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HEALTH INSURANCE AMENDMENT REGULATIONS 2001 (NO. 1) 2001 NO. 272
EXPLANATORY STATEMENTSTATUTORY RULES 2001 No. 272
Issued by the Authority of the Minister for Health and Aged Care
Health Insurance Act 1973
Health Insurance Amendment Regulations 2001 (No. 1)
Section 133 of the Health Insurance Act 1973 (the Act) provides that the Governor-General may make regulations prescribing matters for the purposes of the Act.
Section 3GA of the Act provides for a Register of Approved Placements. Under subsection 3GA(5) of the Act the Managing Director of the Health Insurance Commission (the HIC) must register an applicant medical practitioner who is enrolled in a program of a kind specified in the regulations. The effect of such registration is to enable the applicant medical practitioner to access Medicare in circumstances where the applicant practitioner would be otherwise ineligible to do so.
Subsection 20(3) of the Act provides that the HIC may pay Medicare benefits in respect of a professional service directly to a general practitioner where cheque issued under subsection 20(2) (where a cheque, made out to the doctor, is given to the patient, known as a ` pay doctor via claimant cheque') is not presented within 90 days after issue. Subsection 20(5) of the Act provides that the HIC may pay an amount under subsection 20(3) by means of electronic transmission of the amount to an account kept with a bank in such circumstances, and subject to such conditions, as are prescribed by the regulations.
The purpose of the Health Insurance Amendment Regulations 2001 (the Regulations) is to prescribe:
• two new medical programs to allow them to access Medicare benefits, namely, the Approved Private Emergency Department Program and the Temporary Resident Other Medical Practitioner Program; and
• prescribe the circumstances in which the HIC may pay an amount by electronic transmission to a bank account.
Details of the Regulations are provided in the Attachment.
The Regulations commenced on gazettal.
ATTACHMENT
DETAILS OF THE HEALTH INSURANCE AMENDMENT REGULATIONS 2001 (NO. 1)
Regulation 1 provides that the name of the regulations will be the Health Insurance Amendment Regulations 2001 (No. 1).
Regulation 2 provides that the regulations commence on gazettal.
Regulation 3 provides that Schedule 1 amends the Health Insurance Regulations 1975.
Items 1 and 2 of Schedule 1 are minor technical amendments that correct two wrong references in the Regulations.
Item 3 of Schedule 1 inserts a new regulation 13AA dealing with electronic payments to general practitioners of amounts payable under subsection 20(3) of the Act.
New subregulation 13AA(1) provides that the regulation applies to payments made by the HIC to general practitioners under subsection 20(3) of the Act.
New subregulation 13AA(2) provides that the HIC may make electronic payments under subsection 20(5) of the Act to a general practitioner who:
• is enrolled in the `90 Day Pay Doctor Cheques Scheme' administered by the HIC; and
• has given the HIC written permission to give the Reserve Bank of Australia details of his or her bank account into which the payments may be made.
New subregulation 13AA(3) defines the term `general practitioner' for the purposes of section 20 of the Act.
Item 4 of Schedule 1 amends Part 2 of Schedule of the Regulations by prescribing two new programs for the purposes of subsection 3GA(5) of the Act, namely, the Approved Private Emergency Department Program and the Temporary Resident Other Medical Practitioner Program.
Regulation Impact Statement
Health Insurance Act 1973
Amendment to Health Insurance Regulations 1975
1. BACKGROUND
Section 19AA of the Health Insurance Act 1973 (the Act) provides that a Medicare benefit is only payable in respect of professional services provided by a medical practitioner with a postgraduate specialist or general practice qualification, or as part of a prescribed training course or labour market program. The section provides an incentive to doctors to seek adequate training before moving out of the hospital system and into unsupervised private practice.
A medical practitioner subject to section 19AA can do the following things to become eligible to provide professional services that attract a Medicare benefit:
• Obtain a general practice (GP) or specialist fellowship, in which case he or she ceases to be subject to section 19AA;
• Take part in a relevant training program (eg: general practice training); or
• Be a participant in workforce distribution programs such as the Rural Locum Relief Program.
Temporary resident medical practitioners are generally seen as a short-term solution to pressing workforce shortages where no suitable permanent Australian medical practitioner can be recruited.
