Medicare: What’s New, and
Using the MBS for Chronic
Illness Care
Peter Larter
Larter Consulting
L/O/G/O
Tonight…
1
MBS Changes
2 Medicare Compliance Program
3 MBS for chronic illness care
4
Questions/conclusion
RECENT CHANGES
TO THE MBS
Telehealth & Medicare
• Medicare will pay benefits for medical
specialists providing consultations via
video conferencing to patients
• At the patient end, Medicare will also
pay benefits for GPs or practice nurses
supporting the patient during their
consultation with a specialist
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1(a). Changes to telehealth
eligibility from 1 January 2013
• Only patients outside RA1 or in a
residential aged care facility or in an
Aboriginal Medical Service / ACCHO will
be able to attract MBS benefits for
telehealth consultations with specialists
• This means that people living in the
community in Melton are now Ggggggggggggg
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not eligible, though those in
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Bacchus Marsh are
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Changes to telehealth eligibility
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1(b). New telehealth “minimum
distance” criterion
• The patient and the specialist must be
at least 15km apart.
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15km radius from Ballarat Health Services
1(c). Telehealth “on board” incentive
will be paid in 2 instalments
The first is paid after the first valid telehealth MBS claim is processed by the Department of Human Services (DHS) and
• The 1st incentive is paid after the 1st
telehealth MBS claim; the 2nd is paid
after the 10th telehealth MBS claim
Incentive
2012-13 2013-14
First Telehealth On-Board
instalment
$1,600
$1,300
Second Telehealth On-Board
instalment
$3,200
Total On-Board Incentive
$4,800
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2. Using MBS for the PCHER
• MBS items are available for use in the
creation of shared health summaries
and event summaries
 ITEMS B, C and D (e.g. #23, #36, #44)
• Health professionals will only have to
consider the reasonable time it would
take — not the complexity of the
consultation.
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3. Change to immunisation payments
• General practice immunisation incentive
will end after May 2013 payment
• Australian Childhood Immunisation
Register’s (ACIR) payment to
immunisation providers who administer
and notify the ACIR of a vaccination
that completes one of the age-based
immunisation schedules for a child will
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continue.
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4. Other PIP payments
• General practices required to participate
in the Personally Controlled Electronic
Health Record system to receive the
eHealth PIP incentive from 1 May
• Increased targets for PIP Cervical
Screening Incentive, from 65 % to 70
%of eligible female patients
• Increased targets for PIP Diabetes
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Incentive, from 40% to 50%
of
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eligible diabetics
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MEDICARE COMPLIANCE
PROGRAM 2012-13
Medicare Compliance Philosophy
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Medicare Compliance priorities 2012-13
1. Chronic disease management items:
referring ineligible patients for
subsidised allied/dental health
2. Analysing claiming patterns of allied
health providers re non-compliance
3. Bulk bill incentive items – ensuring
patients are eligible
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Medicare Compliance priorities 2012-13
4. Ensuring practices remain eligible for
programs against which they are
claiming payments
 GPII
 Practice Nurse Incentive Program
 Mental Health Nurse Incentive Program
 PIP (generally)
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Program
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MBS FOR CHRONIC
ILLNESS CARE
MBS for chronic illness care
Prevention: MBS
Care: MBS
• Standard consult MBS
• Health checks – at risk
of chronic disease
• Health checks - a
specific population
• Standard consult MBS
• Care plans
• Case conferencing
• Allied health
• Nurse follow up
Funding
Prevention: support
• Diabetes Life!
