Improving Access for Indigenous Australians to Medicare and the Pharmaceutical Benefits Scheme Geoff Gillett 5th National Rural Health Conference Adelaide, South Australia, 14-17th March 1999 Proceedings
Improving Access for Indigenous Australians to Medicare and the Pharmaceutical Benefits Scheme Geoff Gillett The Health Insurance Commission (HIC) exists in the Commonwealth health portfolio of the Minister for Health and Aged Care, Dr Michael Wooldridge. The Department of Health and Aged Care (Health) manages overall Commonwealth health policy matters such as remote consultations, services covered by Medicare, professionals whose services can attract a Medicare benefit and the descriptions of the services in the Medicare Benefits Schedule Book. The HIC is the claim paying, information management agency within the portfolio. The HIC has a broad role. It administers Medicare, Australia s public national health insurance program, and a number of other programs including the Pharmaceutical Benefits Scheme (PBS), the Australian Childhood Immunisation Register (ACIR), and payment of the Commonwealth Childcare Rebate. The HIC also processes benefit claims for the Department of Veteran Affairs. The HIC exists to support the delivery of quality health and child care to Australian residents by: providing the highest quality benefit payment services; health information; and ensuring that all benefit payments are correctly made for services rendered. Some information about the various programs is set out below. SOME FACTS ABOUT THE HEALTH INSURANCE COMMISSION The following information relates to the 1997/98 financial year: HIC has 4 225 staff located in over 200 locations across Australia; Medicare claims for 202.2 million services were processed with total Medicare benefits of $6,144.7 million. Direct bill services accounted for 71.8 percent of all services and 42 percent of direct bill claims are lodged and paid electronically; 134.4 million PBS services were processed with total benefits of $2,246 million; and under the ACIR 3 865 950 immunisation episodes were recorded, 1 897 781 children were registered and total payments of $8.9 million were made.
In relation to Medicare enrolment records, the HIC deals with a range of situations which involve some modification of policies and processes. These groups include visitors, ethnic groups, homeless people, chronically ill people, unidentifiable children, children with separated parents, diplomats, intellectually and physically disabled people. This information is intended to illustrate the significant volume of transactions and payments made by the HIC to a diverse group of Australian residents. The HIC acknowledges that much needs to be done to modify existing policies and procedures to ensure their cultural appropriateness for Aboriginal people and the variety of circumstances in which they reside. HIC RELATIONSHIP WITH THE DEPARTMENT OF HEALTH AND AGED CARE AND THE RESPONSIBILITIES OF EACH ORGANISATION The HIC enjoys a close working relationship with Health and also consults regularly with the Office of Aboriginal and Torres Strait Islander Health Service on policy and procedural issues associated with Aboriginal and Torres Strait Islander people. Health is responsible for the establishment of overall health policy and matters such as remote consultations, services covered by Medicare, professionals whose services can attract a Medicare benefit and the descriptions of the services in the Medicare Benefit Schedule Book. The HIC deals with administrative policies and procedures associated with the programs it administers. In relation to Medicare and PBS, the HIC deals with matters such as enrolment policies and mechanisms, determination of eligibility status, claiming mechanisms and card issue arrangements. These administrative arrangements must comply with requirements of relevant legislation, however, the HIC adapts its policies and procedures to take account of the needs of its clients which not only include recipients of health services but also the providers of services. KEYS YOUNG REPORT A report on research commissioned by the HIC and Health into Aboriginal and Torres Strait Islander access to Medicare and the PBS was completed in November 1997. The HIC had been aware for some time that there were difficulties for indigenous people and their service providers, however, the information available to the HIC was largely anecdotal. The purpose of the report was to reveal key barriers for Aboriginal and Torres Strait Islander people and their service providers accessing Medicare and PBS. The report also commented on proposals the HIC had drafted to modify elements of these programs. The selection of the research company and writing of terms of reference was undertaken in co-operation with Health, the peak group representing Aboriginal medical services - the National Aboriginal Community Controlled Health
