Commonwealth Numbered Regulations - Explanatory Statements

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HEALTH INSURANCE (1999-2000 GENERAL MEDICAL SERVICES TABLE) REGULATIONS 1999 1999 NO. 256

STATUTORY RULES 1999 NO. 256

Issued by the Authority of the Minister for Health and Family Services

Health Insurance Act 1973

Health Insurance (1999-2000 General Medical Services Table) Regulations 1999

Section 133 of the Health Insurance Act 1973 (the Act) provides that the Governor-General may make regulations for the purposes of the Act.

The Act provides for payments by way of Medicare benefits and payments for hospital services.

Section 4 of the Act provides that the regulations may prescribe a table of medical services, (other than diagnostic imaging services and pathology services) (the table). The Health Insurance (1998-99 General Medical Services Table) Regulations prescribed such a table. Section 4 of the Act also provides that, if not sooner repealed, Regulations made under this Section cease to have effect on the day after the 15th sitting day of the House of Representatives after a period of 12 months beginning on the day on which the Regulations are gazetted.

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

The Regulations amended the current table of general medical services to include the general fee increase of 1.5% as announced in the 1999 Federal Budget. The exceptions to the fee increase relate to attendances by non recognised general practitioners (except specialists and consultant physicians) (items 52 to 98 and 697 and 698), family group therapy attendances (items 170 to 172) and an attendance at which acupuncture is performed (items 173, 193 and 195) in which case no increase was given.

The Regulations also revised the fee structure for contact lens attendance items. The general fee increase of 1.5% was not applied to the contact lens items (items 10921, 10922, 10923, 10925, 10926, 10928 and 10930) and the resultant savings were applied to the three more complex contact lens attendance procedures, covered by items 10924, 10927 and 10929.

Attendance items undertaken by general practitioners increased by 2.33% as a result of negotiations with the medical profession under the terms and conditions of the General Practice Memorandum of Understanding (MoU). The MoU, signed on 6 August 1999, guaranteed full indexation of GP attendance items in 1999 plus a one-off bonus payment equal to 15 cents for a level B attendance rebate and equivalent increases to the other items in the group. The total guaranteed increase on 1 November 1999 was 50 cents on a level B attendance rebate and equivalent increases to the other items in the group. This equated to a percentage increase to all AI items of 2.33%.

Other changes to the table resulted from ongoing reviews by the Medicare Benefits Consultative Committee designed to ensure that the table reflects current medical practice. These include the insertion of new services, the renumbering of an item, the omission of obsolete services and the amendment of existing item descriptions for correction or clarification.

The General Medical Services Table is redrafted each year. The redraft includes all rules and services that have not been changed or amended from the previous Regulation. Thus the Regulations also provided for the repeal of the Health Insurance (1998-1999 General Medical Services Table) Regulations 1998.

Details of the Regulations are set out in the Attachment.

The Regulations commenced on 1 November 1999.

ATTACHMENT

Details of the Health Insurance (1999-2000 General Medical Services Table) Regulations 1999

Regulation 1 provides for the Regulations to be referred to as the Health Insurance (1999-2000 General Medical Services Table) Regulations 1999.

Regulation 2 provides for the Regulations to commence on 1 November 1999.

Regulation 3 provides for the repeal of the Health Insurance (1998-1999 General Medical Services Table) Regulations 1998.

Regulation 4 prescribes the new table of general medical services and rules of interpretation as set out in Schedule 1.

The General Medical Services Table is redrafted each year commencing on the first of November. The redraft takes the form of duplicating all rules and services that have not been changed or amended from the previous Regulation. Listed below are the relevant changes and amendments that have been agreed to by the Minister of Health and Aged Care relating to the 1999-2000 Budget decisions and reviews undertaken by the Department with the medical profession.

Schedule 1 - Table of General Medical Services

Part 1 - Rules of Interpretation

Rule 4 amends the rule of interpretation to include new items 410 to 417 to be included in the definition of professional attendance in certain items.

Subrules 7 (1), (2), (3), (4) and (9) amends fee levels to reflect the general fee increase.

Subrules 7 (10), (11), (12) and (13) provides for derived fee calculations to be applied to new items 414, 415, 416 and 417 respectively.

Subrules 15 (1), (2), (3), (4), (5) and (6) and 16 (1) and (2) amends fee levels to reflect the general fee increase.