Section 3J of the Act provides that temporary residents of Australia are not considered to be medical practitioners unless they hold an exemption to that section of the Act. Section 19AA contains a provision that protects those temporary resident medical practitioners who hold a section 3J exemption from the effect of the qualification requirements in section 19AA.
On 18 October 2001 section 3J will be repealed. At that time, temporary resident medical practitioners will become subject instead to section 19AB of the Act. Section 19AB provides that an overseas trained medical practitioner, or a former overseas medical student, requires an exemption in order to provide a professional service that attracts a Medicare benefit. From 18 October, section 19AA will contain a provision to the effect that temporary resident medical practitioners who hold a section 19AB exemption will not be affected by the restrictions on Medicare access in section 19AA.
Section 19AA provides a strong incentive for doctors who wish to work in private practice to gain relevant general practice or specialist qualifications. Doctors who do this then provide services that attract a higher Medicare benefit in recognition of their commitment to vocational recognition.
2. PROBLEM
Upon repeal of section M of the Act, a number of medical practitioners who were registered in Australia prior to 1 January 1997 will cease to be subject to the restrictions based on overseas training or citizenship (section 19AB of the Act). Most of these doctors have achieved postgraduate qualifications and will not be affected by any of the qualification requirements.
A group of these temporary resident medical practitioners who were registered in Australia prior to 1 January 1997 and who have previously relied upon their holding a section 3J exemption to avoid qualification requirements, will become subject to section 19AA of the Act from 18 October 2001. This is because section 19AB only applies to those who first became medical practitioners, as defined by the Act, from 1 January 1997. As temporary resident doctors who held an exemption to section 3J, or who were registered to practice in Australia prior to 1 January 1996 (the date that section 3J commenced operation) would fall within the definition of "medical practitioner" in section 3 of the Act on a day before 1 January 1997, they would not be subject to its requirements and so would be unable to apply for an exemption to that section of the Act.
The majority of this group of doctors will have entered a training course or achieved a postgraduate qualification since 1996 and so will not be affected by the change. However, an estimated maximum of 100 in this group of medical practitioners will not have sought to obtain a postgraduate qualification. It is this latter group that will be affected by the change. Once they cease to hold an exemption under section 3J of the Act, this group of medical practitioners would not be subject to section 19AB and so would not be able to seek exemption to section 19AB in order to avoid the consequences of section 19AA.
As patients generally expect to receive a Medicare benefit to defray the cost of the medical services that they purchase, medical practitioners unable to provide eligible services may be unable to sustain work in private practice as patients would be unlikely to pay the higher cost of the services. A result of this is that such medical practitioners generally work in the public hospital system where it is not necessary to provide services that attract a Medicare benefit. Those long term temporary residents currently engaged in private medical practice would be unable to provide those services at the price normally expected by patients. Affected medical practitioners who provide services through Medicare for their disadvantaged patients would be unable to provide those services as no Medicare benefit would be payable.
3. OBJECTIVE
The objective of the Government in introducing this regulatory change is to: ensure that medical practitioners are encouraged to attain the qualification requirements of section 19AA if they wish to provide professional services that attract a Medicare benefit; and to prevent a disruption in the service provided by "long term temporary resident medical practitioners", that is, those doctors registered in Australia prior to 1 January 1997, upon the repeal of section 3J of the Act.
4. OPTIONS
Option 1: Limited term section 3GA program
Option 1 would create a section 3GA program to accommodate long term temporary resident medical practitioners who are otherwise ineligible to provide services that attract a Medicare benefit. Such medical practitioners are able to access a Medicare provider number for a limited period if they undertake an approved placement in a course or program prescribed under section 3GA of the Act. Places in the program would be listed on the Register of Approved Placements for the purpose of section 3GA of the Act.
Placements on the program would be limited by administrative guidelines to a maximum term of 5 years. By limiting the term of the placements, medical practitioners wishing to continue to provide professional services that attract a Medicare benefit at the end of the 5 year period would have a strong incentive to undertake postgraduate training or other pathways to vocational recognition.
Five years was selected as a time limit as it is unlikely that a medical practitioner could take more than this time to achieve selection for postgraduate training. This is because there are more training positions on offer than there are new entrants to the medical practitioner workforce each year (Medical Training Review Panel reports, 1997-2000). Once a medical practitioner is accepted onto a training course or program, he or she would be protected from the effect of section 19AA as training programs are prescribed for the purpose of section 3GA of the Act. In addition, 5 years is the usual time that a medical practitioner will spend in private general practice if he or she wishes to sit the Fellowship examination of the Royal Australian College of General Practitioners, instead of undertaking training in general practice, which would normally take only 3 years to complete.