Organisations (NACCHO), the Department of Social Security, Centrelink, the Royal Australian College of General Practitioners, the Australian Medical Association and the Pharmacy Guild of Australia. The report by Keys Young, Market research into Aboriginal and Torres Strait Islander Access to Medicare and the Pharmaceutical Benefits Scheme made recommendations to improve access and after a number of key presentations, was made public in January 1998. The report was also referred to the Aboriginal and Torres Strait Islander Commission, Privacy Commissioner and more recently to the Racial Discrimination Commissioner. The HIC now participates in a joint working group on improving the access of Aboriginal people to Medicare and PBS with representatives from Health, NACCHO and the Department of Finance and Administration. The group uses information provided by the Keys Young report and the Deeble Report (The Expenditures on Health Services for Aboriginal and Torres Strait Islander People Report 1998) to implement their recommendations. The HIC has drafted a strategic framework covering policy and procedural issues to assist the access of Aboriginal and Torres Strait Islander people and their service providers to Medicare and PBS. The draft strategic framework addresses the recommendations in the Keys Young Report. The following tasks have been identified by the HIC: establish a broad team of both central office and State based staff to work on procedural issues, policies, liaison, fieldwork and education; improve the cultural appropriateness of HIC service provision; develop simplified direct-bill and enrolment forms to use when an Aboriginal person seeks treatment without a Medicare card or number. Develop national procedures for the use of these forms; continue the use of electronic enrolment and other simplified paper enrolment processes covered by a Memorandum of Understanding or other legal arrangement to ensure the privacy and rights of Aboriginal people are protected; develop special procedures in specific geographic areas for payment of pharmacy claims at concessional rates where the consumer can be identified as an Aboriginal person; extend special arrangements under Section 100 of the National Health Act; provide in-the-field support by Medicare staff; provide appropriate telephone hotline advice to service providers treating Aboriginal clients; improve liaison with relevant authorities to ensure that Aboriginal children are enrolled and that multiple enrolments for a child are identified; amend the Medicare system to allow matters such as: issuing duplicate cards to avoid subsequent cards outdating an earlier issue,
modifying arrangements for enrolment of children, allowing a carer to enrol an indigenous child, recording aliases in Medicare records; in consultation and agreement with Aboriginal peak bodies, make a submission to the Privacy Commissioner exploring mechanisms to enable the HIC to amend administrative policies and procedures to assist in delivering Medicare and PBS to indigenous people. The HIC wants to have a mechanism which will facilitate matters such as: modification of the Medicare card replacement program to improve arrangements for cards for Aboriginal people, revised Medicare card production arrangements, revised claim resolution procedures, provision of culturally appropriate information, assist with the identification of multiple records; provide training for HIC staff to improve cultural awareness; and develop a communication strategy covering matters such as education material for service providers, advice on HIC procedures, information material for institutions associated with the care of Aboriginal people and information about Medicare cards and their use. The HIC intends to continue to regularly review the satisfaction of Aboriginal Health Services, service providers, pharmacists and Aboriginal people with the delivery of the Medicare and PBS programs. Legislation The Health Insurance Act states that to be eligible for Medicare benefit a person must be an Australian citizen, and that the person must reside in Australia. In respect of Aboriginal people, particularly those in remote areas, the HIC believes that they are eligible persons, thus enabling the usual requirements for proof of residency to be waived. Eligible service providers will direct-bill Aboriginal people in remote areas for their services. The legislation requires that the process of assigning Medicare benefit to a service provider must be in the form of a signed agreement between the patient and the service provider. HIC procedures allow a person to make a mark when a person is unable to sign. While the HIC can be flexible in the way in which a direct bill claim occurs, it must comply with legislative requirements concerning signatures. Any change from this requirement would require a change to legislation. Section 19(2) This section provides that unless the Minister for Health and Aged Care directs, a Medicare benefit is not payable where the provision of a medical service has been provided under an arrangement with a State, Local Government or the Commonwealth. In respect of many Aboriginal clinics, the Minister has directed that Medicare benefits be paid. It is this Ministerial Order that has allowed