• PNIP – nurse support
Care: support
• Health management
coaching
• PNIP – nurse support
• Cycle of care: SIPs &
SOPs
GP-led, MBS-funded care planning
in the community setting
• Patients who would benefit from a
structured approach to chronic disease
care
GP-patient only: GP Management Plans
(GPMPs) (#721)
Multidisciplinary: Team Care
Arrangements (TCAs) (#723)
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Review of either (#732)
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GP
contribution
to
another
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provider’s care plan (#729)
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Care planning
Name
GPMPs
TCAs
Review a GPMP
Or Coordinate a Review
of TCAs/ Multidisciplinary
Item
721
723
732
Medicare
Fee
(100%)
$141.40
$112.05
$70.65
Recommended
Frequency
2 yearly
2 yearly
Minimum
Claiming
period
12 Month
12 Month
6 monthly 3 months
Community Care Plan/
Multidisciplinary Discharge Plan
Contribution to or
729 $70.65
3 months
review of another
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provider’s
care plan
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Contribution
to a care 731 $70.65
3 months
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plan
in residential aged
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care facility
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GPMPs: patient eligibility
Patient is living in the community, with a
chronic or terminal medical condition
• What is meant by a ‘chronic or terminal
medical condition’?
Alcohol /other substance abuse problems?
Unspecified chronic pain?
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• ‘Living in the community’ – what does this
mean specifically?
TCAs: patient eligibility
Patient is living in the community, with a
chronic or terminal medical condition and
complex care needs
• What is meant by ‘complex care needs’?
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TCAs: Who can be one of the
providers?
Any provider who is contributing to the care of
the patient in relation to their chronic/terminal
condition, each of whom must provide a
different kind of ongoing care
Diabetes educator at Hepburn Heath Service
who is not registered with Medicare?
‘Meals on Wheels’ provider?
Optometrist? Pharmacist? 2nd GP?
Specialist? (only one)
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Myofascial therapist?
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Massage therapist?
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Naturopath?
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Allied health MBS rebates
following a GPMP+TCA
5 allied health services per Patient with chronic
disease & complex care
patient per calendar year
needs on MBS Care Plan
Current Medicare
rebate (85% of
schedule fee)
Aboriginal health worker #10950
Diabetes educator
#10951
Audiologist
#10952
Exercise physiologist
#10953
Dietician
#10954
Mental health worker
#10956
$52.95
Occupational therapist
#10958
Physiotherapist
#10960
Podiatrist or Chiropodist #10962
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Chiropractor
#10964
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Osteopath
#10966
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Psychologist
#10968
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Speech
pathologist
#10970
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MBS allied health items: the rules
• 5 services per calendar year…
Do the services ‘roll over’ to the next
calendar year?
 What are the reporting requirements
to the GP?
 Can the patient also use hospital
allied health, and/or private
allied health?
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 In the next calendar year,
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does the patient need a new
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referral? Does a care plan review
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have to be done?
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
Practice nurse monitoring and
support funded through #10997
• Follow up services for patients
on a care plan, 5 per calendar
year (#10997)
•
•
•
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Checks on clinical progress
Medication compliance
Self management advice
Collect information to inform
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reviews
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When is a TCA ‘appropriate’?
•
Chronic illness, ‘complex care needs’
•
requires ongoing care from at least 3
collaborating health or care
professionals
• each of whom provide a different kind of
ongoing service
• must include at least one medical
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practitioner (and a maximum of 2)
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When is a care plan sufficiently
comprehensive?
•
Not all care plans look the same
• Clearly linked to the patient’s chronic
condition
• Not just medical goals, but
personal/patient-centred goals
• Key elements
•
Patient needs/conditions
•
Treatment goals (medical and personal)
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•
Treatment/services to be provided and arrangements for
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the patient
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•
Actions to be taken by the patient
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•
Review date
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Care plans: what could be audited?
• Patient eligibility for the service
• Patient consent for service (or guardian/carer)
• Appropriateness of the plan, in accordance
with patient need
• GP must have consulted with patient and
agreed on care plan (not just nurse)
• Other providers in TCA: # of
providers, communication & input
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• Keeping records: care plan in
patient file, reason for plan, review date
45-49 year old health check
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Thanks
L/O/G/O
© Larter Consulting, 2013.
All rights reserved.