Option 2: Unlimited section 3GA program
As for Option 1, but not time limited.
Option 3: No action
No action taken. Allow the long term temporary residents to lose the ability to provide professional services that attract a Medicare benefit until such time as they enter postgraduate training or achieve vocational recognition as a specialist or general practitioner.
5. AFFECTED PARTIES
Parties affected by the proposed legislation would be:
• Consumers;
• Medical practitioners, both temporary residents and permanent Australian doctors who work in parallel to the temporary resident doctors;
• Government.
6. IMPACT ANALYSIS
The impact of the 3 options is analysed below for:
• Option 1, a limited term section 3GA program;
• Option 2, an unlimited section 3GA program; and
• Option 3, no action.
Costs of Option 1
(a) Consumers
Consumers would continue to have access to a group of medical practitioners who do not hold a postgraduate qualification and who may not undertake Continuing Medical Education (CME). These medical practitioners may not be at the standard now promoted for Australian medical practitioners working independently in private medical practice. The strong incentive to improve qualifications provided by the 5 year time limit on the program would, however, mean that the consumers would eventually get access to their medical practitioners at the higher standard of qualification.
(b) Medical Practitioners
Long term temporary resident medical practitioners
Affected medical practitioners would need to obtain a postgraduate qualification or participate in a training course or program within 5 years. Postgraduate training courses vary in length, for example the Royal Australian College of General Practitioners Training Program takes three years to complete while the Royal Australian College of Surgeons Training Course requires approximately four years of advanced training. Trainees are paid a salary while they train and some training courses also allow the trainee access to Medicare benefits.
Alternative pathways to vocational recognition in general practice are currently being created and will allow medical practitioners to be assessed while they work; most positions are located in rural areas. As another alternative to formal training, medical practitioners who work for 5 years in a general practice setting and undertake quality assurance and Continuing Medical Education (CME) activity may apply to sit the Fellowship examination with the Royal Australian College of General Practitioners without undergoing further training.
Once a medical practitioner holds a vocational qualification, he or she is required to participate in quality assurance and CME, to maintain and improve the quality of the medical practice. This would require the practitioner to spend time and money attending seminars to update medical knowledge.
Permanent Australian medical practitioners
Nil.
(c) Government
Administration of the program would initially be cost-neutral, given that the program will include a pool of medical practitioners already accessing Medicare benefits.
In the long term, this legislation should mean that more medical practitioners train in specialist and general practice vocations. While the Government would pay a higher rebate for the services provided by these medical professionals, this would be in line with the policy intent of section 19AA, to direct Medicare funds into high quality services.
Benefits of Option 1
(a) Consumers
Consumers who choose to visit a long term temporary resident medical practitioner would continue to get a Medicare benefit for the professional services provided. This would ensure continuity of care. As a significant proportion of the estimated 100 medical practitioners affected would see over 1000 patients per year, this program would enable a large number of patients to continue to see their regular medical practitioner.
The time limit on the program would benefit consumers by encouraging medical practitioners to seek a postgraduate qualification appropriate to their field of practice if they wish to provide services that attract a Medicare benefit. This would in turn enable patients to be confident that doctors they consult are adequately trained in the areas in which they practise.
Doctors who have achieved a postgraduate qualification are generally required to undertake Continuing Medical Education, which means that their skills are refreshed and updated regularly. This would benefit consumers, as they would be visiting a medical practitioner with more current medical skills and knowledge. Patients therefore get a higher quality service and also a higher Medicare benefit when they visit such doctors.
(b) Medical Practitioners
Long term temporary resident medical practitioners
Option 1 would be beneficial to long term temporary resident medical practitioners because it would prevent the qualification requirements in section 19AA of the Act taking immediate effect upon businesses and individuals.
Vocational recognition encourages and rewards general practitioners and specialists, who participate in Continuing Medical Education and quality assurance activities, thereby maintaining and improving the quality of their practice. This up-to-date, higher standard of knowledge helps them to deal more confidently with patients' problems. A higher level of qualification may also help to reduce costs for individual practitioners who may pay a lower premium for professional indemnity.
