Services to the community-Health

The department supports individuals, families and communities to achieve greater self-sufficiency by providing access to a range of payments and services.

This includes payments to support retirees, the unemployed, families, carers, parents, students, people with disabilities and Indigenous Australians.

Medicare

Medicare is Australia’s universal health care system, which gives eligible people access to cost-effective medical and hospital care, optometry and, in special circumstances, other allied health services.

In 2014-15, 24.2 million people were enrolled in Medicare and $20.5 billion was paid in benefits. Almost 95% of claims were made electronically. Around one-third of all health practices lodged all Medicare claims electronically—see Figure 4 and Figure 5 on page 33.

Eligibility overview

To be eligible for Medicare a person must reside in Australia and be one of the following:

  • an Australian citizen
  • a permanent resident or a New Zealand citizen residing in Australia
  • an applicant for permanent residency, meeting certain other criteria—restrictions and other requirements apply to people who have applied for a parent visa
  • covered by a ministerial order
  • a resident or citizen of a country with which Australia has a reciprocal health care agreement—only for medically necessary treatment while visiting Australia
Table 7: Medicare enrolments
  2012-13 2013-14 2014-15 % change since
2013-14
People enrolled at 30 June 23.4 million 23.8 million 24.2 million +1.5
Active cards at 30 June 13.3 million 13.5 million 13.7 million +1.6
New enrolments 618,533 603,070 581,922 -3.5

Medicare Entitlement Statements

People who are not eligible for Medicare may apply to be exempt from paying the Medicare levy, which is administered by the Australian Taxation Office (ATO). If the application is approved, the department issues a Medicare Entitlement Statement (previously referred to as the Medicare Levy Exemption Certificate), which the person must lodge at the ATO with their tax return.

Table 8: Medicare Entitlement Statements
  2012-13 2013-14 2014-15 % change since
2013-14
Accepted applications 95,190 134,813 141,625 +5.1
Rejected applications 4,148 6,044 3,699 -38.8
Total applications 99,338 140,857 145,324 +3.2

Medicare Safety Net

The Medicare Safety Net helps eligible people with the cost of out-of-hospital medical services. There are two Medicare safety nets—the Original Medicare Safety Net and the Extended Medicare Safety Net.

The Original Medicare Safety Net applies to all Medicare cardholders and has a threshold of $440.80 (singles and families) for 2015. This is based on the gap amount, which is the difference between the Medicare Benefits Schedule (MBS) fee that the government has set for the service and the Medicare benefit.

The Extended Medicare Safety Net has two threshold levels—$638.40 for Commonwealth concession card holders and FTB Part A recipients, and a general threshold of $2,000 for all Medicare cardholders (singles and registered families). This threshold is based on out-of-pocket costs, which is the difference between the doctor’s charge and the Medicare benefit.

It is possible for singles and families to reach the threshold for either or both the Original Medicare Safety Net and the Extended Medicare Safety Net in a calendar year. The thresholds apply to a calendar year and are indexed.

Medicare claiming

Health professionals can choose to bulk bill their patients. This means that the health professional claims the Medicare benefit directly from the department with the patient’s permission as full payment for the service, and does not charge the patient a fee.

If a health professional charges the patient a fee, the patient can claim by:

  • paying the account, and then, if the health professional or practice offers electronic claiming, practice staff can lodge the claim electronically with the department and the benefit will be paid into the patient’s bank account, usually on the next working day or sometimes sooner
  • paying the account and then claiming the benefit from the department either in person at a service centre, using the Express Plus Medicare mobile app, online, myGov or by phone or mail
  • claiming the unpaid account from the department and receiving a cheque made out in the health professional’s name to give to the health professional along with any outstanding balance

Claims for in-hospital services received by patients can be made through simplified billing arrangements. This means claims are lodged by hospitals, billing agents, health professionals and day surgeries with the department and private health insurers, either through the Electronic Claim Lodgement Information Processing Service Environment (ECLIPSE), Simple Mail Transfer Protocol (SMTP) systems, or manually.

Table 9: Medicare services and benefits by claim type
  2012-13 2013-14 2014-15 % change since
2013-14
Bulk billing 263.0 million 276.8 million 290.6 million +5.0
Patient claiming 55.1 million 53.9 million 53.3 million -1.1
Simplified billing 25.8 million 27.5 million 29.6 million +7.6
Total services processed 344.0 million 358.3 million 373.4 million +4.2
Bulk billing $12.4 billion $13.0 billion $14.0 billion +7.7
Patient claiming $4.2 billion $4.2 billion $4.2 billion 0
Simplified billing $2.0 billion $2.1 billion $2.3 billion +9.5
Total benefits paid $18.6 billion $19.3 billion $20.5 billion +6.3
Average benefit per service $54.15 $53.82 $54.90 +2.0
Average period1 (date of lodgement to processing) 2.6 days 1.9 days 1.7 days -10.5

1. Due to the number of electronic claiming channels available, the gap between date of lodgement and the date of processing has reduced.

