Nurse Practitioner Business Models and Arrangements

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1 Nurse Practitioner Business Models and Arrangements Final Report WA Health, Nursing and Midwifery Office March 2011

2 Contents List of acronyms 3 1. Executive summary Project scope Approach Background Consultation themes and clinical models Employment and business models Recommendations 7 2. Background What is a nurse practitioner? State and national legislation and agreements Medicare Australia requirements for access to the MBS and PBS Rural areas 19(2) exemption Impacts of the regulations Consultation themes and results Clinical models Business and employment models Financial modelling Full Public model Public Private Mix model Full private model Discussion Models for further investment Industrial relations implications Policy implications Development of a nurse practitioner workforce strategy Acceptability criteria 46 1

3 6. Recommendations 48 A Definition of medical practitioner 50 B 19(2) Exemption terminology 51 C Workshop participants 7 December D Summary of financial information 53 D.2 Financial models 55 D.3 Hospital outpatient wound care service 56 D.4 Residential care line 61 D.5 Rural public service 66 D.6 Paediatrics emergency diversion clinic 67 Tables and figures Table 1: MBS items that can be claimed by a nurse practitioner 12 Table 2: Pathology and diagnostic MBS items that can be claimed by a nurse practitioner 15 Table 3: Clinical model and business and employment model applied 28 Table 4: Characteristics of the Full Public model 29 Table 5: Characteristics of the Public Private Mix model 31 Table 6: Characteristics of the Full Private model 35 Table 7: Federal policy implications 41 Figure 1: MBS rebates (benefits paid) for nurse practitioner services by length of consultation 44 Table 8: Nurse practitioner business and employment models:acceptability table 47 Table 9: Average consultation length and respective MBS benefit paid 53 Table 10: Distribution of activity under nurse practitioner MBS items by clinical model 53 Table 11: Labour and cost inputs 54 2

4 List of acronyms ED Emergency Department FP Full Private GP General Practitioner MBS Medicare Benefits Scheme NMBA Nursing and Midwifery Board of Australia PBS Pharmaceutical Benefits Scheme PMH Princess Margaret Hospital PRNI Privately Referred Non Inpatient PPM Public Private Mix RCL Residential Care Line WA Western Australia WACHS WA Country Health Service 3

5 1. Executive summary On the 16 March 2010, the Australian Senate passed legislation to provide eligible nurse practitioners and midwives with access to the Medical Benefits Scheme (MBS) and the Pharmaceutical Benefits Scheme (PBS). The changes to the Health Insurance Act 1973 provides access for eligible nurse practitioners to Medicare, which includes the ability to provide Medicare rebateable services, request pathology and diagnostic imaging services and refer patients to specialist and consultant physicians within their scope of practice Project scope KPMG was engaged by the Government of Western Australia s Department of Health (WA Health) to identify and review the optimum business and employment models for promoting nurse practitioner services to ensure the Western Australian community gains maximum benefit from changes to the legislation. KPMG has analysed selected clinical, business and employment models to assist WA Health in identifying future investment opportunities, considerations and priorities. Financial modelling has been undertaken for a range of clinical scenarios against a range of business and employment models, in order to assist in determining the overall acceptability and viability of these models Approach The clinical models examined for the purpose of this analysis are a: hospital outpatient wound care service; Residential Care Line service; public rural service; and paediatrics emergency department diversion clinic. The business and employment models examined were a: full public employment model; mixed public private employment model and; full privately employed model Background Section 2 of this report provides a high-level overview of the State and Commonwealth legislation and agreements that impact upon the role and function of nurse practitioners in Western Australia. A number of key implications for both nurse practitioners and WA Health have been identified including: the changes to the legislation provide access for eligible nurse practitioners to Medicare arrangements which include providing Medicare rebateable services, requesting pathology and diagnostic imaging services and referral of patients to specialist and consultant physicians; 4

