6.           Background - MBS items for after-hours services

The Australian Government provides a range of programs and funding streams to support access to after-hours services in addition to MBS services (see Attachment C for further information on alternative pathways to seeking care in the after-hours period and other programs funded by the Commonwealth). Of the more than $1.0 billion provided annually in direct funding by the Commonwealth for after-hours primary care services, urgent after-hours items accounted for more than $0.25 billion in 2015–16.

The MBS lists 28 items for after-hours attendances in a range of settings: a doctor’s consultation rooms; the consumer’s home or a hospital or other facility; and services provided in RACFs. Further information on the range of items available is provided at Attachment D. Items also exist for in-hours attendances in these settings.

6.1         Urgent after-hours items

The urgent after-hours items are the focus of this review. There are currently four items for urgent after-hours attendances (current item descriptors and explanatory notes at Attachment E). Items 597 and 599 (for vocationally registered (VR) GPs and non-VR GPs who are part of eligible workforce programs), and 598 and 600 (for non-VR GPs or ‘other medical practitioners’) can be used for urgent services provided in consulting rooms, or at a place other than consulting rooms (including the patient’s home), in the after-hours period. The MBS fees for these items are significantly higher than those for standard attendance items.

Within the urgent after-hours category, a distinction is made between ‘after-hours’ and ‘unsociable after-hours’ to reflect the latter’s greater separation from normal business hours (being between 11pm and 7am) and the greater impost attached to providing services in that period. This is summarised in Table 1.

Table 1: Summary of urgent after-hours items by provider eligibility

 

Time of day

Provider type

 

 

VR GP item

VR GP fee

Non-VR GP item

Non-VR GP fee

After-hours (all other after-hours periods)

597

$129.80

598

$104.75

Unsociable after-hours (between 11pm and 7am)

599

$153.00

600

$124.25

Notes: Items 597 and 599 can also be claimed by non-VR GPs who are part of the AHOMPS workforce program.

MBS items for urgent after-hours attendances have existed since the 1990s. In 2010 there was a restructure of primary care items which reduced the number of after-hours items. The intention of these changes was to simplify the administration of the items. The recent growth in expenditure for urgent after-hours attendances is not a direct result of the 2010 item restructure.

Currently, the attendance for all the urgent items must be requested by the patient or a responsible person in, or not more than 2 hours before, the start of the same unbroken urgent after-hours period. The patient’s condition must require urgent medical treatment and if the attendance is undertaken at consulting rooms, it is necessary for the practitioner to return to and open the consulting rooms for the attendance.

The MBS explanatory notes (A.10) provide the following guidance on claiming urgent after-hours items:

Medical practitioners who routinely provide services to patients in the after-hours periods at consulting rooms, or who provide the services (as a contractor, employee, member or otherwise) for a general practice or clinic that routinely provides services to patients in after-hours periods at consulting rooms will not be able to bill urgent after-hours items 597, 598, 599 and 600.

Therefore, practitioners who work in after-hours clinics cannot bill the urgent items. However, a practitioner who works in the after-hours period providing home visits is able to bill the urgent items.

6.2         Non-urgent after-hours items

In addition to the ‘urgent’ after-hours items there are (by default) ‘non-urgent’ after-hours items. These mirror the standard time-tiered Level A to D GP attendance items and cover services provided in consulting rooms, home visits and RACFs.

For most of these services the rebate payable depends on the time and complexity of the service, and where the service is provided. For home visits and visits to RACFs, the total rebate also depends on how many patients are seen.

The most commonly claimed non-urgent after-hours items are:

  • Item 5020 – a Level B standard GP attendance after-hours with an MBS fee of $49.00.
  • Item 5023 – a Level B home visit with an MBS fee of $74.95

The non-urgent after-hours items for RACF visits also attract higher fees than standard items.

The definition of ‘after-hours’ varies, depending on the day of the week and the setting. Figure 1 sets out the periods in which each different ‘urgent’ MBS item can be claimed. The MBS allows for a premium to be paid for the ‘unsociable’ after-hours period for which an urgent after-hours attendance is made. This ‘unsociable’ period is for after 11pm and before 7am daily, including on weekends and public holidays.