Table 10: Medicare services by payment type
  2012-13 million % 2013-14 million % 2014-15 million %
Cash to claimant1 1.7 0.5 0.0 0.0 0.0 0.0
Cheque to claimant 3.4 1.0 3.3 0.9 3.0 0.8
Electronic funds transfer (EFT) to claimant 34.4 10.0 36.6 10.2 35.6 9.5
EFTPOS payment to claimant 9.3 2.7 8.6 2.4 9.8 2.6
Cheque to health professional2 1.6 0.5 0.0 0.0 0.0 0.0
EFT to health professional 261.4 76.0 276.8 77.3 290.6 77.8
Pay doctor via claimant cheque 6.4 1.9 5.4 1.5 4.8 1.3
Payment to private health fund or billing agent 25.8 7.5 27.5 7.7 29.6 7.9
Total services3 344.0 100 358.3 100 373.4 100

1. Cash payments were phased out from 1 July 2012.

2. Payments by cheque to health professionals for bulk billing services ceased on 1 November 2012.

3. Numbers may differ due to rounding.

Medicare electronic claiming

The six options for lodging Medicare claims electronically are:

  • Medicare Online—a secure internet connection for lodging claims from a health practice using practice management software
  • Medicare Easyclaim—a secure EFTPOS terminal (stand-alone or integrated with practice management software) for lodging claims from a health practice
  • ECLIPSE—a secure connection for claiming services provided in hospitals used by providers, public and private hospitals, billing agents and private health insurers
  • Claiming Medicare Benefits Online—through myGov or through the Express Plus Medicare mobile app for 23 of the most common MBS items. The app also allows patients to lodge claims electronically for other items if an image of the receipt is uploaded with the claim
  • SMTP—uses an electronic format similar to email for claiming bulk billing and simplified billing services
  • Health Professional Online Services (HPOS)—provides secure access for health professionals to bulk bill Medicare directly for any medical and some allied health services received by the patient-see also Online services for health professionals on page 160

Most health practitioners lodge bulk bill claims electronically, benefiting from streamlined processing and improved cash flow. At 30 June 2015, 98% of bulk bill claims were lodged electronically compared to 97.5% at 30 June 2014.

Figure 4: Medicare services by claim type electronic and manual

Figure 4: Medicare services by claim type—electronic and manual

Figure 5: Practices transmitting electronically 2012-13 to 2014-15

Figure 5: Practices transmitting electronically 2012–13 to 2014–15

Table 11: Volumes of services transmitted electronically
  2012-13 2013-14 2014-15 % change since
2013-14
Medicare Online
Bulk billing 234.5 million 253.5 million 265.4 million +4.7
Patient claiming 21.7 million 27.5 million 30 million +9.1
Medicare Easyclaim
Bulk billing 17.3 million 16.3 million 19.1 million +17.2
Patient claiming 7.7 million 8.3 million 10 million +20.5
ECLIPSE
Simplified billing 16.9 million 19.2 million 21.9 million +14.1
SMTP
Bulk billing 154,500 141,500 74,500 -47.3
Simplified billing 8.8 million 8.2 million 7.5 million -8.5
Claiming Medicare Benefits Online
Patient claiming 211,200 251,500 352,400 +40.5
Total services 307.2 million 333.5 million 354.4 million +6.3
Percentage of overall claims lodged electronically 89.3 93.1 94.9 +1.8

Veterans’ Affairs processing

In collaboration with DVA the department assesses claims and makes payments to medical, hospital and allied health professionals who treat eligible veterans, spouses and dependants. The department also produces DVA gold cards (for Personal Treatment Entitlement or Totally and Permanently Incapacitated and all conditions within Australia), white cards (for specific conditions) and orange cards (for pharmaceuticals) for eligible veterans.

The department and DVA continue to promote electronic claiming as the primary way of doing business with government. For health professionals, electronic claiming means faster payment times, paperless lodgement of claims, faster reconciliation and more efficient confirmation of patient details. It also means lower administrative costs for DVA.

DVA electronic claiming increased to 79.3% in 2014-15 compared to 74.3% in 2013-14. Electronic claiming for allied health services increased to 46.4% in 2014-15 compared to 28.4% in 2013-14, largely due to the introduction of DVA Webclaim for allied health professionals in September 2014.

Electronic claiming for medical services increased to 90.7% in 2014-15 compared to 89.8% in 2013-14. This is expected to increase further with the introduction of DVA Webclaim for medical professionals in July 2015.

Hospital electronic claiming increased to 70.8% from 64.1% in 2013-14. Manual claiming for DVA decreased from 25.7% in 2013-14 to 19.7% in 2014-15.

Table 12: Department of Veterans’ Affairs processing
  2012-13 2013-14 2014-15 % change since
2013-14
Cards produced1 19,334 248,3752 20,146 -91.9
Services processed 20.6 million 19.9 million 19.0 million -4.5
Total benefits paid $2.1 billion $2.2 billion $2.1 billion -4.5

1. Personal Treatment Entitlement cards, Repatriation Pharmaceutical Benefits Scheme cards, Specific Treatment Entitlement cards, and Totally and Permanently Incapacitated gold cards.

