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Remote & rural medicare EPC

Discussion in 'Australia' started by Greg Fyfe, Apr 30, 2008.

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  1. Greg Fyfe

    Greg Fyfe Active Member


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    Hi

    I'm working for an aboriginally controlled organisation providing service to remote indignous clients in the NT.

    These are communities smaller than 2000 popln, with a resident remote nurse and visiting GP.

    I am able to claim reimbursement for clients on care plans via the medicare allied health epc process.

    While the main focus of this scheme was to improve access to private providers, aboriginally controlled organisations are able to claim


    It is not often that I get an epc referral . The obvious difficulty is lack of Gp referral.

    My impression is that this is a product of

    1/ a lack of awareness by the GP of the referral process. With a rapid rate of staff turnover the GP is often someone still getting orientated to the new workplace

    2/ The Organisation the GP works for also has a rapid rate of staff turnover and is often understaffed. This compromises the support they can offer the GP as well as visiting health professionals

    3/ With the low number and frequency of allied health service providers to remote communities GP's and health Services are not used to having any professionals to refer clients to. Understandibly they stop referring as they have enough to do already.

    I'd be interested to hear

    1/ Other peoples experiences and what changes may improve the scheme.

    2/ of any links/ medicare reports etc re how the allied health epc scheme has played out in improving access for clients for podiatry or across the allied health professions.

    Cheers
    Greg
     
  2. Asher

    Asher Well-Known Member

    Hi Greg,

    I too have been disappointed with how the Medicare - Allied Health thing has worked out. It seems you have quite some elements working against you in NT, leading to a low referral rate. In my town (Esperance WA), we have a population of 14,500 and about 10 GPs. Although I receive many referrals from all GPs and have a great relationship with them all, when it comes to the EPC Medicare referrals, I have recieved about 4 in total since it started. I have one ongoing patient that I see via Medicare.

    One GP did actually say he is not prepared to do the paperwork to get it going, in spite of how beneficial it would be for certain patients. I have approached them all via their practice managers with info on how to do it, why its important etc etc, but to no avail. I can only assume that all of the GPs think the same way. The physio has gone to even greater lengths than me to get the system going, with no success.

    Not only that, my practice manager is at her wits end :craig: with Medicare staff in regard to the claims side of things. There is so much run around involved its not funny. Each time you call, you get different advice. Maybe the GPs get the same thing at their end.

    I don't really know what can be done to fix it. But its not working for me or my town.

    Rebecca
     
  3. pd6crai

    pd6crai Active Member

    Rebecca, in Kalgoorlie we had a few patients recently as inpatients and I had recommended that they got an epc referral to see you.

    They said they had never heard of it. Then I did wonder if I had got the wrong end of the stick. Maybe if enough patients badger them they may cave.

    In saying that alot here havent heard of it, and I think it is the new Drs that arent aware that the scheme exists, the older more experienced GPs use the system.

    I am glad that it does exist and I wasnt talking through my hat!!!!

    Good luck trying to get that sorted! :)
     
  4. Two Shoes

    Two Shoes Member

    In my part of NSW (Riverina) GPs are pretty much on the ball and we receive a good number of EPC referrals. It does seem to work well, for the most part.

    Interestingly, at a recent meeting with other Allied Health professionals, the issue of GP payment for initiating an EPC was raised.

    For example, it was suggested that a GP is paid about $200 for kicking off the plan, then the Allied Health professional is paid about a total of $200 for 4-5 visits (this figure is likely to vary depending on the practitioner).
     
  5. ely

    ely Member

    Background:

    • I've started working rurally recently, and was surprised people in my area (especially community nursing staff, discharge planners, residential care facilities, much less patients) didn't seem to be aware of EPC; I've been in other rural and metro areas where it was a core part of business, and it was a bigger worry that people who probably didn't need podiatry services under EPC were being referred in that manner. I've heard of one or two GPs around who are hostile to EPC, who won't write the care plans, apparently because of time, or "not believing in it" (I haven't spoken to these GPs though).

    MBS rebates:
    • From what I can tell the rebate for the initial care plan for non-residential care facility residents is 127.70, then for the team care arrangement is 101.15... (both items are needed to accessed allied health services?); it's less for residential aged care facility residents and for reviews of the care plan.

    I'm working in the public sector, and for a few reasons am keen to promote EPC (although don't know if it's a reasonable thing for me to be doing)... Hopefully in 12 months time I'll have more idea of how it's working out here.

    Strategies I'm using at the moment:
    • writing letters back to GPs regarding people who are ineligible for ongoing care in the public sector(still awaiting feedback on the success of that)
    • Mentioning public/private sector roles and EPC when promoting my service to GPs (I have a probably naive hope that private sector podiatrists could be the first port of call for non-acute patients)
    • I have a couple of handouts from the medicare website on EPC and allied health that I give to patients to take to talk to GPs and give to other relevant staff (particularly with respect to community nursing and discharge planning).

    Hopefully awareness is key? And patients, other health service staff etc, encouraging GPs to fill in the forms? The Item 721 notes explicitly state that Aboriginal Health Workers can help the GP prepare the care plan, which might be relevant for your situation Greg? Not sure if you have the same issues with AHW turnover as part of the staff issues in general there.