The ‘urgent’ after-hours period commences at 6pm, while the ‘non-urgent’ after-hours period for services provided in consulting rooms, as shown in Figure 2, commences from 8pm on weekdays. Figure 2 highlights the different times that ‘non-urgent’ after-hours items can be used. Note that a ‘place other than consulting rooms’ includes home and RACF visits.

Figure 1: Operational time periods for urgent after-hours items 597-600

 

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after-hours: items 597-598

 

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Standard

in-hours items.

 

Figure 2: Operational time periods for non-urgent after-hours items 5000-5267

 

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Non-urgent after-hours at a place other than consulting rooms:

items 5003, 5010, 5023, 5028, 5043, 5049, 5063, 5067, and 5220 - 5267

 

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after-hours

in consulting rooms:

items 5000, 5020 5040, 5060, 5200, 5203, 5207 and 5208

 

 

6.3 Claiming of urgent vs. non-urgent items

Non-urgent items (e.g. item 5020 for a standard Level B home attendance with a fee of $74.95) relate to the situation where the attendance is scheduled by the GP as part of their known workload or the consumer’s condition does not require urgent attention.

The urgent items are intended to apply to a situation where a GP is unexpectedly recalled to work to deal with a consumer’s urgent unforseen condition (e.g. item 597 with a fee of $129.80), whether provided at the doctor’s consulting rooms or at the consumer’s home. The higher rebate for the urgent item reflects the greater lifestyle disruption and other imposts incurred by the GP in providing this type of service.

One fundamental problem with the current structure is that the MBS stipulates no clear definition of ‘urgent’. Although desirable, developing a better definition of ‘urgent’ is challenging. After-hours attendances arise from a wide range of clinical presentations which do not lend themselves to defining specific clinical criteria.

The current structure of the urgent items allow a patient to ‘book’ an ostensibly urgent service up to two hours in advance and wait for several hours before seeing a doctor. This principle is inconsistent with the generally understood concept of ‘urgent’.

6.4 Vocationally registered GPs (specialist GPs) and non-vocationally registered GPs

The introduction of the Vocational Register for general practice over 20 years ago recognised general practice as a distinct medical specialty for the purposes of Medicare. GPs who are vocationally registered (VR GPs—those who have completed specialist GP training and hold a fellowship from the RACGP or ACCRM) have access to higher Group A1 MBS items (as well as items 597 and 599 in Group A11). Practitioners without specialist GP qualifications (non-VR GPs) have access only to lower-value Group A2 MBS items (and items 598 and 600 in Group A11).

Non-VR GP fees are set much lower than VR GP fees and have not been indexed since the introduction of this structure. The introduction of vocational registration for general practice and the differential fees was intended to improve professional standards, encourage professional development and to reward high-quality practice.

6.5 Medical deputising services

A medical deputising service (MDS) is an organisation responsible for directly arranging for medical practitioners to provide after-hours services to patients on behalf of practice principals. An Approved Medical Deputising Service (AMDS) belongs to a subset of MDSs whose accreditation under a Commonwealth workforce program enables ‘other medical practitioners’ (OMPs) normally prevented from claiming MBS rebates, to provide MBS-rebatable services.

The AMDS program was established in September 1999 to increase the number of doctors providing after-hours services. The program also provides OMPs, including overseas trained doctors and junior doctors, with vocational experience while working in supervised deputised positions.

6.6 After-Hours Other Medical Practitioners Program

The AMDS program does not confer a right on any doctor who works for a MDS to claim the higher VR GP MBS rebates for urgent after-hours items. However, virtually all AMDS program participants currently claim the higher-rebated items through the After-Hours Other Medical Practitioners (AHOMP) Program, established in 2005. The AHOMP Program provides access to the higher-rebated items to encourage doctors to provide after-hours services and this incentive has been extended to deputising doctors who may not be part of a comprehensive general practice. In practice the AMDSs rely on a workforce which has a large number of non-VR doctors who are able to access the higher-rebated VR GP items and in particular item 597.