Federal Register of Legislation - Australian Government

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SR 1999 No. 17 Regulations as made
These Regulations amend the Health Insurance (1998-99 General Medical Services Table) Regulations 1998.
Tabling HistoryDate
Tabled HR08-Mar-1999
Tabled Senate08-Mar-1999
Gazetted 26 Feb 1999
Date of repeal 01 Nov 1999
Repealed by Health Insurance (1999-2000 General Medical Services Table) Regulations 1999

Health Insurance (1998-99 General Medical Services Table) Amendment Regulations 1999 (No. 2) 1999 No. 17

EXPLANATORY STATEMENT

STATUTORY RULES 1999 NO. 17

Issued by authority of the Minister for Health and Aged Care

Health Insurance Act 1973

Health Insurance (1998-99 General Medical Services Table) Amendment Regulations 1999 (No. 2)

The Health Insurance Act 1973 C'the Act") provides for payments by way of Medicare benefits and payments for hospital services.

Section 133 of the Act provides that the Governor-General may make regulations for the purposes of the Act.

Section 4 of the Act provides that regulations may prescribe a table of medical services, (other than diagnostic imaging services and pathology services) (the table). The Health Insurance (1998-99 General Medical Services Table) Regulations.

Section 9 of the Act provides that Medicare benefits shall be calculated by reference to the fees for medical services set out in the table.

Items 12203 and 12207 of the table provide for the payment of Medicare benefits for overnight investigation of sleep apnoea (sleep studies) where the service is provided by a consultant physician in thoracic medicine or a specialist where the investigation is performed in the sleep laboratory of a recognised hospital.

The Regulations extended the payment of Medicare benefits for items 12203 and 12207 to services provided by 'qualified sleep medicine practitioners'. The amendments ensure appropriate standards in the delivery of sleep studies and therefore improve patient outcomes. Practitioners who wish to attract Medicare benefits for sleep studies services are required to have appropriate training and clinical experience in sleep medicine to be competent in independent clinical assessment and management of patients with respiratory sleep disorders and in reporting sleep studies.

Regulations 1 and 2 set out the name and commencement date of the Regulations.

Regulation 3 provides for amendments to the table as set out in Schedule 1.

Item 1 of Schedule 1 inserted a new Rule of Interpretation, Rule 21A which provides for the recognition of 'qualified sleep medicine practitioners'. Payment of Medicare benefits for items 12203 and 12207 of the table will be made only when a practitioner who is recognised as a qualified sleep medicine practitioner has provided the service.

Practitioners can obtain recognition through one of three ways depending upon when they commenced providing sleep studies services:

For practitioners who commenced providing sleep studies before 1 March 1999

Assessment by the Credentialling Subcommittee of the Specialist Advisory Committee in Thoracic and Sleep Medicine of the Royal Australasian College of Physician as satisfying the requirement for training and clinical experience in sleep medicine to enable independent clinical assessment and management of patients with respiratory sleep disorders to be competent in reporting sleep studies.

For practitioners who commenced providing sleep studies after 1 March 1999

*       Completion of either Level I or Level II of the Advanced Training programs in Sleep Medicine supervised by the Specialist Advisory Committee in Thoracic and Sleep Medicine of the Royal Australasian College of Physicians; or

*       For practitioners who have trained overseas, recognition by the Specialist Advisory Committee in Thoracic and Sleep Medicine of the Royal Australasian College of Physicians, in writing, that the person has training equivalent to either Level 1 or Level H of the Advanced Training Programs in Sleep Medicine.

Practitioners who are assessed by the Credentialling Subcommittee as requiring further specified training or experience are able to attract Medicare benefits for their services during the training period.

Items 2 and 3 of Schedule 1 amend the descriptions for items 12203 and 12207 to extend the payment of Medicare benefits to services provided by 'qualified sleep medicine practitioners'.

The Regulations commenced on 1 March 1999.

Regulation Impact Statement

Recognition of Qualified Sleep Medicine Practitioners for Medicare benefits purposes

Health Insurance (1998-99 General Medical Services Table) Amendment Regulations 1999 (No. 2)

This Regulation Impact Statement relates the Health Insurance (1998-99 General Medical Services Table) Amendment Regulations 1999 which impact on the Medicare rebates payable for sleep studies services provided by medical practitioners.