Affected medical practitioners who choose to improve their qualifications in line with these incentives would be able to receive a higher level of Medicare benefit for the professional services they provide.
Permanent Australian medical practitioners
Upon committing to stay long term in Australia, these medical practitioners become subject to the same qualification requirements as all other Australian medical practitioners.
The time limit would ensure that long term temporary resident doctors are not treated favourably at the expense of Australian permanent resident and citizen medical practitioners, who are all subject to the qualification requirements of section 19AA of the Act. This program would mean that, over time, long term temporary residents would no longer be subject to a lesser qualification standard than permanent Australian medical practitioners, who must undertake postgraduate training if they wish to permanently satisfy the requirements of section 19AA.
(c) Government
Administrative guidelines on the operation of the program would ensure that the medical practitioners would achieve the Government's quality objectives implicit in section 19AA of the Act.
Impact of Option 2
Cost of Option 2
(a) Consumers
The access and quality outcomes available to consumers under Option 1 would not be available. This is because the absence of a time limit would remove the incentive for medical practitioners to improve their qualifications. As a result, the patients of affected medical practitioners would not have access to the higher quality standard of care.
(b) Medical Practitioners
Long term temporary resident medical practitioners
This group would be eligible to provide professional services that attract a Medicare benefit, thereby removing any incentive to improve qualifications to the standard expected of all permanent Australian medical practitioners.
Permanent Australian medical practitioners
If the affected long term temporary resident medical practitioners were not encouraged to undertake postgraduate training then they may be advantaged in competition with vocationally recognised permanent Australians as the latter group need to expend time and money on CME and quality assurance activities.
While there is the possibility that the affected group could provide services at a superficially lower cost than their better-trained permanent Australian counterparts, it is unlikely that this would be the case over the long term as the rate of Medicare benefit that they receive is lower than the rate received by those with postgraduate qualifications.
(c) Government
The program would be cost neutral in that it would involve continued payment for medical practitioners already working in private practice. However, from an accountability perspective, this program would have a negative impact, as the Government would potentially be paying for a lower quality of service delivery than it requires of permanent Australian medical practitioners.
Benefits of Option 2
(a) Consumers
As for Option 1, consumers would not lose access to a long term temporary resident medical practitioner who they prefer to visit.
(b) Medical practitioners
Long term temporary resident medical practitioners
Medical practitioners would continue to access Medicare as they do now and would not be required to undertake further training.
Permanent Australian medical practitioners
Nil.
(c) Government
Nil.
Option 3: No action
Cost of Option 3
(a) Consumers
Some consumers will lose access to the services of their current medical practitioner as it would cost them more to see a medical practitioner where they could not claim a Medicare benefit to defray the cost of the service. This is especially the case for those patients, such as concession holders whose medical practitioner had previously been able to provide bulk billed services at no cost to the patient.
(b) Medical Practitioners
Long term temporary resident medical practitioners
Affected medical practitioners would lose the ability to provide professional services that attract a Medicare benefit from 18 October 2001. This loss of a major source of income could result in affected medical practitioners being terminated from their employment or being unable to sustain profitable small businesses.
Permanent Australian medical practitioners
No effect except where those doctors are participating in business activity in reliance upon an affected long term temporary resident medical practitioner. In such cases, it would be extremely difficult to replace the temporary resident medical practitioner at short notice. Many such medical practitioners work in fields where there is a difficulty in attracting permanent Australian medical practitioners, such as after hours deputising and locum work.
(c) Government
The operation of the Government's legislation would conflict with the Government's policies to promote small business and patient access to health care services.
Benefits of Option 3
(a) Consumers
Nil.
(b) Medical Practitioners
Long term temporary resident medical practitioners
Nil.
Permanent Australian medical practitioners
Some permanent Australian medical practitioners might profit from the closure of competing businesses run by the estimated 100 affected temporary resident medical practitioners.
(c) Government
Nil.
7. CONSULTATION
The proposed amendment would establish a strong economic incentive for those long term temporary resident medical practitioners otherwise subject to qualification requirements to continue to provide professional services that attract a Medicare benefit while they seek to attain the qualification standards expected of Australian medical practitioners.
As the program is clearly beneficial when compared to an immediate loss of eligibility to provide such services from 18 October 2001, consultation has not been undertaken at this point. However, consultation at the time of passage of the Health Legislation Amendment (Medical Practitioners' Qualifications and Other Measures) Act 2001 revealed that there was broad-based support for the qualification requirements from medical organisations, provided that appropriate prevocational and postgraduate training was made available to those affected by the requirements.