2. This number is considerably higher than other years due to a re-issue of new cards to all DVA cardholders.

Australian Childhood Immunisation Register

The Australian Childhood Immunisation Register records information about vaccinations given to children aged under seven years.

Authorised immunisation providers and the child’s parent or guardian can access vaccination records. These records also assist with determining eligibility for various family assistance payments. Parents and guardians can also obtain immunisation history statements for their children. They can be used as proof of immunisation for enrolment in school or child care.

Table 13: Australian Childhood Immunisation Register1
  2012-13 2013-14 2014-15 % change since
2013-14
Valid immunisation episodes recorded at 30 June 5.0 million 4. 7 million 4.8 million +0.8
Children aged under seven years registered at 30 June 2.2 million 2.2 million 2.2 million +0.6
Total amount paid to immunisation providers2 $9.2 million $9.3 million $9.7 million +4.3
Percentage of children registered with appropriate immunisation coverage at 30 June
Children aged 12-15 months 90.4 90.9 92.1 +1.2
Children aged 24-27 months 92.1 92.6 89.0 -3.6
Children aged 60-63 months 91.8 91.9 92.3 +0.4

1. Figures in the table may be rounded to the nearest decimal point.

2. Payments are made when a health professional notifies the department that they have completed an age-based immunisation schedule for a child. Each schedule includes a list of vaccinations needed against a number of diseases. Therefore the payment amount to health professionals does not reflect the number of valid immunisation episodes in a year.

Australian Organ Donor Register

The Australian Organ Donor Register is the national register for people to record their decision about becoming an organ and/or tissue donor for transplantation after death.

The register enables authorised medical personnel to verify a person’s decision about donating their organs and/or tissue for transplantation. People can register their donation decision online on the Australian Organ Donor Register’s website, which also provides general information about organ and tissue donation for transplantation.

Table 14: Australian Organ Donor Register
  2012-13 2013-14 2014-15 % change since
2013-14
Consent registrations (including registrations of people aged between 16-17 years)1 at 30 June 1,679 340 1,762,648 1,833,085 +3.9
Intent registrations2 at 30 June 4,264 242 4,258,713 4,276,626 +0.4
Total registrations 5,943 582 6,021,361 6,109,711 +1.5
Serviced calls to enquiry line 22,330 18,652 17,998 -3.5

1. A legally valid consent registration occurs when someone provides a signed registration form to the Australian Organ Donor Register.

2. Intent registrations occur when people electronically register their decision to donate.

Supporting Leave for Living Organ Donors

The Supporting Leave for Living Organ Donors Scheme was a two-year pilot which provided a payment equivalent to the national minimum wage, for up to six weeks, to employers of people wanting to donate a kidney or partial liver. The scheme’s aim was to help reduce the financial stress associated with living organ donation and to raise employer awareness of organ donation. The Australian Government announced on 12 May 2015 that the scheme would continue for a further two years, from 1 July 2015 to 30 June 2017.

Table 15: Supporting Leave for Living Organ Donors Scheme
  2013-14 2014-15 % change since
2013-14
Number of claims processed 65 112 +72.3
Total amount paid $188,478 $356,292 +89

External Breast Prostheses Reimbursement Program

Under the External Breast Prostheses Reimbursement Program, women who have had a mastectomy as a result of breast cancer are reimbursed up to $400 for each new and replacement external breast prosthesis. Women can make a claim for new or replacement prostheses every two years.

Table 16: External Breast Prostheses Reimbursement Program
  2012-13 2013-14 2014-15 % change since
2013-14
Number of claims processed 14,591 16,078 15,200 -5.4
Total amount paid $5.9 million $6.4 million $6.1 million -4.7

National Bowel Cancer Screening Program

The National Bowel Cancer Screening Program aims to reduce the rate of bowel cancer and associated mortality.

As part of the 2014-15 Budget, the government announced the bringing forward of biennial screening for bowel cancer. All Australians aged 50 to 74 years will be invited to participate. The phased introduction commenced on 1 January 2015 and will be fully implemented in 2020. The department’s role is to:

  • identify and invite eligible people to participate
  • make payments to medical professionals for providing information to the register about consultations and medical procedures for programme participants who have received positive test results
  • operate the information phone line for the general public and health professionals

In 2014-15 the department invited eligible people who turned 50, 55, 60, 65, 70 and 74 years in 2015 to undertake screening.

Table 17: National Bowel Cancer Screening Program
  2012-13 2013-14 2014-15 % change since
2013-14
Invitations distributed 969,749 1,426,814 1,331,711 -6.6
Information line calls received 105,443 100,591 159,967 +59.02

Continence Aids Payment Scheme

The Continence Aids Payment Scheme gives eligible people with severe and permanent incontinence yearly or twice-yearly payments to help them buy continence aids products.

