0
PETER LARTER
DIRECTOR, LARTER EDUCATION
peter@larterconsulting.com.au
How to successfully attract
Medicare Benefits for yo...
• Something interesting
about you
• If you could wave a magic
wand to know something
about using Medicare and
be able to a...
About Medicare
• Medibank from 1975-6, Medibank II
1976-84
• Medicare 1984-99
– Medicare practitioners, optometry,
diagnos...
About Medicare
• 1999-2010: number of Medicare
items quadrupled
– Nurse practitioner items introduced 2010
About item numbers
• To search for items, google „MBS
online‟ and enter the item number there
Item number
Item name
Medica...
Medicare billing
• „Bulk bill‟ – client assigns the Medicare
rebate to the provider
• „Privately bill‟ – client pays full ...
Nurse Practitioner
MBS items
MBS Items (face to face)
Item
#
Fee,
BB
Item description
82200 $8.20 Professional attendance by a nurse practitioner for a...
MBS Items (telehealth)
• Items also available since 2011 to
participate in a video consultation with
a specialist or consu...
MBS Items (telehealth)
Item
#
Fee, BB Item description
82220 $24.10 Attendance, less than 20 mins
Community, Aboriginal Me...
Business models
• 4 kinds of models
Feel free to ask those tricky questions…
MBS in public and private
health services
• Four kinds of models
100% donation
(„salaried‟)
• Staff attracts
MBS rebate
• ...
NP as private provider
• In both private and public settings, the
NP must
– Register with Medicare Australia as a
private ...
MBS in public health
services
• DISCLAIMER - The content of this presentation constitutes
general information only and sho...
MBS in public health
services
• Health Insurance Act 1973 (Cw) –
direct quotation:
s19(2) “Unless the Minister otherwise d...
MBS in public and private
health services
• Four kinds of models
100% donation
(„salaried‟)
• Staff attracts
MBS rebate
• ...
100% donation model
• Some legal ambiguity for others
• s19(2) exemption in public rural health
services with communities ...
100% donation model
100% donation model
• Seek legal & HR advice
• Inform and consult staff
• At end of financial year, provide clinicians wit...
% split & rooms for rent
models
• External private providers OR existing staff
have rights of private practice but keep a
...
External private providers
model
• Very unlikely NP model, but possible.. Usually
a demand management strategy or quality
...
Model acceptability
• 100% donation model
– Legal and HR complexity for organisations
– More admin/clinical control for or...
Model viability and
sustainability
Financial viability
• KPMG1 for Dept Health WA undertook nurse
practitioner MBS business modelling
1. Department of Health...
Modelling assumptions
• Full time equivalent working 201 days a year
– 365-125 weekends – 10 CPD – 20 annual leave –
9 per...
MBS Items (face to face)
Item
#
Fee,
BB
Item description
82200 $8.20 Professional attendance by a nurse practitioner for a...
NP hospital outpatients
would care service1
1. Department of Health, Western Australia. 2011. Nurse practitioner business ...
NP rural/remote outreach
model, not s19(2) exempt
1. Department of Health, Western Australia. 2011. Nurse practitioner bus...
NP rural/remote outreach
model, not s19(2) exempt
e.g. #700-#715 – health assessments by nurses
“for an on behalf of a gen...
Thinking and
discussion break
1. What sort of model may best suit your
organisation?
2. Is there anything unclear about the four
models?
3. Project plan...
Project planning
Project planning
Project Advisory Group (PAG)
AA, Project Sponsor (e.g. CEO)
BB, Senior Program Manager
CC, Clinician r...
Conclusions
• MBS won‟t fully pay for a service without
– Private billing (non-bulk billing), and/or further
public subsid...
Final point
• MBS models are complex and require a
complex project with effective governance,
knowledge and communication ...
Lessons from the field
• Two key resources
– Dept. of Health, Western Australia. 2011. Nurse
practitioner business models ...
THANK YOU!