Once the program is in operation, the Department will notify all medical practitioners placed on the program of the issues relevant to their continued eligibility. Those medical practitioners who do not wish to participate in the program will be removed from the Register of Approved Placements at their request.
8. CONCLUSION AND RECOMMENDED OPTION
Option 1 is recommended as the best balance between the intent of section 19AA to encourage medical practitioners to attain vocational recognition prior to entering independent private medical practice and the need for long term temporary resident medical practitioners to continue their existing private practice work with minimum interference.
Option 2 is not recommended, as it is not consistent with the aim of section 19AA to promote postgraduate training to medical practitioners seeking to engage in private practice. This is because allowing an unlimited period of eligibility to provide professional services that attract a Medicare benefit would not provide any incentive to seek admission to a postgraduate training course or program prescribed under section 3GA of the Act.
Option 3 is not recommended, as it would have unduly harsh effects on medical practitioners who have established their practices over a long term. This is because an immediate cessation of eligibility to provide professional services that attract a Medicare benefit from 18 October 2001 would not allow a sufficient transition time for the medical practitioners to make arrangements to undertake postgraduate training or to seek recognition of specialist or general practice qualifications. The loss of eligibility without prior notice would have a significant detrimental effect upon established practitioners' ability to sustain their business operations.
9. REVIEW
In the event that consultation reveals that an affected temporary resident medical practitioner no longer wishes to participate in the program, the voluntary nature of the scheme makes it possible for a service to cease participation, subject to any contractual arrangements in place.
Section 19AD of the Act provides that the Minister must table a report in Parliament on the details of the operation of sections 19AA, 3GA and 3GC on a biannual basis, commencing from 31 December 2001. This will require a review of the operation of each of the programs established under section 3GA of the Act.
In addition, the Medical Training Review Panel tables a report in Parliament each year. This report contains research into the availability of postgraduate training positions, with emphasis on ensuring that there are sufficient places to accommodate all Australian medical practitioners who wish to undertake such training. This means that there will be evidence to refer to in the event that a medical practitioner is unable to secure a training place or postgraduate qualification after 5 years on the program based on Option 1.
Regulation Impact Statement
Approved Private Emergency Department Program
Additional program to commence under section 3GA of the Health Insurance Act 1973
BACKGROUND
Section 19AA of the Health Insurance Act 1973 (the Act), which came into effect on November 1996, provides an incentive for newly graduated doctors to seek postgraduate qualifications prior to their accessing Medicare benefits for work performed independently of supervision in private practice. It applies to generally prohibit such doctors from providing professional services that attract a Medicare benefit until they obtain a postgraduate qualification.
Section 19AA of the Act does not apply to medical practitioners who are participating in a training course under section 3GA of the Act. This allows medical practitioners who do not have post graduate qualifications to provide professional services that attract a Medicare benefit by working in an approved placement, such as a training placement, under section 3GA of the Act.
Section 3GA of the Act provides for the creation of a Register of Approved Placements. Persons may be listed on the Register once they are enrolled or taking a course or program of a kind specified in the regulations. Once included on the Register a person is able to provide services for which a Medicare benefit will be payable, if the service is performed during the course or program. This ensures that only persons in supervised and recognised positions are able to provide services for which a Medicare benefit will be payable.
PROBLEM
The training program of the Australian College of Emergency Medicine (ACEM) is a prescribed training course for the purposes of paragraph 3GA(5)(a) of the Act. This means that trainees under the program can provide professional services that attract Medicare benefits while they are working as advanced trainees in the accident and emergency departments of private hospitals. However, existing ACEM training course places are almost exclusively located in public hospitals. There is currently only one private hospital training position in the ACEM training course.
The Mid-Term Review of Provider Number Legislation completed in December 1999 noted that there was no doubt that provider number legislation has had an impact on the workforce of private hospitals. In particular, it pointed out there is a shortage of doctors, with the appropriate skills, practicing in the accident and emergency departments of private hospitals. This is because private hospitals have historically recruited from a pool of new graduates who have not entered training programs and this source of recruitment is no longer available. It is also because many of the doctors previously recruited in this manner have left the accident and emergency departments to pursue careers in other fields of medicine. Therefore, the provider number legislation, combined with a proliferation of new private hospital accident and emergency departments, of which there are now 28, has brought with it staffing pressures for the private hospital emergency departments.