Table 18: Continence Aids Payment Scheme
  2012-13 2013-14 2014-15 % change since
2013-14
Number of applications processed 31,837 31,776 30,212 -4.9
Total amount paid $62.0 million $66.8 million $74.1 million +10.9

Child Dental Benefits Schedule

The Child Dental Benefits Schedule provides financial support for basic dental services for eligible children. Services include examinations, x-rays, cleaning, fissure sealing, fillings, root canals and extractions.

To be eligible a child must be aged between 2 and 17 years, be eligible for Medicare, and they, or their family, guardian or carer receives a relevant Australian Government payment, such as FTB Part A, at any time in the calendar year.

In 2014 and 2015 benefits for basic dental services are capped at $1,000 per child over two consecutive calendar years.

In 2014-15, the first full year after the schedule’s introduction, the department processed 4.9 million services and paid $311.2 million in benefits.

Private Health Insurance Rebate

The rebate on private health insurance reimburses or discounts the cost of private health insurance cover. It is available to all people who are eligible for Medicare and have a complying health insurance policy.

The rebate is income-tested. The level of rebate that people are entitled to claim depends on their age and income. From 1 July 2015 income thresholds were paused for three years to 1 July 2018.

In 2014-15 the rebate could be claimed in one of two ways:

  • an upfront reduction in the cost of premiums—the Premiums Reduction Scheme (administered by the department)
  • a tax offset in annual income tax returns (administered by the ATO)
Table 19: Private Health Insurance Rebate
  2012-13 2013-14 2014-15 % change since
2013-14
Memberships registered 6.5 million 6.6 million 6.9 million +4.5
Total paid to private health funds $5.2 billion $5.6 billion $5.8 billion +3.6

Hearing Services Program

The Australian Government provides hearing services to people who are determined to be eligible by the Office of Hearing Services within the Department of Health. The department processes claims and pays claims via the eClaim facility to accredited hearing service contractors for the Hearing Services Program. The department administers the programme on behalf of the Department of Health.

Table 20: Hearing Services Program services and payments
  2012-13 2013-14 2014-15 % change since
2013-14
Services processed1 1,236,515 1,265,890 1,320,763 +4.3
Total amount paid2 $312.7 million $337.0 million $378.0 million +12.2

1. Services provided to individuals.

2. Payments made to hearing service contractors.

Medicare Compensation Recovery

Medicare Compensation Recovery aims to prevent double claiming when a person receives a lump sum compensation payment of more than $5,000. If the person had received any Medicare benefits, or nursing home or residential care government subsidies because of their injury, they may have to pay the costs of these back to the Australian Government before they get their compensation payment.

Table 21: Medicare Compensation Recovery
  2012-13 2013-14 2014-15 % change since
2013-14
Cases finalised 40,463 52,678 50,268 -4.6
Total amount of benefits recovered $64.5 million $51.4 million $48.5 million -6.0

Practice Incentives Programme

The Practice Incentives Programme (PIP) consists of 10 incentives—see Table 22 below. The incentives are paid to medical practices and individual providers to encourage improvements to general practice—see Table 23 on page 42 for data on practice participation in the programme.

Table 22: Practice Incentives Programme payments
Aged care access Service Incentive Payments (SIPs) to GPs encourage increased and continuing services in Australian Government funded residential aged care facilities.
Asthma Sign-on payments to practices encourage GPs to better manage the clinical care of people with moderate to severe asthma. SIPs are available to GPs for each asthma cycle of care completed for a patient with moderate to severe asthma.
Cervical screening Sign-on and outcomes payments to practices encourage GPs to screen women who have not had a cervical smear in the past four years, increasing overall screening rates. SIPs are available to GPs for each cervical smear taken on a woman aged between 20 and 69 years who has not had a cervical smear in the past four years.
Diabetes Sign-on and outcomes payments to practices encourage GPs to provide earlier diagnosis and effective management of people with established diabetes mellitus. SIPs are available to GPs for completing an annual diabetes cycle of care.
eHealth Incentive payments encourage practices to adopt new eHealth technology as it becomes available, to improve administration processes and the quality of care provided to patients.
Indigenous health Payments to practices encourage GPs to provide better health care for Aboriginal and Torres Strait Islander patients, including best practice management of chronic disease.
Procedural GP payment Incentive payments to practices encourage rural GPs to provide procedural services.
Quality prescribing Payments to practices encourage GPs to keep up to date with information on the quality use of medicines by taking part in activities recognised or provided by the National Prescribing Service.
Rural loading A rural loading is applied to the PIP payments of practices where the main location is outside a major metropolitan area.
Teaching Incentive payments to practices encourage GPs to provide teaching sessions to undergraduate medical students, to ensure the practitioners of tomorrow are appropriately trained and have actual experience of general practice.
Table 23: Practice participation in the Practice Incentives Programme
  2012-13 2013-14 2014-15 % change since
2013-14
Total number of practices participating 5,189 5,250 5,392 +2.7
Practices registered per incentive1
Asthma 3,136 3,346 3,575 +6.8
Cervical screening 3,220 3,418 3,637 +6.4
Diabetes 3,209 3,410 3,632 +6.5
eHealth 4,012 4,618 4,876 +5.6
Indigenous health 3,417 3,763 4,041 +7.4
Practices receiving outcomes payments2
Procedural GP3 360 375 373 -0.5
Cervical screening 1,017 516 484 -6.2
Diabetes 2,437 1,001 1,091 +9.0
Indigenous health 4,356 5,086 5,691 +11.9
Other information
Indigenous health incentive patient registration payments 54,944 62,266 64,780 +4.0
Teaching session payments 196,494 230,662 211,196 -8.4
Service incentive payments4 (asthma, cervical, diabetes, aged care access incentive) 57,824 62,978 67,555 +7.3
Total amount paid at 30 June $279.6 million $218.6 million $228.1 million +4.3