6 section 19(2) of the Health Insurance Act 1973 states that, unless the Health 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 the Commonwealth, a State, a local governing body; or an authority established by a law of the Commonwealth, a State or internal Territory. Therefore, unless the Federal Minister for Health and Ageing otherwise directs, Medicare benefits are not payable where funding has already been provided under an arrangement with the Commonwealth, state or a local governing body; and access to nurse practitioner item numbers under the Medicare Benefits Schedule is restricted to private practitioners, as indicated by the issuing of a Medicare provider number by Medicare Australia. Full time employees of WA Health are not considered to be private providers Consultation themes and clinical models Section 3 of this report provides an overview of key features of each of the clinical models investigated. Stakeholder interviews were conducted to inform these key features. The purpose of the consultations was to better understand current and potential clinical activity and gather key information associated with the relevant business and clinical models investigated. The consultations confirmed that the clinical activity of nurse practitioners will vary according to the type of service, complexity of the presentation, and whether this is a first presentation for the patient (i.e. longer consultation) or a follow up visit (i.e. shorter consultation). The specialist services i.e. wound care and aged care services are consistent and predictable in the number and length of consultations, whereas the primary care models remote area and paediatrics emergency department diversion clinic can be expected to be highly variable. Similarly, seasonal variations are more likely to be experienced in primary care services. Stakeholders also identified a range of other issues during consultations. These included potential industrial relations implications of new models, increased resourcing and staff requirements, stakeholder acceptability and clinical governance Employment and business models Section 4 and 5 of this report describes potential employment and business models to support the clinical models and identifies a range of policy implications. The business / employment models are informed by advice and feedback provided by stakeholder consultation and by interpretation of relevant legislation and agreements with the Australian Government. The clinical models (as discussed previously) are applied to potential business / employment models that may support their development and application. The employment models identified are: a full public employment model; a mixed public private employment model and; a full private practice model 5

7 Financial analysis is provided for each of the four nurse practitioner clinical models identified and the potential business / employment model. The analysis is provided for a range of business models where the nurse practitioner either retains the MBS or assigns it to the organisation. In addition, a range of employment arrangements are modelled to demonstrate the viability of the individual models. Models in which the nurse practitioner takes on all activity risk (such as the Full Private and Public-Private models where the nurse retains revenue) offer the greatest financial return for WA Health. However, these models also present the greatest risk for individual nurse practitioners and have a lower likelihood of acceptance because of this risk. While providing moderate financial return to a rural hospital with 19(2) exemption status, the nurse practitioner s ability to remain a full time employee of the state and hence minimise the overall impact on their allowances and conditions, would be the model with the highest acceptability. It is noted from the financial modelling that MBS revenue could offset as much as 37 per cent of a nurse practitioner s salary ($46,895) under this scenario. A shift to full private practice, whilst less complicated from a Commonwealth perspective, is unlikely to be fully embraced by nurse practitioners at this time as the structure of the rebates would only be viable in high volume environments with rapid patient turnover. A nurse practitioner that continues to practice in the way he / she is trained would most likely experience a loss in income. Although gap fees may be charged to improve the profitability of services, these would need to be significant to offset the loss in income and may exceed community acceptance. Opportunity may exist within areas of high volume such as the paediatrics emergency department diversion clinic to work with private stakeholders (such as divisions of general practice / Medicare Locals and private hospitals) to establish such a service. The Public-Private Mix model where the nurse practitioner assigns their revenue to the organisation offers potential for mutual benefit to both WA Health and the nurse practitioner. The model provides both the capacity to introduce a private model whilst maintaining an income guarantee for the nurse practitioner. This model, whilst conservative in revenue earned by the organisation, has high likelihood of nurse practitioner acceptability especially at an 80 per cent public / 20 per cent private mix. This business and employment option is the most suitable for the hospital outpatient wound care service, Residential Care Line service and paediatrics emergency department diversion clinic. The success of the Public-Private Mix model depends on the nurse practitioner obtaining a Medicare provider number, which is reliant on demonstrating to Medicare that they are a private practitioner. It is also reliant on being acceptable to the Commonwealth with respect to sections 19(2) and 128c of the Health Insurance Act Given the inherent ambiguity within the legislation, it is recommended that legal advice be obtained as to whether the model is permissible under the regulations. If indicated by legal counsel, Commonwealth agreement may also be required. This report further identifies a range of issues that have emerged through analysis and consultation including that: nurse practitioners operating in private practice will require medical indemnity insurance. The financial cost to the individual nurse practitioner may represent a significant barrier for the successful implementation of this program across WA Health; 6