In the financial year 1999/2000, private accident and emergency departments treated 486,000 patients, providing an important relief in this respect to the public hospital system which treated 5,220,000 patients that year.
In January 1997, the Australian Medical Workforce Advisory Committee (AMWAC) report The Emergency Medical Workforce in Australia concluded that the size of the emergency specialist workforce needed to increase to match an estimated requirement in 2007 of 1200 emergency specialists. The ACEM reports that there are currently 881 trainees in various stages of the program. The majority of trainees are in public hospitals.
OBJECTIVE
The Government's objective is to enhance patient access to private emergency departments by expanding the pool of available doctors, while also maintaining the impetus for medical service providers to increase their skills.
OPTIONS
Two alternatives have been considered as options in addressing the workforce shortage in private hospital emergency departments.
Option 1: Maintain existing arrangements
Option 1 is to maintain existing Medicare Benefits Schedule (MBS) arrangements for private hospital emergency department services. There would be no additional workforce assistance in the form of medical practitioners excepted from Medicare provider number restrictions under this option. This option would not require the Commonwealth to take any action.
Option 2 Establish a program under section 3GA of the Act
Under this option the Department of Health and Aged Care would establish a 3GA program, the Approved Private Emergency Department Program (APEDP). The program would allow nonspecialist medical practitioners who were also trainees of the ACEM to be excepted from the qualification requirements of section 19AA under specific conditions which have been agreed to by the ACEM. Exemptions granted under the program would be for a period of 12 months. The short term of the placements is consistent with the strong incentive in section 19AA of the Act to obtain postgraduate qualifications.
Administrative guidelines that underpin the program would provide that the private hospital should ensure that medical practitioners nominated by the hospital for Approved Placement to act as emergency medicine doctors shall:
• hold medical registration in the State/Territory of practice;
• have a minimum of three years post-graduate experience, including experience in emergency medicine, paediatrics, medicine and surgery;
• hold appropriate membership of a medical defence organisation approved by the private hospital
• be advanced trainees of the Australasian College for Emergency Medicine
Medical practitioners working for approved service providers will be listed on the Register of Approved Placements under section 3GA. A Medicare benefit would then be payable in respect of specific emergency medicine services performed by such doctors.
Conditions to be imposed under administrative guidelines for this option would specify quality, supervision and training requirements. This would ensure that funding of MBS services in private hospital emergency departments is linked to quality delivery both in terms of workforce and facilities. The requirements for exemptions would include:
• ACEM agreement to criteria for the medical providers
- A private hospital wishing to apply for participation in this program must ensure that the medical practitioners they nominate are doctors who are subject to restrictions imposed by section 19AA of the Act and that they comply with the provisions as mentioned above and that they have clinical support.
• Department of Health and Aged Care accreditation of the hospital emergency department as agreed with ACEM, to the effect that a private hospital emergency department must meet the following criteria to be deemed an approved emergency department:
- The emergency department shall be part of a hospital and this department must be licensed as an "emergency department" by the appropriate State government authority. The department must be purpose designed and must include a designated separate area for the reception and stabilisation of critically ill patients. This designated area must have the capacity for mechanical ventilation and invasive vital signs monitoring.
- There are registered nurses on duty in the department 24 hours a day. There must be a nursing structure within the department with a senior nurse with appropriate emergency nursing qualifications and experience designated as being responsible for the organisation and operation of its nursing services. There must be adequate policies and procedures for the administration of the department for example triage policy.
- The emergency department has 24-hour on-site medical cover. Where this is not an emergency physician, there will be an emergency physician available on-call for clinical support. The medical staff establishment will include at least 2 Full Time Equivalents (FTE) of emergency physicians. While the on-site doctor's primary commitment is the emergency department and he/she will be based in the department, he/she may be called to other parts of the hospital in the event of an emergency. The emergency department will have an emergency physician who is responsible for the quality management, medical education activities and other similar activities.
- The emergency department will provide initial assessment and management of all emergencies and extended care for most patients depending on the hospital's supporting infrastructure. Networking and transfer arrangements should also be in place for those patients whose clinical needs cannot be met within the hospital.