Background

The Australian Medicare Program provides access to medical and hospital services for all Australian residents and certain categories of visitors to Australia. Legislation covering the major elements of the Program is contained in the Health Insurance Act 19 73 (as amended).

With regard to medical services the Medicare program provides financial assistance through

the payment of Medicare benefits to people who incur expenses for private medical services.

Medicare benefits are based on the services and fees contained in the Medicare Benefits

Schedule (MBS).        1

Under the Health Insurance Act 19 73, medical practitioners have to meet minimum proficiency requirements before any services they provide can attract a Medicare benefit. Appropriate medical practice is an important element of the payment of Medicare benefits and many of the services listed in the MBS have additional proficiency requirements upon which payment of a benefit is conditional.

Medicare benefits are payable for overnight investigation of sleep apnoea (items 12203 and 12209), commonly known as sleep studies.

Sleep studies are performed to assess sleep-disordered breathing which is encompassed by a spectrum of conditions linked by the loss of a normal pattern of respiration in sleep or in particular stages of sleep. Symptoms of sleep disordered breathing include daytime sleepiness, psycho-social impairment, hypertension, cardiovascular disease, stroke and hypertension.

During a sleep study, called a polysomnogram, a record is made of several types of measurements used to identify different sleep stages and classify various sleep problems. These include brain waves, eye movements, muscle tone, heart rate and respiration. The results are interpreted by the physician who makes a recommendation to improve the patient's sleep architecture based on a number of treatments. These could include medication, behaviour modification, lifestyle changes, respiratory therapy and/or surgery.

Regulation Impact Statement Health Insurance (1998-99 General Medical Services Table) Regulations Recognition of qualified sleep medicine practitioners for Medicare benefits purposes 27/01199

The relevant UBS items were introduced in November 1989. In 1997198 over 29,500 services with an outlay of $11 million were provided by 125 practitioners whose services attracted Medicare benefits.

Problem

The MBS currently provides rebates for sleep studies with the restriction that they are provided under the supervision of a consultant physician in thoracic medicine or a specialist where the investigation is performed in the sleep laboratory of a recognised (ie public) hospital.

The latter criterion allows non-thoracic physicians who are qualified and experienced in sleep medicine to provide sleep studies, but only in public hospitals. There are currently two difficulties with this restriction. Firstly, and most importantly, it is not possible to determine whether or not the specialist is sufficiently qualified to provide sleep studies. Secondly, it is very hard to properly evaluate when assessing a claim for Medicare benefits.

In addition, the Thoracic Society of Australia and New Zealand and the Australasian Sleep Association advise there are practitioners who are not formally recognised as thoracic physicians, such as paediatricians, anaesthetists and consultant physicians in non-respiratory specialities such as neurology who have appropriate experience to properly interpret sleep studies. Conversely, some consultant physicians in thoracic medicine may not have appropriate training or clinical experience. Although a thoracic medicine trainee completes 3 months core training in sleep medicine as part of core training in thoracic medicine, the profession do not consider this alone is sufficient for independent practice of sleep studies.

Therefore the primary inadequacy of the current restriction prevents medical practitioners in other areas of medicine with suitable experience in sleep studies from attracting Medicare benefits for their services, while services provided by consultant physicians in thoracic medicine with limited training attract benefits.

In short, the current restrictions do not adequately ensure that Medicare benefits are being

paid for sleep studies performed by suitably qualified practitioners. Consequently, it is

possible both that patient outcomes are being compromised and that Medicare benefits may

be paid for inappropriate sleep medicine practice.

Objectives

The Government is committed to ensuring that Medicare benefits are paid for appropriate medical practice for all services. The current restriction for sleep studies needs to be opened up to allow appropriately trained practitioners to attract Medicare benefits, but at the same time facilitate better patient outcomes through a wider availability of suitably qualified sleep medicine practitioners in the community,

The profession consider the minimum competency for sleep medicine practitioners to be "sufficient training and clinical experience in sleep medicine to enable independent clinical assessment and management of patients with respiratory sleep disorders and to be competent in reporting sleep studies". The Thoracic Society of Australia and New Zealand and the

Regulation Impact Statement

Health Insurance (1998-99 General Medical Services Table) Regulations

Recognition of qualified sleep medicine practitioners for Medicare benefits purposes

Australasian Sleep Association have jointly developed and offer Advanced Training Programs in Sleep Medicine in recognition of the need for comprehensive sleep medicine training.