8 the introduction of Medicare billing for nurse practitioner services has potential industrial implications. If the Public / Private Mix model is pursued, it is likely that nurse practitioners may need to seek changes to their current Enterprise Bargaining Agreement (EBA) with WA Health. It should be noted that any alteration to the award structure covering nurse practitioners would not necessarily be supported by equivalent productivity increases or work value, and may have flow on effects to other nursing classifications; it appears that design of the nurse practitioner MBS item numbers does not adequately reflect the nursing model of care. The MBS item numbers that nurse practitioners have access to are maximised when consultation lengths are limited. The nursing model is more holistic covering the physical, psychosocial and spiritual aspects of patient care and is built around more extended patient interaction; the current MBS item numbers that nurse practitioners have access to have a number of limitations; key among these are that: nurse practitioners can not claim for practice nurse services performed on their behalf and under their delegation, using MBS item numbers to Amendment of these item numbers should be sought to allow practice nurses to provide service on behalf of a nurse practitioner; nurse practitioner item numbers are generalist in nature and do not reflect the specialist nurse practitioner workforce within WA, which is highly procedural. GPs have procedural MBS items covering specialist interventions and procedures. Appropriate procedural MBS item numbers should be developed for nurse practitioners also; and the regulatory and legislative changes are designed to support private practice and the improved delivery of primary care services across Australia. Currently WA has a specialist nurse practitioner workforce focused on secondary and tertiary care. A workforce strategy that supports the attraction and retention of nurse practitioners in areas such as primary care and rural and remote health to maximise benefits from the relevant changes would assist WA Health to encourage greater take up of MBS rebateable services for nurse practitioners Recommendations The changes of the Health Insurance Act 1973 offers opportunity for WA Health and the nursing profession which may be realised by combining the appropriate clinical and business / employment models. However, these opportunities do not come without political, technical and financial challenges and risks. Core to the success of implementing these models is ensuring that they are acceptable to all key stakeholders and meet all Commonwealth and Medicare eligibility requirements. The following recommendations are made to assist WA Health in determining the most appropriate future investment opportunities, considerations and priorities for the State. 1. Seek formal legal opinion from Health Legal Services and State Solicitors to determine whether any of the proposed business / employment models contravene sections 19(2) and 128c of the Health Insurance Act 1973 and relevant health care agreements. 7

9 2. Seek formal opinion from the WA Health Industrial Relations Service regarding potential impacts, risks, benefits and strategies relating to the WA Nursing Enterprise Bargain Agreement. 3. Establish a Nurse Practitioner Working Group to undertake further development work to consider a range of outstanding issues. The purpose of the Working Group would be to advise WA Health on the development and implementation of nurse practitioner services in WA, including: strategies for working with key stakeholders such as the Australian and Western Australian Governments, peak nursing groups and other stakeholders to achieve further policy and legislation reform to support nurse practitioner services; solutions surrounding medical indemnity insurance for nurse practitioners, with a particular focus on affordability, as well as clarity regarding the implications of managing staff such as practice nurses; develop a workforce strategy that includes a targeted recruitment plan to support the implementation of respective business / employment models, especially in the context of developing a primary care generalist nurse practitioner workforce. 4. If indicated by legal counsel, consider seeking the agreement of the Federal Health Minister for the payment of Medicare benefits in respect of professional services rendered by nurse practitioners engaged under the Public Private Mix business / employment model. 5. Consider working with the Australian Government and relevant stakeholders including peak nursing and general practice groups to seek amendment of the MBS item numbers to to allow practice nurses to provide service on behalf of a nurse practitioner. Consideration should also be given to the possibility of procedural items which are reflective of nurse practitioner specialist practice. 6. In partnership with the WA Country Health Service, identify appropriate 19(2) exemption sites for establishing nurse practitioner services using clear selection criteria (such as ability to recruit a nurse practitioner and availability of local infrastructure to support MBS billing). 7. Once eligibility and provider number issues have been addressed, commence a trial of approved clinical models in public / private mix models utilising agreed business / employment models to determine their financial viability, effectiveness and community benefit. Trials should include a formal evaluation over a period of six to 12 months that includes extensive stakeholder consultation, data analysis and a cost benefit analysis. 8. Develop and deliver a range of education and business tools to support nurse practitioners in the establishment and management of their own business. 8