The emergency department should have adequate specialist cover for opinion and/or referral 24 hours a day in such specialties as Intensive Care, Anaesthesia, General Surgery, General Medicine, Paediatrics, Orthopaedics, Neurosurgery, Vascular Surgery and Psychiatry. Adequate arrangements must be in place for the transfer of patients who require additional specialist care to an appropriate alternative facility.
Pathology, radiology and operating theatres are available 24 hours a day. There is also 24 hours a day access to CT and ultrasound on site.
There is a formal quality improvement program which includes morbidity and mortality review and review of recognised emergency medicine clinical indicators. The medical record system reflects the requirement of emergency medicine doctors to hand patients on to other doctors for continuing care whether admitted or not. There is a dedicated clinical and management information system in which the Emergency Medicine Minimum Data Set or equivalent is recorded. There is a system of doctor credentialling in line with the hospital's medical by-laws and which includes requirements for current medical registration, medical indemnity insurance and participation in an appropriate continuing medical education program. The emergency department should collect and submit Clinical Indicator data to a hospital Quality Program such as ACHS EQuIP.
The emergency department will have in place contingency arrangements, quality assurance, continuing medical education (CME), safe working hours policies, communication and information strategies and complaints processes.
IMPACT OF THE OPTIONS
Affected Parties
Parties affected by the proposed legislation would be:
(a) The community
(b) Trainees of the ACEM
(c) Private hospitals with emergency departments
(d) Public hospitals
(e) The Commonwealth
Cost of Option 1
(a) Community
There would be no monetary cost to the community. However, the community will continue to experience difficulty in accessing private accident and emergency services. This is significant given that a-growing proportion of the Australian community has chosen to take up private health insurance and so is likely to wish to take advantage of private accident and emergency facilities.
(b) Trainees of the ACEM
There would be no monetary cost to the trainees. However, they would be unable to supplement their income and gain more experience in private accident and emergency departments.
(c) Private hospitals with emergency departments
At present approximately 75% of private hospital emergency department staff are not Emergency Medicine specialists because any doctor who was registered before 1 November 1996 is able to provide professional services that attract a Medicare benefit without needing to undertake postgraduate training. As all new medical graduates are subject to the section 19AA qualification requirements, it follows that the pool of recently graduated medical practitioners who can provide services that attract a Medicare benefit is shrinking over time. This means that the private hospitals are now recruiting from a pool of doctors who are able to earn less from Medicare benefits than previous recruits, requiring a proportionally greater contribution of resources by the private hospitals. The Australian Private Hospitals Association has claimed that this increased cost makes it difficult for private hospitals to recruit sufficient staff for accident and emergency work.
There may thus be a loss of income suffered by private hospitals with emergency departments as a result of inability to provide service to potential clients. This is because 27% of private hospital bed occupancy is generated through private accident and emergency departments.
If the government accepts Option 1 this may affect the sustainability of some private hospital emergency department services in the medium term. This would be as a result of the inability to recruit medical practitioners who are able to provide professional services that attract a Medicare rebate to staff private hospital emergency departments.
The private hospital sector would thus have to cope with the current workforce shortage of emergency medicine specialists until such time as it establishes its own ACEM training places in greater numbers, or until sufficient numbers of doctors graduate from the ACEM training program and become able to access MBS items for private hospital emergency department services. However, as more emergency specialists graduate from the ACEM training program, they will have access to MBS for professional services that they provide in private hospital emergency department services.
(d) Public hospitals
Cost to the public hospital system would be in terms of overworked staff and the difficulties in meeting the demand for accident and emergency services.
(e) The Commonwealth
No action from the Commonwealth would result in continued shortages of staff in private hospital emergency departments.
Benefits of Option 1
There are no discernable benefits, either social or financial, to the community in general, trainees of the ACEM or hospitals with emergency departments both private and public.
The Commonwealth could benefit financially as doctors who are subject to restrictions under section 19AA of the Act would not access MBS items for services performed in private accident and emergency departments. This option could also be seen to maintain the strong incentive to complete postgraduate training in section 19AA because trainees would be confined to working within their training placements.
Cost of Option 2
(a) Community
Nil. Those who elect to be treated in a private accident and emergency department generally do so of their own volition based on their holding appropriate private health insurance to cover the costs of admission and emergency treatment.
(b) Trainees of the ACEM
Costs to trainees would be measured in terms of time expended. There are no discernable financial costs.