1. Practices are automatically registered for the teaching, rural loading and quality prescribing incentives when approved for the programme.

2. Outcome payments are made to practices that have reached the target level required to receive the incentive under the programme. For the cervical screening and diabetes incentives, this is the number of practices that received an outcomes payment in the May quarter. For the Indigenous health incentive, this is the total number of outcomes payments.

3. This is the number of practices that received a procedural GP payment.

4. This is the total number of service incentive payments which includes the asthma incentive, cervical screening incentive, diabetes incentive and the general practitioner aged care access incentive.

Practice Nurse Incentive Program

The Practice Nurse Incentive Program provides incentive payments to practices that support an expanded role for nurses working in general practice.

General practices across Australia, including those in urban areas, as well as Aboriginal Medical Services and Aboriginal Community Controlled Health Services, may be eligible for an incentive to help with the costs of employing a practice nurse. To be eligible, the practice must be accredited under the current Royal Australian College of General Practitioners Standards for general practices.

Table 24: Practice Nurse Incentive Program
  2012-13 2013-14 2014-15 % change since
2013-14
Practices approved 3,994 4,252 4,338 +4.3
Payments made $313.2 million $295.8 million $314.3 million1 +6.3

1. The figure shown represents the total amount of the incentive paid, including the DVA loading.

Mental Health Nurse Incentive Programme

The Mental Health Nurse Incentive Programme funds community-based general practices, private psychiatric practices and other appropriate organisations so they can employ mental health nurses to help provide coordinated clinical care for people with severe and persistent mental disorders.

Table 25: Mental Health Nurse Incentive Programme
  2012-13 2013-14 2014-15 % change since
2013-14
Organisations registered 418 381 341 -10.5
Payments made $35.3 million $31.7 million $32.7 million +3.2

Rural health programmes

Four rural health programmes administered by the department offer incentives and support for medical practitioners providing services in rural areas.

General Practice Rural Incentives Program

The General Practice Rural Incentives Program comprises the GP component and the Rural Relocation Incentive Grant. The programme encourages medical practitioners to practice in rural and remote communities and promotes careers in rural medicine.

Table 26: General Practice Rural Incentives Program
  2012-13 2013-14 2014-15 % change since
2013-14
Medical practitioners paid 11,587 11,529 12,630 +9.5
Payments made 12,771 12,688 14,600 +15.4
Total amount paid $113.2 million $137.6 million $157.8 million +14.7

HECS Reimbursement Scheme

The HECS (Higher Education Contribution Scheme) Reimbursement Scheme encourages medical graduates to pursue a career in rural medicine and increases the number of doctors in rural and regional areas.

Eligible graduates, who have completed their final year of study and obtained their medical degree in the last six years, have a proportion of their HECS debt reimbursed for each year of training undertaken, or service provided, in rural and remote Australia.

Payments are scaled to provide the greatest rewards for medical practitioners working in the most remote areas. The Australian Standard Geographical Classification—Remoteness Area system is used to define eligible areas.

Table 27: HECS Reimbursement Scheme
  2012-13 2013-14 2014-15 % change since 2013-14
Number of medical graduates paid 1,011 1,050 1,126 +7.2
Number of payments made 1,738 1,695 1,909 +12.6
Total amount paid $14.3 million $14.9 million $23.8 million1 +59.7

1. $7.9 million of the $23.8 million is the accrual amount for 2014-15. This figure Includes pro-rata payments for the cessation of the HECS Reimbursement Scheme on 30 June 2015.

Rural Procedural Grants Program

The Rural Procedural Grants Program assists GPs who provide procedural or emergency medicine services in rural and remote areas to attend training courses in maintaining and improving skills, up to $20,000 per GP a year.

The Australian College of Rural and Remote Medicine and the Royal Australian College of General Practitioners determine eligibility.

In 2014-15, 1,992 GPs were paid a total of $18.9 million compared to 2013-14 when 1,999 GPs were paid a total of $16.9 million.

Rural Locum Education Assistance Program

The Rural Locum Education Assistance Program provides financial assistance to urban GPs who undertake emergency medicine training. They must commit to a four-week general practice locum placement in a rural locality within two years of finishing their training.