10 2. Background This section provides an overview of what a nurse practitioner is, what determines their scope of practice and what collaborative arrangements need to be in place to support their introduction into the health workforce. This information has been informed by a range of legislation and regulation, both National and State, such as the: Health Practitioner Regulation National Law (WA) Act 2010; WA Poisons Act 1964; and WA Poisons Regulations What is a nurse practitioner? A nurse practitioner is commonly defined as a nurse with extensive clinical skills and knowledge that allows them to undertake advanced practice in their area of expertise. The Australian Nursing and Midwifery Council define a nurse practitioner as a: Registered nurse educated and authorised to function autonomously and collaboratively in an advanced and extended clinical role. The nurse practitioner role includes assessment and management of clients using nursing knowledge and skills and may include, but is not limited to the direct referral of patients to other health care professionals, prescribing medications and ordering diagnostic investigations. The scope of practice of the nurse practitioner is determined by the context in which the nurse practitioner is authorised to practice. The role of the nurse practitioner is designed to enhance the services of other health and medical service providers. Nurse practitioners work collaboratively with other health professionals to provide advanced and extended care to the community, individuals, and families. Their scope of work extends beyond that of the registered nurse and includes: advanced clinical assessment; initiating, interpreting and responding to diagnostic tests; initiating and monitoring therapeutic regimes; prescribing medicines; and initiating and receiving referrals Nurse practitioners in Australia The nurse practitioner role has its roots in providing primary health care the United States in the early 1960s. Nurse practitioners were introduced to alleviate a shortage of primary care medical practitioners. Although the role emerged in Australia in the 1980s, the first recognised nurse practitioner was only authorised to practice in 2000, in New South Wales. Now nurse practitioners provide care in all eight states and territories, with all jurisdictions enacting legislation to protect the title of nurse practitioners and their associated extended practice privileges. 1. Australian Nursing Federation. A snapshot of nurse practitioners in Australia. Accessed 2 August 2010 at Snap_Shot_Nurse_Practitioners.pdf. 9

11 Nurse practitioners work across a broad spectrum of specialties and settings. Research on the effectiveness of nurse practitioners has shown safe practice, cost effective care, and outcomes at a level at least similar to that of medical practitioners within similar clinical settings. 2 Significantly, until November 2010 nurse practitioners working in clinical settings had no access to Medicare provider numbers or authority to prescribe through the Pharmaceutical Benefits Scheme. A recent survey of Australian nurse practitioners identified access to these two enabling features as the most significant aspects limiting their practice. 3 On the 16 March 2010, the Australian Senate passed legislation to provide eligible nurse practitioners and midwives with access to the Medical Benefits Scheme (MBS) and the Pharmaceutical Benefits Scheme (PBS). The legislative changes provide access for eligible nurse practitioners to Medicare arrangements which include providing Medicare rebateable services, requesting pathology and diagnostic imaging services, and referral of patients to specialist and consultant physicians. The legislation also allows nurse practitioners to prescribe certain medicines under the PBS, within their designated scope of practice and in accordance with relevant State / Territory legislation National registration requirements The Health Practitioner Regulation National Law (WA) Act 2010 states that the Nursing and Midwifery Board of Australia (NMBA) may endorse the registration of a registered health practitioner whose name is included in the Register of Nurses as being qualified to practise as a nurse practitioner. 4 To be eligible for endorsement as a nurse practitioner, the nurse must be able to demonstrate all of the following: general registration as a registered nurse with no restrictions on practice; advanced nursing practice in a clinical leadership role in the area of practice in which he or she intends to practice as a nurse practitioner, within the past five years, complemented by research, education and management; competence in the competency standards for nurse practitioners approved by the NMBA; and completion of the requisite qualification determined by the NMBA Western Australian requirements To practice in WA, a nurse practitioner must: be registered with the NMBA; be employed in a designated nurse practitioner area; and have agreed clinical protocols. 2. Mundinger MO. Nurse practitioners: a safe and competent choice for primary care. Int Nursing Rev 2000; 17: Accesed Proquest 23 August Middleton,A ;Gardner,A & Della,P (2010) The Status of Australian Nurse practitioners: the second national census Unpublished. 4. Parliament of Western Australian. Health Practitioner Regulation National Law (WA) Act August Nursing and Midwifery Board of Australia, 2010, Registration Standard for Endorsement of Nurse Practitioners. 10