Questions,
comments?Peter Larter – peter@larterconsulting.com.au
Presentation © Larter Consulting, 2014.
All ri...
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Peter Larter, Larter Consulting - Attracting Medicare Benefits to Support Nurse Practitioner Roles in Public and Private Healthcare Settings

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Peter Larter, Director, Larter Consulting delivered the presentation at the 2014 Developing the Role of the Nurse Practitioner Conference.

The Developing the Role of the Nurse Practitioner Conference 2014 is for organisations and managers looking to better understand, utilise and grow the role of the nurse practitioner in their health service.

For more information about the event, please visit: http://www.healthcareconferences.com.au/npconference14

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Transcript of "Peter Larter, Larter Consulting - Attracting Medicare Benefits to Support Nurse Practitioner Roles in Public and Private Healthcare Settings"

  1. 1. PETER LARTER DIRECTOR, LARTER EDUCATION peter@larterconsulting.com.au How to successfully attract Medicare Benefits for your organisation Developing the Role of the Nurse Practitioner Conference, 2014
  2. 2. • Something interesting about you • If you could wave a magic wand to know something about using Medicare and be able to apply it immediately at work, what would it be? You and a magic wand
  3. 3. About Medicare • Medibank from 1975-6, Medibank II 1976-84 • Medicare 1984-99 – Medicare practitioners, optometry, diagnostic imaging, radiology.. – Stable
  4. 4. About Medicare • 1999-2010: number of Medicare items quadrupled – Nurse practitioner items introduced 2010
  5. 5. About item numbers • To search for items, google „MBS online‟ and enter the item number there Item number Item name Medicare benefit • 100% of fee for GP and PN services • 85% of schedule fee for NP and allied health Click here for explanatory notes: “The Rules”Schedule fee
  6. 6. Medicare billing • „Bulk bill‟ – client assigns the Medicare rebate to the provider • „Privately bill‟ – client pays full amount up front, and – Medicare benefit deposited in their bank account, or – Goes to Medicare office to collect benefit
  7. 7. Nurse Practitioner MBS items
  8. 8. MBS Items (face to face) Item # Fee, BB Item description 82200 $8.20 Professional attendance by a nurse practitioner for an obvious problem – straightforward, limited examination and management 82205 $17.85 Professional attendance by a nurse practitioner lasting less than 20 minutes involving: • Clinical signs and symptoms • Easily identifiable underlying cause 82210 $33.80 Professional attendance by a nurse practitioner lasting at least 20 minutes involving: • Clinical signs and symptoms • No obvious underlying cause 82215 $49.80 Professional attendance by a nurse practitioner lasting at least 40 minutes involving: • Multiple clinical signs and symptoms • Possibility of multiple causes
  9. 9. MBS Items (telehealth) • Items also available since 2011 to participate in a video consultation with a specialist or consultant physician – With the patient, providing clinically relevant support whilst they are consulted by a specialist or consultant physician – At least 15km distance away – Not for admitted hospital patients
  10. 10. MBS Items (telehealth) Item # Fee, BB Item description 82220 $24.10 Attendance, less than 20 mins Community, Aboriginal Medical Service, ACCHO 82221 $45.65 Attendance, at least 20 mins Community, Aboriginal Medical Service, ACCHO 82222 $67.15 Attendance, at least 40 mins Community, Aboriginal Medical Service, ACCHO 82223 $24.10 Attendance, less than 20 mins Residential aged care 82224 $45.65 Attendance, at least 20 mins Residential aged care 82225 $67.15 Attendance, at least 40 mins Residential aged care
  11. 11. Business models • 4 kinds of models
  12. 12. Feel free to ask those tricky questions…
  13. 13. MBS in public and private health services • Four kinds of models 100% donation („salaried‟) • Staff attracts MBS rebate • MBS is „handed over‟ to employing org • MBS is income to the staff member, offset by their donation % split • Provider runs a business • Hands over a % of MBS income via a contractual agreement in exchange for rooms, admin support etc. Rooms for rent • Provider runs a business • Rooms rented out to a private provider • Similar but simpler than % split Partner with private providers • Informal or formal partnership with private provider who is offsite • No need to be involved with MBS billing
  14. 14. NP as private provider • In both private and public settings, the NP must – Register with Medicare Australia as a private provider - provider number – Have professional indemnity insurance – Have collaborative arrangements in place with a medical practitioner
  15. 15. MBS in public health services • DISCLAIMER - The content of this presentation constitutes general information only and should not be relied upon in any circumstance. Larter Consulting Pty Ltd ABN 16 151 460 927 its officers, employees, contractors and agents (Larter Consulting) does not warrant the accuracy of the information contained in this presentation and it is not intended to be, and should not be used as, a substitute for professional advice. Larter Consulting does not provide, or intend to provide, legal advice. Persons or entities requiring legal advice should consult a suitably qualified Australian legal practitioner or other appropriately qualified adviser. Larter Consulting expressly disclaims all liability for any loss or damage however arising from reliance upon any information contained in this presentation.