Rule 23 has been rewritten in a plain English format to clarify the items that apply to the treatment cycle relating to assisted reproductive services.

Subrule 34(b), and rules 41 and 46 amended fee levels to reflect the general fee increase to apply to certain anaesthetic services.

Rule 49 defines the circumstances where a benefit is payable for an attendance by a public health physician in the clinical practice of public health medicine.

Rules 50, 51, 52, 53, 54, 55, 56, 57, 58, 59 and 60 provides for a new range of items arising out of the 1999-2000 Budget for services relating to preventative health care and coordination and management of patient care. These items enhance primary care particularly for older Australians and people with chronic or terminal illnesses who require a range of care and services to support them in the community.

The items cover:

* health assessments;

* care planning; and

* case conferencing.

These items allow medical practitioners providing primary care to focus on prevention and better coordination of care. The most important benefit is that health care be improved through a more flexible, efficient and responsive match between patient needs and services, and greater empowerment and participation by patients and their carers. The items encourage private medical practitioners to link into existing services in the health care system, such as those offered by the public sector, to ensure patients receive more integrated care in the community.

Prevention and coordinated care services, by their very nature, involve a high degree of management as part of the service. While the items describe the medical service, the rules of interpretation contain the management elements of the services to complement the medical services.

Health Assessments

The health assessment items allow medical practitioners to conduct a comprehensive assessment of the patient to identify opportunities to put in place preventative measures with a view to maintaining or improving the patient's current health status. Generally, patients requiring annual health assessments would be those who do not seek ongoing care of a current condition i.e. those patients who visit their general practitioner infrequently.

Four items (700, 702, 704 and 706) cover health assessments for the elderly. Two items (700 and 702) cover health assessments in the doctor's rooms or in the patient's home for people aged 75 years and over. Similar items (704 and 706) relate to people of Aboriginal and Torres Strait Islander descent aged 55 years and over. The lower age for the latter group is in recognition of their poorer health status than the rest of the population.

As the items are for care in the community and because of the high level of care they receive, rule 51 specified that health assessments are not available to residents of nursing homes.

Rule 52 sets out the minimum parameters of the health assessment service and administration which must be carried out for a Medicare benefit to be payable.

Care Plans

Patients with chronic and complex care needs often find it difficult to organise and receive the care and services they need. Patient care is improved through better coordination of care services by using a team approach to the planning of care services and which involve the patient in the planning and goal setting process.

Items 720 and 724 cover the development and review of care plans for people with chronic conditions and multidisciplinary care needs. Practitioners can prepare the care plans themselves and make arrangements for care by other providers. Alternatively, under item 726 practitioners can contribute to care plans developed by other care providers. Items 722 and 728 cover discharge care plans from hospital in recognition of the growing role of primary care practitioners in providing care to patients after a period in hospital.

As the items are for care in the community and because of the high level of care they receive, rule 51 specifies that the care planning items are not available to residents of nursing homes. The rule also provides for discharge care plans for people who are in-patients of a hospital or day hospital facility.

Rule 52 sets out all of the elements of a care planning service which must be fulfilled in order for a Medicare benefit to be payable for the service. One of the important aspects of care planning is that the plan must describe the management goals which the patient and the doctor agree to and aim to achieve.

Rule 53 provides for the "multidisciplinary" element of care planning. Benefits are only payable for care planning services where there are at least 3 care providers involved in the care plan, and who provide different kinds of care or services. Rule 55 clarifies that the services relating to discharge care plans must be provided before the patient is discharged from a hospital.

Rule 56 specifies how a review of a care plan must be conducted and the matters that must be considered. Rule 57 defines contribution to a care plan.

Case Conferencing

A range of time tiered items for case conferencing with other providers in planning care for people with chronic conditions and multidisciplinary care needs have been included. Like the care planning items, general practitioners can contribute to case conferences organised by other care providers. There are items that also cover discharge care plans from hospital in recognition of the growing role of primary care practitioners in providing care to patients after a period in hospital.

As the items are for care in the community, rule 51 specifies that these items are not available to residents of nursing homes.

Rule 58 sets out all of the elements of a case conference service which must be fulfilled in order for a Medicare benefit to be payable for the service.