12 Designated nurse practitioner areas There are approximately 180 designated nurse practitioner areas covering the Perth metropolitan, WA Country Health Service remote area nursing posts, remote practice sites, emergency care services, Department of Corrective Services, private sector services, Australian Defence Force and Aboriginal community controlled health services. Designated nurse practitioner areas may be set for a specific service (e.g. Sir Charles Gairdner Hospital), organisation (e.g. Silver Chain Health Services) or location (e.g. Bremer Bay). Successful designation is not limited or determined by geography, sector or setting that the nurse practitioner operates within. Clinical protocols Clinical protocols are developed in collaboration and partnership with the health service / organisation as part of the process of having an area designated to employ a nurse practitioner. Amendments to the Poisons Regulations 1965 require that before the Western Australian Director General of Health can designate an area, clinical protocols for the specific area must be approved by: the officer of the department who is principally responsible for providing advice on matters related to nursing (currently the Chief Nursing Officer); the person holding or acting in the office of Executive Director, Personal Health Services in the department (currently the Chief Medical Officer); and the person holding or acting in the office of Executive Director, Population Health, or if there is no such office at the relevant time, the office of Executive Director, Public Health and Scientific Support Services in the department (currently the Executive Director of Population Health) State and national legislation and agreements Prior to undertaking any financial analysis it is important to understand the legislative and regulatory context in which nurse practitioners will operate into the future. This chapter sets out the legislated rules around permissible care (including referral, prescribing and diagnostic ordering), collaborative care, settings and scope of practice that will apply to nurse practitioners in Australia and Western Australia. The chapter also describes permissible access for nurse practitioners to the Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS). This section of the report outlines: nurse practitioner access to the MBS and PBS; and the Remote Area 19(2) Exemption. The legislative framework scan has been informed by the following legislation: Health Insurance Act 1973; and National Health (Collaborative arrangements for nurse practitioners) Determination 2010, under the National Health Act

13 2.3. Medicare Australia requirements for access to the MBS and PBS The Medicare Program ( Medicare ) provides access to medical and hospital services for all Australian residents and certain categories of visitors to Australia. Medicare Australia administers Medicare and the payment of Medicare benefits. The major elements of Medicare are prescribed in the Health Insurance Act The Health Legislation Amendment (Midwives and nurse practitioners) Act (the Act) was assented on 12 April It amended the Health Insurance Act 1973 and the National Health Act 1953 to enable eligible nurse practitioners to request appropriate diagnostic imaging and pathology services for which benefits may be paid under the Medicare Benefits Schedule (MBS). It also allows these health professionals to prescribe certain medicines under the Pharmaceutical Benefits Scheme (PBS). To be eligible to access MBS services or refer and request, the nurse practitioner must: be registered or authorised (however described) under State and Territory law; and Item number Description Professional attendance by a participating nurse practitioner for an obvious problem characterised by the straightforward nature of the task that requires a short patient history and, if required, limited examination and management Professional attendance by a participating nurse practitioner lasting less than 20 minutes and including any of the following: a) taking a history; b) undertaking clinical examination; c) arranging any necessary investigation; d) implementing a management plan; e) providing appropriate preventive health care; for 1 or more health related issues, with appropriate documentation Professional attendance by a participating nurse practitioner lasting at least 20 minutes and including any of the following: a) taking a detailed history; b) undertaking clinical examination; c) arranging any necessary investigation; d) implementing a management plan; Schedule fee (100 %) Benefit paid (85%) $9.20 $7.85 $20.15 $17.15 $38.25 $ Commonwealth of Australia. Explanatory Memoranda: Health Legislation Amendment (Midwives and nurse practitioners) Bill Accessed 11 November 2010 at practitionerb /memo_0.html. 12