  16. 16. MBS in public health services • Health Insurance Act 1973 (Cw) – direct quotation: s19(2) “Unless the Minister otherwise directs, a medicare benefit is not payable in respect of a professional service that has been rendered by, or on behalf of, or under an arrangement with: • (a) the Commonwealth; • (b) a State; • (c) a local governing body; or • (d) an authority established by a law of the Commonwealth, a law of a State or a law of an internal Territory”.
  17. 17. MBS in public and private health services • Four kinds of models 100% donation („salaried‟) • Staff attracts MBS rebate • MBS is „handed over‟ to employing org • MBS is income to the staff member, offset by their donation % split • Provider runs a business • Hands over a % of MBS income via a contractual agreement in exchange for rooms, admin support etc. Rooms for rent • Provider runs a business • Rooms rented out to a private provider • Similar but simpler than % split Partner with private providers • Informal or formal partnership with private provider who is offsite • No need to be involved with MBS billing
  18. 18. 100% donation model • Some legal ambiguity for others • s19(2) exemption in public rural health services with communities of <7,000 persons • Some health services allow private practice arrangements for employees, mandating that MBS fees generated are handed back to them, and they pay a private practice component
  19. 19. 100% donation model
  20. 20. 100% donation model • Seek legal & HR advice • Inform and consult staff • At end of financial year, provide clinicians with a statement of MBS income that they „handed over‟ for their tax purposes • Amend employment contracts • May need to establish a „craft group‟
  21. 21. % split & rooms for rent models • External private providers OR existing staff have rights of private practice but keep a proportion of the MBS revenue • Contract should consider – How provider is paid, and amount – Billing and administrative arrangements – Shared or independent client records – Other expectations e.g. CPD, meeting attendance – Insurances – etc.