(c) Private hospitals with emergency departments
There would additional costs to private hospital emergency departments should they choose to upgrade their facilities to comply with the standards required by the ACEM for an accident and emergency department to be eligible for this program.
Once a private hospital emergency department has reached this standard it will need to seek approval from the Department of Health and Aged Care so that medical practitioners working at the hospital can be placed on the Register of Approved Placements.
(d) Public hospitals
There are no discernable costs to public hospitals
(e) The Commonwealth
The ACEM commissioned a relative value study which found that the average cost per patient for treatment in an accident and emergency department is $211. The cost to the Commonwealth therefore could be estimated as the proportion of the $211 per patient that each patient is able to claim from MBS multiplied by the number of patients treated by a trainee. However, if patients were not being treated at private emergency departments they would have to be treated at public hospitals. This would offset the identified costs noted above as the Commonwealth provides the States with funding for the public hospital system through the Australian Health Care Agreements.
There would be a small staff cost to the Commonwealth arising from its monitoring the program to ensure that arrangements do not impact adversely on the supply of junior medical staff in public hospitals and monitoring the use of Medicare provider numbers to ensure that they are used only for services performed in private hospital emergency departments.
Benefits of Option 2
(a) Community
Option 2 would be of benefit to the community in general as patients would have greater choice of, and access to, accident and emergency services.
(b) Trainees
Trainees would benefit from working in private hospital emergency departments due to the opportunity to work more closely with other specialists in the hospital.
The opportunity to perform part-time work in the private sector would form an important income supplement.
(c) Private hospitals with accident and emergency departments
The hospitals would gain access to a pool of medical practitioners who would be able to provide professional services that attract a Medicare benefit. These medical practitioners would also be in the process of improving their qualifications and so would eventually become eligible to work long term in the private hospital as qualified ACEM specialists.
(d) Public hospitals
This option is likely to alleviate some of the demands on public hospital accident emergency departments as holders of private health insurance would be better able to access private equivalents.
(e) Commonwealth
Finally, the Commonwealth will benefit in terms of better fulfilling the objective of delivery of quality health care to the community.
CONSULTATION
Senator Meg Lees initially raised the issue of the shortage of doctors in private hospital emergency departments in debate in Parliament concerning retention of the sunset clause in section 19AA of the Act.
As a result of Senator Lees' disclosure and recommendations made by the Midterm Review of the Provider Number Legislation in December 1999, extensive consultation took place between the Department of Health and Aged Care, the ACEM and the Australian Private Hospitals Association. Other interested organisations such as the Private Health Industry, the Health Insurance Commission and the Australian Medical Association were also consulted.
All organisations were supportive of Option 2
CONCLUSION AND RECOMMENDED OPTION
Option 1 would not improve access to medical services across the country and could indirectly reduce the options available to holders of private health insurance. It is therefore not recommended.
Option 2, the preferred option, would enhance the sustainability of private hospital emergency departments that are bona fide facilities. These hospitals are delivering quality services and are able to adequately supervise medical practitioners so as to ensure that the quality objectives of section 19AA of the Act are not undermined.
This option is consistent with an increasing role for the Commonwealth in ensuring that the quality of health services is maintained and delivered through the MBS.
It should be noted that it is difficult to estimate an accurate cost of the APED program to Medicare is difficult to estimate. There are currently 28 bona-fide private emergency departments in Australia which could potentially participate on the program. However, at the present time there is only one private hospital emergency department able to meet the guidelines criteria for this program. Additionally, approximately 120-150 accident and emergency trainees commence each year. These trainees need first to reach an advanced level of training to be eligible to participate on the program. It is unknown how many will want to supplement their income by participating in the program.
IMPLEMENTATION AND REVIEW
The program in Option 2, for advanced trainees of the ACEM in private hospital emergency departments, may only be justified while emergency medicine specialists are in short supply.
Option 2 will take 2 weeks to be fully operational.
Option 2 is administratively simple because the Department of Health and Aged Care is able to identify the trainees through the Health Insurance Commission computer system. Additionally, the ACEM will monitor the accident and emergency departments and assess trainee qualifications.
Option 2 will be monitored as section 19AD of the Act provides that the Minister must table a report in Parliament on the details of the operation of sections 19AA, 3GA and 3GC on a biannual basis, commencing from 31 December 2001. This will require a review of the operation of each of the programs established under section 3GA of the Act.