14 e) providing appropriate preventive health care, for 1 or more health related issues, with appropriate documentation Professional attendance by a participating nurse practitioner lasting at least 40 minutes and including any of the following: a) taking an extensive history; b) undertaking clinical examination; c) arranging any necessary investigation; d) implementing a management plan; e) providing appropriate preventive health care, for 1 or more health related issues, with appropriate documentation. $56.30 $47.90 demonstrate that he or she has the appropriate qualifications and experience to meet the registration standard developed by the NMBA, which was developed for the purposes of the National Registration and Accreditation Scheme (NRAS), a single regulation and accreditation scheme for health professionals, including nurse practitioners; 7 and be in private practice. 8 A participating nurse practitioner is an eligible nurse practitioner who has a Medicare provider number and who provides Medicare services in collaborative arrangements with one or more medical practitioners. To access the Medicare arrangements, eligible nurse practitioners need to apply to Medicare Australia for a provider number. A Medicare provider number will only be issued for nurse practitioners in private practice. 9 A separate provider number is required for each location at which a nurse practitioner practices MBS item numbers for professional attendances From 1 November 2010, eligible nurse practitioners are able to access specific items in the Medicare Benefits Schedule (MBS). New MBS items for services provided by participating nurse practitioners working collaboratively with doctors have been created. Participating nurse practitioners are limited to providing services within their authorised scope of practice and level of experience and competency. They are also able to refer their patients, under the MBS, to specialists / consultant physicians. To provide MBS services and prescribe certain PBS subsidised medicines, nurse practitioners will need to apply for a Medicare provider number and PBS prescriber number. 7. Department of Health and Ageing. Medicare Benefits Schedule Note M14.2. Accessed 11 November 2010 at www9.health.gov.au/mbs/ fulldisplay.cfm?type=note&q=m14.2&qt=noteid. 8. Medicare Australia website. Nurse practitioners and midwives. Accessed 25 November 2010 at other-healthcare/nurse-midwives.jsp. 9. Ibid. 13

15 Medicare benefits are only payable for clinically relevant services. Clinically relevant in relation to nurse practitioner care means a service generally accepted by the nursing profession as necessary to the appropriate treatment of the patient s clinical condition. Medicare benefits are only payable where the participating nurse practitioner provides care to not more than one patient on one occasion. Table 1 outlines the MBS items that a participating nurse practitioner can claim. Table 1: MBS items that can be claimed by a nurse practitioner 10 Setting Professional attendance for MBS items 82200, 82205, 82210, 82215, may be provided in an appropriate setting that includes but is not limited to: the patient s home; a nurse practitioner group practice; a nurse practitioner s rooms; or a medical practice. Benefits paid vs schedule fee The payments of benefits (or rebates) and schedule fees for professional services are listed in the Medicare Benefits Schedule (MBS). The fee is referred to in these notes as the schedule fee. The schedule fee for any item listed in the MBS is that determined by Medicare Australia as being reasonable on average for that service having regard to usual and reasonable variations in the time involved in performing the service on different occasions and to reasonable ranges of complexity and technical difficulty encountered. Benefits paid describes the rebate paid to eligible community members for services rendered to non-admitted patients. 11 The benefit paid for most services is 85 per cent of the schedule fee. As a general rule scheduled fees are adjusted on an annual basis, usually in November. 12 Bulk billing and participating nurse practitioners Bulk billing is a matter for each participating nurse practitioner and involves acceptance by participating nurse practitioners of the relevant Medicare benefit assigned to them as payment in full for the service. If a participating nurse practitioner direct-bills, the participating nurse practitioner undertakes to accept the relevant Medicare benefit as full payment for the service. Additional charges for that service (irrespective of the purpose or title of the charge) cannot be raised against the patient MBS item numbers for pathology and diagnostics requests 10. Medicare Financing and Analysis Branch. MBS items for nurse practitioners fact sheet. Medicare Australia website; undated. Accessed 25 January 2011 at 11. Australian Government Department of Health and Ageing website. Participating Nurse Practitioners Questions and Answers. Accessed 25 January 2011 at 12. See Australian Government Department of Health and Ageing. Medicare Benefits Schedule Book: Operating from 01 November Commonwealth of Australia; Canberra: Accessed 25 January 2011 at E03510F96A7DD1CA2574E40017C116/$File/ Cat%202.pdf. 13. Ibid. 14. Ibid 14