The current restriction of the sleep studies items limits the field of practitioners whose services attract Medicare benefits. Linking the payment of Medicare benefits with competency based requirements is an effective way of ensuring appropriate medical practice and of increasing the number of practitioners whose services would attract Medicare benefits. This would widen the choice of practitioners for patients and ensure they receive the best of medical care for their particular condition.

It should be noted that the Department of Health and Aged Care and the Health Insurance Commission do not have the professional expertise to determine the appropriate level of medical competency, qualification or experience and therefore relies on the advice of the profession on this issue.

Options

Option 1. Do nothing.

No action by the Government would effectively condone the payment of Medicare benefits for sleep studies that may not be providing positive outcomes for patients. Practitioners who are not suitably qualified may order tests unnecessarily, or be unable to competently read reports and therefore prescribe inappropriate treatment and/or medication.

Patients of practitioners who are qualified to provide sleep studies, but who are not consultant physicians in thoracic medicine or providing services in recognised hospitals, will continue to be financially disadvantaged by not being able to claim a Medicare rebate.

Option 2.       Regulate to extend the payment of Medicare benefits to suitably qualified sleep medicine practitioners.

Extending the payment of Medicare rebates for sleep studies to services provided by practitioners who have appropriate training and clinical experience through the recognition of 'qualified sleep medicine practitioners' presents the best option for ensuring appropriate medical practice.

Both options are cost neutral.

Option 2 is the preferred action to ensure that Medicare benefits are paid for appropriate medical practice for sleep studies.

Consultation

The Australian Medical Association represents the medical profession generally, with sleep medicine practitioners specifically being represented by the Thoracic Society of Australia and New Zealand and the Australasian Sleep Association. Consultations have been held with all

parties, who support the proposal.

Regulation Impact Statement

Health Insurance (1998-99 General Medical Services Table) Regulations

Recognition of qualified sleep medicine practitioners for Medicare benefits purposes

In early 1996 the Government initiated discussion with the profession about the current restriction of sleep studies items. Given the profession's contention that some consultant physicians in thoracic medicine are not necessarily qualified to interpret sleep studies and that some consultant physicians in non-respiratory specialties such as paediatrics and neurology have appropriate experience to interpret sleep studies, the concept of a recognition process was raised. The profession agreed that accreditation of providers should be embedded in the MBS and were determined that existing providers not be automatically "grandfathered" in. The profession agreed to develop a peer assessment process for the recognition of qualified sleep medicine practitioners and work with the Department of Health and Aged Care on implementation of the process.

In the past the Australian Medical Association has opposed accreditation schemes of the nature proposed. However, its involvement in the development of the proposal, has led to the AMA to endorsing the introduction of minimum training and clinical experience requirements in sleep studies in order to attract Medicare rebates for those services.

Impact analysis

The profession identified 5 groups who would be affected by a process to recognise training and clinical experience:

1.       experts who have pioneered work in the area;

2.       established providers of sleep studies who have variable training;

3.       thoracic physicians who have relatively recently entered the area of sleep studies;

4.       thoracic physicians currently in training; and

5.       future trainees who want a career in sleep studies including paediatricians and neurologists.

Practitioners falling in groups 4 and 5 are easily accommodated by linking formal training programs offered by the Royal Australasian College of Physicians with the recognition of "qualified sleep medicine practitioners" for Medicare benefits purposes.

In terms of recognising the training and clinical experience for current providers of sleep studies, the profession considered that the practitioners in group 1, who have been involved in the development of sleep medicine and are themselves training new physicians, are expected to meet the requirements.

The practitioners most likely to be afFected by the measure are those who have limited training in sleep medicine. The profession was of the view that a peer assessment process for all current providers was the most equitable way to determine if they possess appropriate levels of training and clinical experience for the payment of Medicare benefits for their services. This process would ensure the services of those practitioners were not automatically excluded from attracting Medicare benefits, nor would it require them to undertake any formal training if their training and clinical experience was appropriate.