The Australian College of Rural and Remote Medicine and the Royal Australian College of General Practitioners determine eligibility.

In 2014-15, 20 GPs were paid a total of $90,000 compared to 2013-14 when 31 GPs were paid a total of $144,000.

Medical indemnity

The Australian Government’s medical indemnity framework consists of a number of schemes to strengthen the longer-term viability and success of the medical insurance industry. To achieve this, the government provides financial support to reduce the impact of large claims and makes medical indemnity insurance more affordable for medical practitioners. The department administers the schemes under the Medical Indemnity Act 2002 and associated legislation.

Exceptional Claims Indemnity Scheme

Under the Exceptional Claims Indemnity Scheme medical practitioners are protected against personal liability for eligible claims that exceed the level of their insurance cover. In 2014-15 no claims were submitted against this scheme.

High Cost Claims Indemnity Scheme

Under the High Cost Claims Indemnity Scheme the government funds 50% of the cost of medical indemnity insurance payouts that are greater than the threshold amount, up to the limit of a medical practitioner’s insurance cover.

Table 28: High Cost Claims Indemnity Scheme
  2012-13 2013-14 2014-15 % change since
2013-14
Claims received 211 231 445 +92.6
Total benefits paid $33.4 million $30.1 million $47.2 million +56.8

Premium Support Scheme

Under the Premium Support Scheme eligible medical practitioners receive a subsidised reduction in their insurance premiums. Insurers are then reimbursed the subsidised amount. The scheme subsidises 60% of the cost of the premium beyond the 7.5% threshold.

Table 29: Premium Support Scheme
  2012-13 2013-14 2014-15 % change since
2013-14
Eligible practitioners 1,993 1,671 1,400 -16.2
Amount paid $9.3 million $9.3 million $7.8 million -16.1
Administration fees1 $2.4 million $1.4 million $1.3 million -7.1

1. The decrease in administration fees is primarily due to a reduced monthly invoice amount from the insurance provider. The monthly amount is calculated by the Department of Health at the beginning of the financial year.

Run-off Cover Scheme for doctors

Under the Run-off Cover Scheme the government covers the cost of claims for eligible medical practitioners who have left the private medical workforce. The government uses funds paid into the scheme by medical indemnity insurers to cover incidents that occur in connection with a medical practitioner’s practice. Indemnity cover for eligible medical practitioners reflects the last claims arrangement they had with their insurer.

Table 30: Run-off Cover Scheme
  2012-13 2013-14 2014-15 % change since
2013-14
Claims received 72 60 81 +35.0
Total benefit paid $2.9 million $2.0 million $5.6 million +180.0

Run-off Cover Scheme support payment

Under the Run-off Cover Scheme the government guarantees funding for claims against eligible medical practitioners who have left the private medical workforce and have been provided with free run-off cover. The support payment is imposed as a tax on each medical indemnity insurer for each contribution year. This is used to fund eligible claims made under the scheme.

Medical indemnity insurers are reimbursed for implementation and compliance costs. In 2014-15, $1.8 million in administration fees was paid compared to $1.1 million in 2013-14. No implementation fees were paid.

Incurred-But-Not-Reported Indemnity Claims Scheme

Under the Incurred-But-Not-Reported Indemnity Claims Scheme the government covers the costs of claims from medical defence organisations that do not have adequate reserves to cover their liabilities. United Medical Protection—now known as Avant Insurance Limited—is the only medical defence organisation actively participating in the scheme.

Ongoing costs associated with the scheme are partly funded through a contribution payment called the United Medical Protection Support Payment which is imposed on people who were members of United Medical Protection on 30 June 2000. To be eligible, incidents that led to claims must have occurred before 30 June 2002.

Table 31: Incurred-but-not-reported indemnity claim scheme
  2012-13 2013-14 2014-15 % change since
2013-14
Claims received 34 65 65 0.0
Total benefit paid $3.7 million $7.8 million $2.3 million -70.5

Midwife Professional Indemnity Scheme

The Midwife Professional Indemnity Scheme gives financial help to eligible insurers who provide indemnity to eligible midwives. The scheme includes a government contribution to assist with claims made against eligible midwives. It benefits private independent midwives by providing indemnity insurance policies. In 2014-15 no claims were made under this scheme.

Midwife indemnity administration fees

Run-off Cover Scheme administration fees are paid to midwife professional indemnity insurers to compensate for the work they undertake to administer the scheme.

In 2014-15, $175,000 in administration fees was paid compared with $125,000 in 2013-14 and $173,916 in 2012-13.

Visiting medical practitioners

Under a service agreement with the Western Australian Government the department administers a payment and information system for hospital staff. The payment is for claims processing from visiting health professionals who treat public hospital patients under individual contracts with participating public hospitals in Western Australia.