16 Table 2 outlines the pathology and diagnostic items that can be claimed by a nurse practitioner. Table 2: Pathology and diagnostic MBS items that can be claimed by a nurse practitioner 14 Item Number Description Pathology items A nurse practitioner may only request pathology services if this is within their scope of practice (inclusive) Diagnostic Imaging Services 55036, 55070, Subgroup 1: General Ultrasound for the abdomen and breast Subgroup 4: Urological Ultrasound for prostate Subgroup 5: Obstetric and Gynaecological Ultrasound 55800, 55804, Subgroup 6: Musculoskeletal Ultrasound 55808, 55812, 55816, 55820, 55824, 55828, 55832, 55836, 55840, 55844, 55848, 55850, , 57515, Subgroup 1: Radiographic X-ray examination of the extremities Subgroup 6: Radiographic X-ray examination of the thoracic (inclusive) region Conditions for requests for pathology or diagnostic services The nurse practitioner requesting a pathology or diagnostic service for a patient must determine that the pathology service is necessary. In the case of pathology services, these may only be requested if they are in the nurse practitioner s scope of practice. The pathology service may only be provided in response to a request from the treating nurse practitioner and the request must be in writing (or, if oral, confirmed in writing within fourteen days). The diagnostic service may only be provided in response to a request from the treating nurse practitioner, and the request must be in writing, signed and dated. The legislation provides that a request must be in writing and contain sufficient information, in terms that are generally understood by the profession, to clearly identify the item(s) of service requested. This includes, where relevant, noting on the request the clinical indication(s) for the requested service. It is not necessary that a written request for a diagnostic imaging service be addressed to a particular provider or that, if the request is addressed to a particular provider, the service must be rendered by that provider. A single request may be used to order a number of diagnostic imaging services. However, 15

17 all services provided under this request must be rendered within seven days after rendering the first service Referral A participating nurse practitioner is able to refer private patients to a specialist and consultant physician as appropriate. However, this does not include referral for allied health care. A referral given by a participating nurse practitioner is valid until 12 months after the first service given in accordance with the referral. A referral to a specialist must be in writing in the form of a letter or a note to the specialist and must be signed and dated by the referring nurse practitioner. The referral must contain any information relevant to the patient and the specialist must have received the referral on or prior to providing a specialist consultation. There are exemptions from this requirement in an emergency if the specialist considers the patient s condition requires immediate attention without a referral. In that situation, the specialist is taken to be the referring practitioner Where Medicare benefits are not payable Medicare benefits are not available: where the service rendered does not meet the item description and associated requirements; is not personally performed by the participating nurse practitioner; for any time period in the consultation periods when the patient is not receiving active attention; e.g. the time the provider may take to travel to the patient s home or where the patient is resting between blood pressure readings; services provided where the patient is not in attendance, such as the issuing of repeat prescriptions; for telephone attendances; and group sessions. Medicare benefits are also not payable for goods or appliances associated with the service, such as bandages or other skin dressings. Unless the Minister otherwise directs, Medicare benefits are not payable where funding has already been provided under an arrangement with the Commonwealth, state or a local governing body. Specifically: section 19(2) of the Health Insurance Act 1973 states that, unless the Health 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 the Commonwealth, a State, a local governing body; or an authority established by a law of the Commonwealth, a State or internal Territory; and section 128c of the Health Insurance Act 1973 prohibits specified persons (including nurse practitioners) from charging a fee for the provision of a public hospital service or from receiving any payment or other consideration from anyone in respect of the provision of a public hospital service to a public patient. 16

18 Other specified persons are medical practitioners, midwives and anyone acting on their behalf. A public hospital service means a hospital service provided in a public hospital or a hospital providing services to publicly funded patients Pharmaceutical Benefits Scheme From 1 November 2010, authorised nurse practitioners will be able to access a limited list of items under the PBS, the total number being Authorisation for PBS prescribing purposes is in addition to authorisation for registration purposes. Prescribing under the PBS will be limited to certain PBS medicines and will only be permitted within the scope of practice of an authorised nurse practitioner, and in accordance with the State or Territory legislation under which they work. Medicines which can be prescribed by nurse practitioners are identified by nurse practitioner in the PBS Schedule. PBS schedules The medicines that can be prescribed by nurse practitioners fall under the following schedules: Emergency Drug Supplies; General Schedule; S100 Opiate Dependence; Palliative Care; and Special Pharmaceutical Benefits. Additional conditions Further to prescribing within collaborative arrangements, certain medicines also have additional conditions for prescribing by nurse practitioners: continuing therapy only model, where the patient s treatment and prescribing of a medicine has been initiated by a medical practitioner, but prescribing is continued by a nurse practitioner; and shared care model, where care is shared between a nurse practitioner and medical practitioner in a formalised arrangement with an agreed plan to manage the patient, in a patient-centred model of care Rural areas 19(2) exemption In September 2006, the Australian and Western Australian Governments signed a Memorandum of Understanding in relation to the Better Access to Primary Care Services in Rural Areas 19(2) exemptions initiative. Initially intended to end on 30 June 2010, the agreement has been extended until 30 June The Australian Government has declared its commitment to continue the Remote Area 19(2) exemptions. 17 The basis of the initiative is that to improve access to primary care 15. Department of Health and Ageing website. PBS Schedule Search. Accessed 11 November 2010 at search?base=prescribergroup:n. 16. Department of Health and Ageing website. Nurse Practitioner PBS Prescribing. Accessed 11 November 2010 at nurse. 17. See Department of Health and Ageing. Improving access to primary care in rural and remote areas s19(2) exemptions initiative. Accessed 15 November 2010 at 17

