Commonwealth Numbered Regulations - Explanatory Statements

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HEALTH INSURANCE (1996-97 GENERAL MEDICAL SERVICES TABLE) REGULATIONS 1996NO. 230

EXPLANATORY STATEMENT

STATUTORY RULES 1996 No. 230

Issued by authority of the Minister for Health and Family Services

Health Insurance Act 1973

Health Insurance (1996-97 General Medical Services Table) Regulations

The Health Insurance Act 1973 (the Act) in part provides for payments by way of Medicare benefits, payments for hospital services and payments for matters concerning related committees and tribunals.

Section 133 of the Act provides that the Governor-General may make regulations for the purposes of the Act.

Section 4 of the Act provides that the Regulations may prescribe a table of medical services (the table), other than diagnostic imaging services and pathology services. The Health Insurance (1995-96 General Medical Services Table) Regulations currently prescribe such a table. The Act provides that, if not sooner repealed, these proposed Regulations cease to have effect on the day after the 15th sitting day after the end of the 12 month period commencing from the date of gazettal (which was on 26 October 1995).

Section 9 of the Act provides that Medicare benefits shall be calculated by reference to the fees for general medical services set out in the table.

The purpose of the Regulations is to prescribe a new table of general medical services and rules of interpretation which incorporate the introduction of new services, the deletion of obsolete services and the amendment to the descriptions and/or fees of other services. The Regulations also provides for the repeal of the 1995-96 General Medical Services Table. Further details of the Regulations are set out in the Attachment.

The Regulations come into effect from 1 November 1996.

Attachment

DETAILS OF THE PROPOSED HEALTH INSURANCE (1996-97 GENERAL MEDICAL SERVICES TABLE) REGULATIONS

Proposed Regulation 2 provides for the proposed regulations to commence on 1 November 1996.

Proposed Regulation 3 provides for the repeal of the 1995-96 General Medical Services Table.

Proposed Regulation 4 prescribes, the new table of general medical services and rules of interpretation.

Rules of Interpretation

Amended rules have been introduced for the purpose of interpreting the table. These are as follows:

(a)        The item range in Rule 1 sub-rule (3) has been amended to reflect the addition of item 61503 to the table.

(b)        The item range in Rule 6 sub-rules (1) and (2) have been amended to take into account the new item range relating to the new psychiatric attendance services.

(c)        The item range in Rule 10 sub-rules (2) and (3) have been amended to take into account the new item range relating to two new emergency after hours attendance' items and the new psychiatric attendance services.

(d)       Item number 11235 has been added to Rule 12 sub-rule (2) as this procedure may be performed on behalf of a medical practitioner in accordance with accepted medical practice.

(e)        Rule 36 has been amended to include item 16636 which was inadvertently omitted from the last regulation.

(f)        Rule 40 has been introduced to provide a definition of the derived fee that applies to item 30161.

The remaining rules are unchanged.

Table of Services and Fees

Budget related Amendments

(a)       The fees for certain identified overpriced services have been reduced by approximately 10%. The reduction in the fee levels result from a Budget decision and apply to the following items:

11215,

11218,

11221,

11224,

11700,

11701,

11702,

11708,

11709,

11708,

11712,

12203,

13200,

13203,

13206,

13209,

13212,

13215,

13218,

13221,

14050,

30445,

30446,

30473,

30475,

30476,

30478,

32081,

32084,

32087,

32090,

32093,

37203,

42698,

42701,

49558,

49559,

49560,

49561,

49562,

49563.


Services effected by the fee reduction include retinal photography, computerised perimetry, electrocardiography, sleep apnoea, PUVA and UVB therapy, laparoscopic cholecystectomy. oesophagoscopy, endoscopy, sigmoidoscopy and colonoscopy, prostatectomy (endoscopic), artificial lens extraction and insertion, and arthroscopic surgery of the knee.

(b)       EXCISION OF SKIN LESIONS - The range of item descriptors covering excision of skin lesions have been replaced by 28 new descriptors which differentiate type of lesion, site of the lesion and the size of the lesion.

The new fee levels are based on relativities provided by the profession.

(c)       PSYCHIATRY ATTENDANCES - As a Budget measure Medicare rebates applicable to attendances with a psychiatrist in consulting rooms should be reduced by 50 percent where there are more than 50 attendances by a patient in a 12 month period.

(d)       REVERSAL OF PREVIOUS STERILISATION - As a budget measure Medicare rebates for reversal of previous elective sterilisation have been removed.