Table 32: Visiting medical practitioners
  2012-13 2013-14 2014-15 % change since
2013-14
Number of services 283,621 292,216 264,834 -9.4
Total value $71.3 million $78.9 million $78.4 million -0.6

Medical, dental and pharmaceutical advisers

The department employs 42 health professionals such as doctors, pharmacists, a dentist and an optometrist, to provide specialist advice.

These health professionals undertake various activities including:

  • reviewing health practitioners under the Practitioner Review Program
  • assisting with compliance audits, projects and investigations
  • assisting with assessment of complex claims and highly specialised drugs applications
  • developing educational products and providing education to health professionals

National Health Funding Administrator Payments System

The National Health Funding Administrator Payments System facilitates payments from the Australian Government to states and territories for public hospital services through the National Health Funding Pool, as required under the National Health Reform Agreement.

The department provides programme, corporate and support services to the National Health Funding Body and the Administrator of the National Health Funding Pool to carry out their functions. All eight jurisdictions are successfully using the payments system. In 2014-15 payments of $35.2 billion were made compared to $33.4 billion in 2013-14.

Pharmaceutical Benefits Scheme

The Pharmaceutical Benefits Scheme (PBS) subsidises the cost of many prescription medicines, making them more affordable for Australian residents and eligible overseas visitors.

Under the Repatriation Pharmaceutical Benefits Scheme (RPBS) eligible veterans, war widows and widowers can access some additional medicines and dressings at concession rates and, if clinically justified, items not listed in either the PBS or RPBS schedules.

In administering both schemes the department processes pharmacist claims, approves authority prescriptions, approves pharmacists and certain doctors to supply PBS medicines, and approves private hospitals and participating public hospitals to supply PBS medicines to eligible patients. It also administers associated programmes that support access to medicines and their quality use, such as pharmacist incentive payments.

Table 33: PBS and RPBS expenditure
  2012-13 2013-14 2014-15 % change since
2013-142
PBS benefits paid $9.1 billion $9.3 billion $9.2 billion -1.1
RPBS benefits paid1 $0.4 billion $0.4 billion $0.4 billion 0.0
Total benefits paid $9.5 billion $9.6 billion $9.5 billion -1.0
PBS services processed1 198.7 million 211.8 million 213.9 million +1.0
RPBS services processed 12.4 million 12.3 million 11.6 million -5.6
Total services processed 211.1 million 224.1 million 225.6 million +0.6

1. Payments/services processed on behalf of Department of Veterans’ Affairs.

2. Percentages in this table may have been rounded to the nearest decimal point.

PBS eligibility

The price paid for PBS medicines depends on a person’s level of eligibility. The 2 levels of eligibility are the general rate and the concession rate—see also PBS Safety Net on page 50.

The patient contribution at the general rate rose to $37.70 from 1 January 2015. All Australian residents and eligible overseas visitors can access PBS medicines at the general rate.

Patients and their families with a valid concession card from the department or from the Department of Veterans’ Affairs are eligible for the concession rate of $6.10. These amounts were adjusted on 1 January 2015 in line with the consumer price index. Patients pay extra for more expensive brands of medicines.

PBS Safety Net

The PBS Safety Net helps people who require a lot of prescription medicines in a calendar year with their cost.

The PBS Safety Net thresholds were adjusted from 1 January 2015, in line with the consumer price index. The 2015 general threshold is $1,453.90 and the concession threshold is $366 for concession card holders. Once people reach the relevant threshold, a pharmacist can issue them with a PBS Safety Net card. Their contribution for PBS medicines for the rest of the year will then be:

  • $6.10 for general patients
  • free for concession card holders

Patients pay extra for more expensive brands of medicines.

Indigenous people’s access to the PBS

The department administers special PBS arrangements in remote Indigenous communities through Aboriginal Health Services and some state and territory funded health services. Patients of approved remote area Aboriginal Health Services can access free PBS medicines without a prescription. Patients can also receive medicine in the usual way by taking a prescription to a community pharmacy.

At 30 June 2015 there were 173 approved Aboriginal Health Services around the country. This is consistent with the number of approved Aboriginal Health Services in 2013-14.

The Closing the Gap PBS Co-Payment helps Aboriginal and Torres Strait Islander people living with chronic disease, or at risk of it, with the cost of PBS medicines. Since 1 July 2010 eligible patients have received PBS medicines free of charge or for the concession patient contribution rate.

Travelling with PBS medicines

The Travelling with PBS medicines enquiry line provides information and advice to people about their responsibilities and rights when travelling overseas with PBS medicines. In 2014-15 the enquiry line received almost 2,500 calls compared to 3,300 calls 2013-14. During the year there were 35,000 visits to the relevant page on the department’s website compared to 30,000 in 2013-14.

PBS processing

Online claiming for PBS allows pharmacies to lodge prescription claims with the department each time a PBS or RPBS medicine is dispensed.

Table 34 shows data relevant to the administration of the PBS.