19 in rural and remote areas, the Australian Government will allow Medicare benefits to be claimed in respect of bulk-billed, non-admitted, non-referred professional services provided in emergency departments and outpatient clinics at some small rural hospitals. The patient is not charged a co-payment for services. Medicare benefits may be claimed by medical practitioners, nurses and allied health professionals under the 19(2) exemption; however, medical practitioners who intend to claim require a Medicare provider number specific to the location from which the service is provided. To be eligible for the Remote Area 19(2) exemption, a locality must: have a population of less than 7,000 people; not be in a major city; and be in an area of workforce shortage (as defined by the Commonwealth s Area of Workforce Shortage Index). The current agreement between the Australian and Western Australian Governments requires the endorsement and written agreement of local primary care providers (including general practitioners, the Royal Flying Doctor Service and Aboriginal Health Services) of the 19(2) exemption. The funds generated must be used to enhance primary health care in the community in which the funds were generated Impacts of the regulations The key implications for development of the nurse practitioner business cases arising from the Australian and Western Australian rules and regulations are that: WA must allocate designated nurse practitioner area status to sites that support the preferred models, and put in place clinical protocols for each nurse practitioner that specify their scope of practice, based on his or her experience and training; a collaborative arrangement for each nurse practitioner must be established with a medical practitioner and / or medical service; only services delivered personally, face-to-face to with the patient, by the nurse practitioner will be funded by Medicare Australia; Medicare Australia expects that access to the MBS will be by nurse practitioners operating as private practitioners; and where an arrangement exists between the State and the nurse practitioner, the Federal Health Minister s agreement will be required for MBS payments for services delivered by the nurse practitioner. 18

20 3. Consultation themes and results This chapter sets out the themes and results arising from a number of consultations conducted with key stakeholders. The consultations informed the understanding of the four clinical models selected by the Department: hospital outpatient wound care service; Residential Care Line service; public rural service; and paediatrics emergency department diversion clinic. The consultations were conducted in order to: understand the current and potential clinical activity that could occur under each of the four clinical models investigated; test and validate assumptions relating to the business / employment models; seek expert opinion of key stakeholders on the scenario based clinical and business models; and identify how business and operational risks to nurse practitioners and the State can be mitigated. One-on-one interviews were conducted with the following stakeholders: Catherine Stoddart, Chief Nurse and Midwifery Officer; Michelle Dillon, Principal Nursing Advisor; and Annette Fraser, Senior Nursing Officer, Nursing and Midwifery Office, Western Australian Department of Health; Carol Douglas, Clinical Nurse Consultant, 18 Residential Care Line, North Metropolitan Area Health Service; Deirdre Louw, Remote nurse practitioner, Bremer Bay; Pam Morey and Sue Davis, Sir Charles Gairdner Hospital; Anne Bourke, Sue Peters and Ben Irish, Princess Margaret Hospital; Paul Fraser and Anna McDonald, WA Country Health Service (WACHS); Don Black, Department of Health, Legal Services; Dr Peter Goldswain, Geriatric Medicine, 19 Western Australian Department of Health; and Craig Gleeson, Principal Industrial Relations Consultant and Marshall Warner, WA Health Industrial Relations Service, Western Australian Department of Health. A workshop was held on 7 December 2010 to further test and validate assumptions and explore implications arising from the nurse practitioner clinical and business models. A list of workshop participants is located at Appendix C. Key consultation themes and results are discussed below. 18. Ms Douglas is a qualified nurse practitioner, but is not currently practising in this role. 19. Dr Goldswain is a geriatrician. 19

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