L/O/G/O Medicare: What’s New, and Using the MBS for Chronic Illness Care Peter Larter Larter Consulting

Tonight… MBS Changes Medicare Compliance Program MBS for chronic illness care 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 Ggggggggggggg gggggggggggggg gggggggggggggg gggggggggggggg ggggggggggg ggg

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 not eligible, though those in Bacchus Marsh are Ggggggggggggg gggggggggggggg gggggggggggggg gggggggggggggg ggggggggggg ggg

Changes to telehealth eligibility gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg

1(b). New telehealth “minimum distance” criterion The patient and the specialist must be at least 15km apart. Ggggggggggggg gggggggggggggg gggggggggggggg gggggggggggggg ggggggggggg ggg

15km radius from Ballarat Health Services

1(c). Telehealth “on board” incentive will be paid in 2 instalments The 1 st incentive is paid after the 1 st telehealth MBS claim; the 2 nd is paid after the 10 th telehealth MBS claim Ggggggggggggg gggggggggggggg gggggggggggggg gggggggggggggg ggggggggggg ggg Incentive First Telehealth On-Board instalment $1,600$1,300 Second Telehealth On-Board instalment $3,200$2,600 Total On-Board Incentive$4,800$3,900 The first is paid after the first valid telehealth MBS claim is processed by the Department of Human Services (DHS) and the second is paid after the tenth valid telehealth MBS claim is processed by DHS (see below table).

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. Ggggggggggggg gggggggggggggg gggggggggggggg gggggggggggggg ggggggggggg ggg

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 continue. Ggggggggggggg gggggggggggggg gggggggggggggg gggggggggggggg ggggggggggg ggg

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 Incentive, from 40% to 50% of eligible diabetics Ggggggggggggg gggggggggggggg gggggggggggggg gggggggggggggg ggggggggggg ggg

MEDICARE COMPLIANCE PROGRAM

Medicare Compliance Philosophy Ggggggggggggg gggggggggggggg gggggggggggggg gggggggggggggg ggggggggggg ggg

Medicare Compliance priorities Chronic disease management items: referring ineligible patients for subsidised allied/dental health Ggggggggggggg gggggggggggggg gggggggggggggg gggggggggggggg ggggggggggg ggg 2.Analysing claiming patterns of allied health providers re non-compliance 3.Bulk bill incentive items – ensuring patients are eligible

Medicare Compliance priorities Ensuring practices remain eligible for programs against which they are claiming payments  GPII  Practice Nurse Incentive Program  Mental Health Nurse Incentive Program  PIP (generally)  General Practice Rural Incentives Program Ggggggggggggg gggggggggggggg gggggggggggggg gggggggggggggg ggggggggggg ggg

MBS FOR CHRONIC ILLNESS CARE

MBS for chronic illness care Funding Prevention: support Diabetes Life! PNIP – nurse support Prevention: MBS Standard consult MBS Health checks – at risk of chronic disease Health checks - a specific population Care: support Health management coaching PNIP – nurse support Cycle of care: SIPs & SOPs Care: MBS Standard consult MBS Care plans Case conferencing Allied health Nurse follow up

GP-led, MBS-funded care planning in the community setting gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg 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)  Review of either (#732)  GP contribution to another provider’s care plan (#729)

Care planning gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg NameItemMedicare Fee (100%) Recomm- ended Frequency Minimum Claiming period GPMPs721$ yearly12 Months TCAs723$ yearly12 Months Review a GPMP Or Coordinate a Review of TCAs / Multidisciplinary Community Care Plan/ Multidisciplinary Discharge Plan 732$ monthly 3 months Contribution to or review of another provider’s care plan 729$ months Contribution to a care plan in residential aged care facility 731$ months

gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg ggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg 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? ‘ Living in the community’ – what does this mean specifically?

TCAs: patient eligibility gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg Patient is living in the community, with a chronic or terminal medical condition and complex care needs What is meant by ‘complex care needs’?

TCAs: Who can be one of the providers? gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg 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? 2 nd GP? Specialist? (only one) Myofascial therapist? Massage therapist? Naturopath?

Allied health MBS rebates following a GPMP+TCA gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg 5 allied health services per patient per calendar year Patient with chronic disease & complex care 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 Occupational therapist#10958 Physiotherapist#10960 Podiatrist or Chiropodist#10962 Chiropractor#10964 Osteopath#10966 Psychologist#10968 Speech pathologist#10970 $52.95

MBS allied health items: the rules gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg 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? In the next calendar year, does the patient need a new referral? Does a care plan review have to be done?

Practice nurse monitoring and support funded through #10997 gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg Follow up services for patients on a care plan, 5 per calendar year (#10997) Checks on clinical progress Medication compliance Self management advice Collect information to inform reviews

gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg 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 practitioner (and a maximum of 2)

When is a care plan sufficiently comprehensive? gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg 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) Treatment/services to be provided and arrangements for the patient Actions to be taken by the patient Review date

Care plans: what could be audited? gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg 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 Keeping records: care plan in patient file, reason for plan, review date

45-49 year old health check gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg

L/O/G/O Thanks © Larter Consulting, All rights reserved.