Table 34: PBS administration
Deliverables and key performance indicators 2012-13 2013-14 2014-15
Claims processed accurately1 98.6 98.2 98.2
PBS claims submitted online 99.6 99.9 99.9
Applicants approved to supply PBS medicines advised within five days of the decision being made 100 100 100

1. Target ≥98%.

Authority-required prescriptions

Authority-required medicines for the treatment of specific conditions are listed in the Schedule of Pharmaceutical Benefits and may require approval from the department before they are prescribed to patients. An authority prescription provides the option of seeking more or repeat prescriptions of PBS or RPBS medicines. In 2014-15 the department received 6.9 million authority requests, and 6.9 million in 2013-14.

Approving suppliers of PBS medicines

Under section 90 of the National Health Act 1953 and with agreement from the Australian Community Pharmacy Authority (ACPA), the department can grant approvals to community pharmacies, certain doctors and hospital authorities to supply PBS medicines.

The number of section 90 applications referred to ACPA decreased from 401 in 2013-14 to 349 in 2014-15:

  • 100% of applications were referred to ACPA within nine working days of registration
  • 100% of applications recommended by ACPA were advised within five working days of the decision to approve
Table 35: Approved PBS suppliers at 30 June
  At 30 June 2013 At 30 June 2014 At 30 June 2015 % change since
30 June 2014
Approved pharmacists 5,351 5,457 5,511 +1.0%
Approved medical practitioners 33 23 21 +6.3
Approved hospital authorities—private hospitals 95 104 116 -8.7%
Approved hospital authorities—public hospitals participating in pharmaceutical reforms 159 159 161 +11.5%
Approved hospital authorities—highly specialised drugs only 77 78 77 -1.3%

Pharmaceutical reforms in public hospitals

Under the National Healthcare Agreement, the Australian Government and state and territory governments have reformed the supply of pharmaceutical benefits to eligible patients in public hospitals. Eligible patients include:

  • admitted patients on discharge
  • outpatients
  • day patients accessing chemotherapy drugs

At 30 June 2015 the department had approved 161 public hospitals under these arrangements—five in the Northern Territory, 49 in Queensland, 15 in South Australia, four in Tasmania, 69 in Victoria, 19 in Western Australia and none in either New South Wales or the Australian Capital Territory.

eHealth

The eHealth programme is a national approach to delivering electronic health system standards and infrastructure. It is transforming the way information is accessed and used to plan, manage and deliver health services in Australia. The department is delivering core components of the eHealth programme including:

  • the Healthcare Identifiers Service
  • the National Authentication Service for Health

The department is also delivering components of the Personally Controlled Electronic Health Record system on behalf of the eHealth System Operator, the Department of Health.

Healthcare Identifiers Service

The Healthcare Identifiers Service (HI Service) is a national system for uniquely identifying health care providers, organisations and individuals.

Use of Health Identifiers gives individuals and providers confidence that the right information is associated with the right individual at the point of care. A Healthcare Identifier is not a health record and is not required to receive health care or to claim health care benefits such as Medicare.

As the HI service operator (as defined in the Healthcare Identifiers Act 2010), the department assigns, collects, stores and maintains HIs.

In 2014-15 the department has:

  • assigned 585,330 HIs to individuals
  • collected or assigned 33,387 HIs to individual health care providers
  • assigned 531 HIs to health care organisations (such as hospitals or general practices)

The HI Service annual report contains full details of HI Service operations and is tabled in the Parliament each year.

National Authentication Service for Health

The National Authentication Service for Health (NASH) delivers authentication services for health care providers and supporting organisations.

NASH Public Key Infrastructure (PKI) certificates are used to access the eHealth record system. The NASH PKI certificates can also be used to send and receive information securely between health care organisations.

In 2014-15 the department issued:

  • 5,559 certificates to health care provider organisations
  • 687 certificates to health care provider individuals
  • 12 certificates to supporting organisations

Health Professional Education Services

The department provides high quality, accessible information and education resources and services to help health professionals access programmes. In 2014-15 these included:

  • developing and delivering seven MBS presentations and workshops for health professional peak bodies, which had 261 attendees
  • engaging internal and external stakeholders to develop information and education resources for health professionals
  • running 56 intern training workshops with 1,398 attendees under the national training programme for pharmacy interns
  • facilitating four presentations to 59 health professionals through the National Broadband Network across 35 sites

The department also developed targeted resources to assist health professionals in understanding Medicare and the PBS. These new resources include:

  • Medicare ultrasound services guide
  • information about prescribing, dispensing and claiming highly specialised drugs guide
  • five guides supporting online claiming
  • Medicare reason codes and reducing claim rejections guide
  • five guides and an eLearning programme supporting Indigenous health
  • introduction to Compliance within Medicare eLearning Programme

During the year more than 17,600 educational products were downloaded from the department’s website and there were more than 196,000 visits to its education pages.

Page last updated: 30 March 2016

This information was printed Monday 26 September 2016 from humanservices.gov.au/corporate/annual-reports/annual-report-2014-15/part-2/services-community-health It may not include all of the relevant information on this topic. Please consider any relevant site notices at humanservices.gov.au/siteinformation when using this material.