Regulation Impact Statement

Health Insurance (1998-99 General Medical Services Table) Regulations

Recognition of qualified sleep medicine practitioners for Medicare benefits purposes

The regulation to provide for the recognition of qualified sleep medicine practitioners for Medicare benefits purposes is relatively simple and easy to administer. Practitioners can be recognised in one of three ways:

For practitioners providing sleep studies services before 1 March 1999:

Assessment by the Credentialling Subcommittee of the Specialist Advisory Committee in Thoracic and Sleep Medicine of the Royal Australasian College of Physicians, as satisfying the requirement for training and clinical experience to enable independent clinical assessment and management of patients with respiratory sleep disorders and to be competent in reporting sleep studies.

For practitioners who commence providing sleep studies services after 1 March 1999:

*       Completion of Level 1 or Level II of the Advanced Training Programs in Sleep Medicine of the Thoracic Society of Australia and New Zealand and the Australasian Sleep Association, being a minimum of 12 months core training; or

*       Written advice from the Specialist Advisory Committee in Thoracic and Sleep Medicine of the Royal Australasian College of Physicians that the practitioner has equivalent training to that of Level I or Level H of the Advanced Training Programs in Sleep Medicine mentioned above (primarily for practitioners who have training overseas).

It is difficult to determine how many current providers will be assessed by the Credentialling Subcommittee as having insufficient training and clinical experience, but the profession has advised it is expected to be very small. Practitioners who the Credentialling Subcommittee conclude require further training in order to meet the competency standard will have access to Medicare rebates during the training period so there will be no impact on the practitioner's income or the patient's ability to claim a rebate for the practitioner's services. The Credentialling Subcommittee will specify the training required and the timeframe in which the training is to be completed and verify that the additional training is completed.

Neither the Department of Health and Aged Care nor the Health Insurance Commission will make any decision in relation to a practitioner's competency of the quality of the service he or she provides. In recognising qualified sleep medicine practitioners for Medicare benefits purposes both agencies will rely on the judgement and advice of the medical profession. It is important that the profession has carriage of the accreditation process. Appropriately trained professionals set the standard and therefore there is no need for the Government to be over prescriptive in the description of the sleep studies items in the MBS.

The commencement date of 1 March 1999 was selected by the profession who were keen to

have the changes in place after two years of development and consultation.

Regulation Impact Statement

Health Insurance (1998-99 General Medical Services Table) Regulations

Recognition of qualified sleep medicine practitioners for Medicare benefits purposes

Implementation and Review

Practitioners will be responsible for providing the necessary information to the Health Insurance Commission to allow it to recognise them as qualified sleep medicine practitioners for Medicare benefits purposes for sleep studies. This will be in the form of.

a certificate of completion of either Level I or Level H of the Advanced Training Programs in Sleep Medicine issued jointly by the Thoracic Society of Australia and New Zealand and the Australasian Sleep Association; or a letter from the Specialist Advisory Committee in Thoracic and Sleep Medicine of the Royal Australasian College of Physicians that the practitioner has training equivalent to Level 1 or Level H of the Advanced Training Programs in Sleep Medicine; or a letter from the Credentialling Subcommittee of the Specialist Advisory Committee in Thoracic and Sleep Medicine of the Royal Australasian College of Physicians that the practitioner satisfies the requirement for training and clinical experience in sleep medicine to enable independent clinical assessment and management of patients with respiratory sleep disorders and to be competent in reporting sleep studies.

Current providers of sleep medicine services have been invited to apply for assessment for recognition as a qualified sleep medicine practitioner. The Credentialling Subcommittee will assess applications during February 1999.

All items on the Medicare Benefits Schedule undergo continual review. The Department will seek advice from the Thoracic Society of Australia and New Zealand and the Australasian Sleep Association about the acceptance and effectiveness of the changes.

Costs

Administration of recognition of qualified sleep medicine practitioners by the Health Insurance Commission will be cost-neutral. Presently the Commission has to verify a practitioner's qualifications as a consultant physician in thoracic medicine, or whether the procedures were performed in a recognised hospital before payment of benefits for sleep studies can be made. The Health Insurance Commission has advised that administration of the new arrangements will be much more streamlined than the existing process.

The Royal Australasian College of Physicians and the Thoracic Society of Australia and New

Zealand will have carriage of the assessment process. The Government has contributed

$10,000 towards the administration costs of the assessment process._

Regulation Impact Statement

Health Insurance (1998-99 General Medical Services Table) Regulations

Recognition of qualified sleep medicine practitioners for Medicare benefits purposes