Rule 59 clarifies that the services relating to discharge case conferences must be provided before the patient is discharged from a hospital.

Subrule 60 provides for the "multidisciplinary" element of case conferences. Benefits are only payable for case conference services where there are at least 3 care providers involved in the case conference, and who provide different kinds of care or services.

Rule 61 defines the terms organise and coordinate, and participation in, a case conference.

Subrule 61 (1) describes the tasks to be carried out by a medical practitioner when organising and coordinating a case conference.

Rule 61(2) describes the tasks to be carried out by a medical practitioner when participating in a case conference.

Part 2 - Services and Fees

There have been 6 major reviews of the services in the table undertaken by the Department. These reviews related to services provided by public health physicians, a new range of enhanced primary care items, amputation procedures, plastic and reconstructive procedures including free grafting to burns, endoluminal grafting of abdominal aortic aneurysms and a restructure of the fee levels for contact lens attendances. All other minor changes resulted from negotiations with the profession in order to reflect modem medical practice within the Table.

Public Health Physicians

New items 410, 411, 412 and 413 cover the professional attendance at consulting rooms by a public health physician in the practice of public health medicine. Four new items 414, 415, 416 and 417 were introduced to cover the professional attendance at a location other than consulting rooms by a public health physician in the practice of public health medicine.

Enhanced Primary Care

New items 700 to 706 provides for annual health assessments for the elderly. New items 720 to 728 provide for care planning for people with chronic conditions or terminal illness. New items 740 to 773 provide for case conferencing for people with chronic conditions or terminal illness.

Endoluminal Grafting

The descriptions of items 33115 and 33118 have restricted the repair of abdominal aortic aneurysm to an open procedure. The procedure of endoluminal repair undertaken by bifurcation or tube graft attracted Medicare benefits under items which were intended to cover open repair. The Medicare Services Advisory Committee had recommended that the items for treatment of abdominal aortic aneurysm be restricted to open aortic repair and endoluminal repair and continue to receive public funding under alternative arrangements. Implementation arrangements were discussed with key stakeholder groups including the Royal Australasian

College of Surgeons Division of Vascular Surgery and the Australian Medical Association. Accordingly, existing items were amended to restrict payment of benefits to open aortic repair while new items have been introduced via a 3C Ministerial Determination to allow monitoring and evaluation of the endoluminal procedure.

Amputation

New item 44359 provides for the amputation of the foot and toes in patients with diabetic or other microvascular disease. The item excludes aftercare, so that additional benefits will be payable for postoperative attendances. The profession had advised that diabetic patients require prolonged postoperative care due to circulatory problems, and requested that additional visits be claimable in the postoperative period. The general practitioner/specialist fee differentials for the range of amputation items 44324 to 44358 have been removed and the item descriptors revised to more accurately describe the services provided.

Plastic and Reconstructive Surgery

The description of items 45025 and 45026 have been amended to include the use of an erbium laser for laser resurfacing of the face or neck for severely disfiguring scarring.

Two new items 45543 and 45544 are for the correction of breast ptosis in specific circumstances. Claims for bilateral correction (item 45544) will be reviewed by the Health Insurance Commission prior to Medicare benefits being paid.

Two new items 45564 and 45565 are for conjoint surgery for microvascular reconstructive surgery involving free transfer of tissue. Team surgery is now the preferred approach for surgery for repair of major tissue defects, as it significantly reduces operating and anaesthesia times, resulting in better patient outcomes and savings in theatre occupation times.

Contact Lens Attendances

A revised fee structure for optometrical items involving contact lens assessment was introduced. The profession had requested that the fee levels applying to the more complex contact lens items be restructured to recognise the level of complexity involved. The general fee increase was not applied to the non complex contact lens items (items 10921, 10922, 10923, 10925, 10926, 10928 and 10930) and the resultant sayings was applied to the three more complex contact lens items (items 10924, 10927 and 10929). This resulted in an increase of the fees for the complex contact lens procedures that appropriately reflect their complexity.

Miscellaneous Services

Two new items 31450 and 31452 for laparoscopic division of adhesions as an independent procedure were introduced. The service previously was only covered in the gynaecological area of the table and the profession has advised that the procedure may sometimes be indicated for male patients.

The description of item 35321 amended the wording to clarify the intent of the item. Both venous and arterial catheterisation are covered by this item.