcd-programs-mahs

Home Medicines Review

A Home Medicines Review(HMR), previously known as a Domiciliary Medication Management Review (DMMR), provides an opportunity for patients to benefit from a partnership approach between their usual GP and pharmacist. A HMR may be provided as an annual service to patients living at home in the community.

A review can be offered to any patient for whom the GP feels it is clinically necessary to ensure quality use of medicines or address patient needs. There are some known risk factors that may predispose people to medication related problems, these include:

• patient is taking five or more regular medications
• patient is taking more that 12 doses of medication/day
• significant changes have been made to the medication regimen in the last three months
• symptoms suggest of an adverse drug reaction
• sub-therapeutic response to treatment
• suspected non-compliance with the medication/s
• literacy or language, eye sight, confusion/dementia or other cognitive concerns
• recent discharge from hospital.

A referral is sent to the accredited pharmacy of the patient’s choice and a specially accredited pharmacist completes a thorough evaluation of the medications, including any complementary therapies. A report is sent to the referring GP and a Medication Management Plan is formulated from the information gleaned. For more information visit
http://www.health.gov.au/internet/wcms/Publishing.nsf/Content/health-epc-dmmr.htm

Residential Medication Management Reviews (RMMR)

A Residential Medication Management Review (RMMR) is similar to HMR but it is specifically for permanent residents of Commonwealth funded Residential Aged Care Facilities. Respite residents are eligible for HMR once they return home.

Prior to the introduction of RMMR in November 2004, medication review was conducted by the Aged Care Home’s accredited pharmacist in consultation with staff. This system was (and still is) available to all residents.

RMMR is a collaborative service between a GP and accredited pharmacist to review the medication management needs of new or existing residents, where in the opinion of the GP there is a clinical need for a review. RMMR is dependent upon a referral from the resident’s
usual GP.

More information is available at http://www.health.gov.au/internet/wcms/publishing.nsf/Content/rmmr-factsheet/$FILE/rmmrfactsheet.pdf

Medicare Benefits Schedule attendance items

The MBS contains a unique item number for each professional medical service or ‘attendance’. An electronic version is available on: www.health.gov.au/internet/wcms/publishing.nsf/Content/mbsonline-summary-intro

The needs of patients vary widely and practices need to have flexible appointment systems that can accommodate patients with urgent, non-urgent, complex, planned chronic care and preventive health needs during normal opening hours.

Appointment systems vary widely from practice to practice and have evolved to meet community and practice needs. The majority of practices, but not all, make appointments within 10 to 15 minute time frames for the majority of patients. Patients are billed according to the consultation scale below. The GP determines the level of consultation according to the needs of the patient. Patients can be encouraged to book consultations of appropriate length particularly if they know they will need a long consultation for a complex issue or a procedure such as a Pap smear.

The most common or ‘standard’ GP consultation is known as a Level ‘B’ and usually lasts less than 20 minutes. There is greater‘content’ in a Level ‘B’ than in a Level ‘A’ consultation. A Level‘A’ consultation might be for an annual Fluvax, for example (see table below).