special arrangement to be introduced in Queensland which allows Medicare benefits to be paid for services rendered by salaried doctors in Queensland public hospitals in some areas Privacy The HIC has discussed its ideas in relation to modified arrangements for Aboriginal people with the Privacy Commission and expects to have further discussions with the Privacy Commissioner to ensure that the HIC is complying with privacy requirements. In introducing arrangements the HIC wishes to ensure that Aboriginal people maintain their rights by ensuring that matters such as informed consent by Aboriginal people is obtained. WHAT S BEEN DONE The HIC entered into Memorandums of Understanding (MOU) with the Department of Health in Queensland and the Nganampa Health Council regarding the electronic enrolment of Aboriginal people. The MOUs specifically covered privacy requirements including the need for informed consent of Aboriginal people to the provision of information to the HIC. Discussions are being held with the Department of Health in Western Australia and the Royal Flying Doctor Service in WA to arrange for the use of simplified enrolment and claims processes for Aboriginal people in remote areas. The HIC is attempting to introduce revised eligibility tests without compromising the integrity of the Medicare and PBS programs. The revised approach is based on the assumption that all Aboriginal people in remote areas are eligible because they reside in Australia and are an Australian citizen. Under this policy, where a claim is received for a person with no Medicare number or Medicare enrolment record, and the HIC has confidence that the patient is an Aboriginal person, the HIC will enrol the person and issue a new Medicare number and card. Revised enrolment and direct-bill forms have been introduced to allow for the use of simplified arrangements in remote areas. Particularly in the Northern Territory, the HIC has been active in providing assistance to Aboriginal communities and health services with Medicare enrolment and claims processes. This assistance has included Medicare staff travelling to remote communities to provide information to clinic/community staff about Medicare processes, answering enquiries, training staff, assisting in resolution of problems and updating Medicare records (eg enrolling new born babies). The HIC wishes to extend this type of assistance to other areas. In response to the Keys Young report, the HIC has developed a strategic plan covering policies and procedures to ensure the delivery of Medicare and PBS in a manner which recognises the cultural and demographic circumstances of
Aboriginal people. The plan also involves additional HIC staff resources in each State and Central office to continue to develop and implement revised arrangements in respect of the Medicare and PBS programs. Discussions have been held with the NACCHO on a range of matters affecting the delivery of the Medicare and PBS programs. The HIC is interested in identifying other interested organisations and discussing arrangements for providing access to Medicare and PBS benefits to eligible persons. RISKS FOR THE HIC The HIC is responsible for the administration of Medicare and PBS and must ensure that public funds are correctly controlled. The HIC is aware that the use of simplified arrangements may increase the risk of bogus enrolment records and bogus Medicare claims. As a result, the HIC will initially limit use of the revised procedures to remote areas to ensure appropriate controls are in place before allowing use in other areas of Australia. While the HIC is keen to assist, it must ensure that it exercises appropriate care to avoid any abuse of the Medicare and PBS programs. PBS SECTION 100 ARRANGEMENTS In April 1997 the Minister of Health And Family Services the Hon Dr Michael Wooldridge approved an arrangement under Section 100 of the National Health Act to supply PBS items to all Aboriginal people in remote and isolated regions of Australia. Prior to the implementation of this new arrangement there were three communities in WA that were already in receipt of PBS items under a section 100 arrangement. Under the section 100 arrangement, eligible communities are entitled to: bulk supplies of PBS medicines are made available to Aboriginal Medical Services; the health service provides medications to their clients free of charge based on clinical need; the cost of bulk supply is met by the Department of Health and Aged Care; and the stock of PBS medicines are maintained where necessary by the provision of additional bulk supplies. The HIC and Health proposed a new arrangement for the supply of pharmaceuticals to all eligible Aboriginal Health Services. The arrangement has been agreed by Health, The Pharmacy Guild, NACCHO and the HIC. All parties were congratulated on the outcome by the Chairperson Professor Lloyd Sansom. The arrangement involves: bulk supplies of PBS medicines being made available to a community approved by Health;
the community provides medications to their clients free of charge based on clinical need and keeps a record of the drugs dispensed; the cost of the supply is reimbursed by the HIC through Community Pharmacy; and the stock of PBS medicines are maintained where necessary by the provision of additional bulk supplies. The new Section 100 arrangements will avoid the necessity for an Aboriginal patient to obtain a prescription, present that prescription at a pharmacy, establish entitlement by presenting a health care card and wait for the supply of the required medication which is supplied at no cost to the patient. The current administrative arrangements for pharmaceuticals present barriers to the supply of drugs to individuals in remote areas because of costs and inconvenience. This was identified as a problem area by the Keys Young Report. To be eligible to receive PBS items under the Section 100 arrangement, each AHS will be subject to an approval procedure, the criteria for which will be determined by Health.