Medicare Benefits Consultative Committee initiated changes

Other changes incorporated in the table result from reviews facilitated through the Medicare Benefits Consultative Committee (MBCC). These changes involve the introduction of new services, the deletion of obsolete services and amendment to the descriptions and/or fees of other services. The changes are designed to ensure that the table reflects current medical practice. Details are as follows:

(a)       ORTHOPAEDIC SURGERY - The review arose from a submission by the Australian Society of Orthopaedic Surgeons. The Society's submission was discussed at a meeting of the MBCC held on 10 May 1996. It is proposed that some orthopaedic item descriptors be revised in order that the table better reflect current surgical practice and that other item descriptors be amended to clarify the extent of the coverage.

(b)       OPHTHALMOLOGY - The review arose from representations by the Royal Australian College of Ophthalmologists. The College's proposals were discussed at a, meeting of the MBCC held on 27 May 1996. It is proposed that new items be incorporated in the table to cover impression cytology of the cornea, the use of electrical cautery to either permanently or temporarily occlude the puncturn, artificial lens insertion into the posterior chamber and phototherapeutic laser keratectomy. Certain existing items are to be amended so that the table better reflects current surgical practice and to clarify the extent of the coverage.

(c)       UPPER GI SURGERY - The review arose from a submission from the Upper GI Section of the Royal Australian College of Surgeons. The College's submission was discussed at a meeting of the MBCC held on 28 May 1996. It is proposed that new items be introduced to cover laparoscopic marsupialisation of liver cysts, excision of hydatid cyst with excision of fiver tissue, intra operative ultrasound for staging of intra abdominal tumours, extraction of calculus of biliary or renal tract and non-endoscopic insertion/replacement of gastrostomy button. It is proposed that the descriptor for item 30439 be amended so that it clearly covers intra-operative ultrasound of the biliary tract.

(d)       INVESTIGATION FOR SLEEP APNOEA - The review of the item covering overnight investigations for sleep apnoea was initiated by the Department in light of the escalatine usage of the service (a growth from approximately 3000 services in 19901/91 to 25,000 services in 1995/96). In 1995/96 $10.5 million in Medicare benefits was paid for sleep studies.

Following receipt of a submission from the Australasian Sleep Association meetings of the MBCC were held on 23 April and 15 May 1996 to discuss the Department's concerns. It was agreed that the credentialling of providers of sleep studies by the College of Physicians was the preferred course of action. However, it was acknowledged that this would take some time to establish. In the meantime, it was agreed that the item descriptors be amended to include a requirement for better supervision and manual analysis of computerised scoring by the supervising practitioner.

(e)       AUTOLOGOUS STEM CELL TRANSPLANT AS AN ADJUNCT TO HIGH DOSE CHEMOTHERAPY - On 1 July 1996 a new item was included in the table covering "In vitro processing (and cryopreservation) of bone marrow or peripheral blood for autologous stem cell transplantation as an adjunct to high dose chemotherapy for (i) chemosensitive intermediate. or high grade non-Hodgkin's lymphoma at high risk of relapse following first line chemotherapy; or (ii) Hodgkin's disease which has relapsed following, or is refractory to, chemotherapy".

The efficacy of two further indications has been established which also require inclusion in the item descriptor. The descriptor has now been amended to include: (i) acute myelogenous leukaemia in first remission, where suitable genotypically matched sibling donor is not available for allogenic bone marrow transplant, and (ii) multiple mycloma in remission (complete or partial) following standard chemotherapy. These changes result from ongoing reviews through the MBCC process.

(f)       FOLLOW-UP ELECTROPHYSIOLOGICAL TESTING OF IMPLANTED DEFIBRILLATOR -Item 38212 covers a number of different cardiac electrophysiological studies. One of the studies associated with the item involves defibrillator implantation and testing of a defibrillator at time-of implant. It appears that the item is being inappropriately itemised for follow-up testing of an implanted defibrillator (a service much less complex than the original intention of the item descriptor).

A new item has been introduced to cover electrophysicial study for testing an implanted defibrillator at a reduced fee level from the original item.

(g)       OTHER MINOR AMENDMENTS - In order to improve the presentation of item descriptors and better define certain items a number of amendments are proposed as follows:

Two new emergency after hours items have been introduced for completeness in the General Practitioners' attendances area of the table.

Minor amendments covering certain diagnostic vascular investigations (as suggested by the Vascular Section of the Royal Australian College of Surgeons) have been included.

Descriptors have been revised to overcome an inconsistency in the definition of lesions considered disfiguring for Medicare benefits purposes.

The descriptor for item 30586 has been revised to accommodate endoscopic pancreatic cyst gastrostomy.


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