  22. 22. External private providers model • Very unlikely NP model, but possible.. Usually a demand management strategy or quality improvement strategy
  23. 23. Model acceptability • 100% donation model – Legal and HR complexity for organisations – More admin/clinical control for organisations – Most palatable to most NPs • % split and rooms for rent models – Easier for organisations to administer – NPs take more financial and clinical risk
  24. 24. Model viability and sustainability
  25. 25. Financial viability • KPMG1 for Dept Health WA undertook nurse practitioner MBS business modelling 1. Department of Health, Western Australia. 2011. Nurse practitioner business models and arrangements. http://www.nursing.health.wa.gov.au/docs/reports/business_models_arrangements.pdf • MBS is activity-based funding and is most “financially rewarding” for high, consistent throughput • Some NP models fit this bill, some don‟t. • Bulk-billed MBS NP models will never be financially viable under current MBS– private billing could be
  26. 26. Modelling assumptions • Full time equivalent working 201 days a year – 365-125 weekends – 10 CPD – 20 annual leave – 9 personal leave • Mix of consultation-based item numbers only (not telehealth support) • NP salary $94,000 + 15% oncosts + 20% corporate charge • 100% bulk billing
  27. 27. MBS Items (face to face) Item # Fee, BB Item description 82200 $8.20 Professional attendance by a nurse practitioner for an obvious problem – straightforward, limited examination and management 82205 $17.85 Professional attendance by a nurse practitioner lasting less than 20 minutes involving: • Clinical signs and symptoms • Easily identifiable underlying cause 82210 $33.80 Professional attendance by a nurse practitioner lasting at least 20 minutes involving: • Clinical signs and symptoms • No obvious underlying cause 82215 $49.80 Professional attendance by a nurse practitioner lasting at least 40 minutes involving: • Multiple clinical signs and symptoms • Possibility of multiple causes
  28. 28. NP hospital outpatients would care service1 1. Department of Health, Western Australia. 2011. Nurse practitioner business models and arrangements. http://www.nursing.health.wa.gov.au/docs/reports/business_models_arrangements.pdf • 24 patients per 8 hour session – 6x15min, 16x20 min, 1x30 min, 1x45 min (some clinical, some admin) • Not financially viable without private billing or other subsidy, but provides substantial income • INCOME: $584.08 per day over 201 working days = $117,504 • EXPENSE: $94,000 + 43% (13% oncosts + 30% corporate charge) = $134,420
  29. 29. NP rural/remote outreach model, not s19(2) exempt 1. Department of Health, Western Australia. 2011. Nurse practitioner business models and arrangements. http://www.nursing.health.wa.gov.au/docs/reports/business_models_arrangements.pdf • 5 patients per 8 hour session – 1x15min, 1x20 min, 1x30 min, 3x45 min + • Similar story – not viable under MBS in any circumstances • E.g. if charging higher MBS rebates, INCOME: $119.30 per day = $23,979 EXPENSE: $134,420 • Community nursing, with significant travel, providing holistic care which can take >60 mins
  30. 30. NP rural/remote outreach model, not s19(2) exempt e.g. #700-#715 – health assessments by nurses “for an on behalf of a general practitioner” may provide additional MBS income • If the nurse practitioner is employed by or retained by a general practice, they can attract additional Medicare Benefits which go to the GP and could ultimately support the NP‟s employment (though may not be professionally ideal)
  31. 31. Thinking and discussion break
  32. 32. 1. What sort of model may best suit your organisation? 2. Is there anything unclear about the four models? 3. Project planning – what would some of the steps be, and who would need to be involved?
  33. 33. Project planning
  34. 34. Project planning Project Advisory Group (PAG) AA, Project Sponsor (e.g. CEO) BB, Senior Program Manager CC, Clinician representative DD, Quality & Risk Coordinator EE, Finance team FF, Administrative team GG, Medicare Local representative Project sponsor (e.g. CEO) Project manager / project officer Project Advisory Group
  35. 35. Conclusions • MBS won‟t fully pay for a service without – Private billing (non-bulk billing), and/or further public subsidy – Efficient and reliable billing and administrative systems – Reliable & minimum level of throughput • Difficult to make a model sustainable if – the NP workforce is not convinced about HR arrangements required to make it happen – Other parts of workforce don‟t understand MBS or won‟t take on more roles
  36. 36. Final point • MBS models are complex and require a complex project with effective governance, knowledge and communication to make it happen • See supplied “MBS Checklist” for an example of the process that community health services undertake
  37. 37. Lessons from the field • Two key resources – Dept. of Health, Western Australia. 2011. Nurse practitioner business models and arrangements. http://www.nursing.health.wa.gov.au/docs/reports/ business_models_arrangements.pdf See „Lessons – „Lessons Learned‟ document – Victorian community health service MBS implementation (provided and http://www.health.vic.gov.au/pch/downloads/lesson s_learned.pdf )
  38. 38. THANK YOU! Questions, comments?Peter Larter – peter@larterconsulting.com.au Presentation © Larter Consulting, 2014. All rights reserved.
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