l/o/g/o medicare: what’s new, and using the mbs for chronic illness care peter larter larter...

L/O/G/O

Medicare: What’s New, and Using the MBS for Chronic

Illness Care

Medicare: What’s New, and Using the MBS for Chronic

Illness CarePeter Larter

Larter Consulting

Tonight…Tonight…

MBS Changes

Medicare Compliance Program

MBS for chronic illness care

Questions/conclusion4

1

2

3

RECENT CHANGES TO THE MBS

RECENT CHANGES TO THE MBS

Telehealth & MedicareTelehealth & 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

Ggggggggggggggggggggggggggggggggggggggggggggggggggggggg

ggggggggggg ggg

1(a). Changes to telehealth eligibility from 1 January 20131(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

Ggggggggggggggggggggggggggggggggggggggggggggggggggggggg

ggggggggggg ggg

Changes to telehealth eligibilityChanges to telehealth eligibility

gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg

gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg

1(b). New telehealth “minimum distance” criterion1(b). New telehealth “minimum distance” criterion

• The patient and the specialist must be at least 15km apart.

Ggggggggggggggggggggggggggggggggggggggggggggggggggggggg

ggggggggggg ggg

15km radius from Ballarat Health Services

1(c). Telehealth “on board” incentive will be paid in 2 instalments1(c). Telehealth “on board” incentive will be paid in 2 instalments

• The 1st incentive is paid after the 1st telehealth MBS claim; the 2nd is paid after the 10th telehealth MBS claim

Ggggggggggggggggggggggggggggggggggggggggggggggggggggggg

ggggggggggg ggg

Incentive 2012-13 2013-14

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 PCHER2. 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.

Ggggggggggggggggggggggggggggggggggggggggggggggggggggggg

ggggggggggg ggg

3. Change to immunisation payments3. 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

gggggggggggggggggggggggggggggggggggggggggg

ggggggggggg ggg

4. Other PIP payments4. 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

Ggggggggggggggggggggggggggggggggggggggggggggggggggggggg

ggggggggggg ggg

MEDICARE COMPLIANCE PROGRAM 2012-13

MEDICARE COMPLIANCE PROGRAM 2012-13

Medicare Compliance PhilosophyMedicare Compliance Philosophy

Ggggggggggggggggggggggggggggggggggggggggggggggggggggggg

ggggggggggg ggg

Medicare Compliance priorities 2012-13Medicare Compliance priorities 2012-13

1. Chronic disease management items: referring ineligible patients for subsidised allied/dental health

Ggggggggggggggggggggggggggggggggggggggggggggggggggggggg

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 2012-13Medicare 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) General Practice Rural Incentives

ProgramGgggggggggggg

gggggggggggggggggggggggggggggggggggggggggg

ggggggggggg ggg

MBS FOR CHRONIC ILLNESS CARE

MBS FOR CHRONIC ILLNESS CARE

MBS for chronic illness careMBS 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 settingGP-led, MBS-funded care planning in the community setting

gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg

gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg

• Patients who would benefit from a structured approach to chronic disease careGP-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 planningCare planning

gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg

gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg

Name Item

Medicare Fee

(100%)

Recomm-endedFrequency

Minimum Claiming period

GPMPs 721 $141.40 2 yearly 12 Months

TCAs 723 $112.05 2 yearly 12 MonthsReview a GPMPOr Coordinate a Reviewof TCAs/ MultidisciplinaryCommunity Care Plan/ Multidisciplinary Discharge Plan

732 $70.656 monthly

3 months

Contribution to or review of another provider’s care plan

729 $70.65 - 3 months

Contribution to a care plan in residential aged care facility

731 $70.65 - 3 months

gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg

gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg

gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg

ggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg

GPMPs: patient eligibilityGPMPs: 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 eligibilityTCAs: patient eligibility

gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg

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? TCAs: Who can be one of the providers?

gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg

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? 2nd GP? Specialist? (only one)Myofascial therapist?Massage therapist? Naturopath?

Allied health MBS rebates following a GPMP+TCAAllied health MBS rebates following a GPMP+TCA

gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg

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 #10951Audiologist #10952Exercise physiologist #10953Dietician #10954Mental health worker #10956Occupational therapist #10958Physiotherapist #10960Podiatrist or Chiropodist #10962Chiropractor #10964Osteopath #10966Psychologist #10968Speech pathologist #10970

$52.95

MBS allied health items: the rulesMBS allied health items: the rules

gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg

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 #10997Practice nurse monitoring and support funded through #10997

gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg

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

gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg

gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg

When is a TCA ‘appropriate’?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?When is a care plan sufficiently comprehensive?

gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg

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?Care plans: what could be audited?

gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg

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 check45-49 year old health check

gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg

gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg

L/O/G/O

ThanksThanks

© Larter Consulting, 2013. All rights reserved.