    Good luck, sounds like a great job, for many reasons!
     
    Last edited: Apr 30, 2008
  6. Greg Fyfe

    Greg Fyfe Active Member

    Thanks Ely

    With regard to the ? in the quote below.


    MBS rebates:
    • From what I can tell the rebate for the initial care plan for non-residential care facility residents is 127.70, then for the team care arrangement is 101.15... (both items are needed to accessed allied health services?); it's less for residential aged care facility residents and for reviews of the care plan.

    To be eligible for epc referral clients do need to have both a claimed 721 (GP plan) and 723 ( Team care Arrangement) or a 727 ( Review) in the past 2 years and GP's must use the approved referral form.


    I have found that if I have a list of referrals in advance I can fax it to the medicare office and they are able to tell me who is eligible.

    Interestingly I have also had the experience of a service being reluctant to refer as they prefer to refer clients to allied health staff within their own organisations and gain additional income. This includes referring to ,Aboriginal Health Workers, who are also eligible to claim these allied health items under this initiative.

    I suspect my situation is fairly unique. I would be interested to hear from any other allied health personell working within the indigenous context.

    Cheers
    Greg
     
  7. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    Greg

    Thank you for raising this important issue. I think it is high time we stood back as a profession and passed a critical eye over the way Medicare EPC has unfolded, and what can be done to better improve the system.

    Though not dealing with an ATSI population I have had quite a deal of experience in the program despite being in a metropolitan location. I am currently working on a project with my local Division of GPs to improve the uptake of EPC be GPs in our area. That's another story though.

    There are a few observations I would like to make;

    * Reluctance from GPs to refer typically is related to a time issue, despite the fact they are well reimbursed for what is essentially a spread sheet activity that is spat out of Medical Director.
    * GPs that do refer well are typically employing a practice nurse (with assistance under the Practice Nurse scheme) to do the Care Plans, and they are signing off and making good money
    * There has been, and will continue to be, an upswing in GPs using the program as they watch their colleagues generate significant incomes, for what is essentially a no-brainer exercise in massaging the system for economic benefit
    * The government will recognise this very soon, and change the system again
    * Medicare EPC *has not changed* what was already occuring anyway in terms of appropriate referrals before it was conceived and implemented, and has not achieved anything other that giving rebates for a small number of allied health services to a small section of the community

    For the purposes of improvement to the system, I would argue the following would improve outcomes and save considerable taxpayer funds.

    * Remove the requirement for a Care Plan to exist for a GP to refer under Medicare EPC (ie just refer the bloody patient if thats what you want to do!)
    * Remove the requirement for a GP to refer a patient for a patient to claim a rebate. As exists in the US, if the patient meets appropriate criteria, then the podiatrist can be the one to advise the patient if a rebate will apply. They were going to come and see you anyway!
    * Medicare EPC payments to allied health professionals are inconsistent with the costs of providing the service, and have taken 'one size fits all' approach. Podiatry has been short changed, as the costs of providing podiatry services far exceeds other professions (eg dietetics) which rely on minimal overheads. For me to treat an active diabetic foot ulcer under Medicare EPC I need to charge far in excess of the rebate.
    * Podiatry consultations and interventions should therefore be funded at the same rate as dentistry has been under the dental program, as this is the closest economic comparator to podiatry

    This post probably come across harshly against GPs. But I feel the *system* provides many incentives for GPs to simply do the job that they are already getting paid to do through the rebate on their consultation. I find it odd that GPs should be payed "Practice Incentive Payments", Information Technology incentives, Immunisiation Payments are a host of other "incentives" on top of the payment for their consultation. Care Plan preparation hence seems to me to be a completely ineffectual process producing limited benefit for the community (except the hip pockets of GPs).

    Can any other profession receiv taypayer funding, on top of their standard fees, just to do what they are trained to do? I bet my accountant would love to.

    Too cynical? Maybe its just that I recently went to a meeting where a GP said they couldn't be bothered writing a proper specialist referral letter, which included history and examination findings, because they didn't get paid to...:rolleyes:

    LL
     
  8. DAVOhorn

    DAVOhorn Well-Known Member

    Dear All,

    As a foreigner, alright UK pod working here, a major point seems to have been missed by this discussion.

    For an EPC plan to be invoked the patient has to have a Formal Care Plan for an omgoing Chronic health problem. They must be under the care of two Consultants for this to be done.

    So as far as i can see the typical EPC eligible patient would be :

    1: Diabetic under Endocrinologist and Cardiac

    2: Rheumatoid under Rheumatologist and Orthopaedics

    3: Vascular under Vascular Surgeon and Cardiologist

    4: Neurological under Neurologist and Vascular

    The reason for the EPC plan referral system was introduced was to provide ongoing AHP care for those who previously were seen at the Hospital but who now have been discharged to Private Practice.

    Certainly in my area we see many diabetics and Rh vascualr and neuro patients under EPC plans. Most of whom were previously seen at the Hospital . Now only Ulcer and at risk foot care is provided at At Risk Foot clinics. And at the practice i work at we refer ulcer pts to the Hospital at risk foot clinic for ulcer intensive tt . These pts are then referred back to us on resolution.

    The pt refund via medicare is 85% up to a maximum of $47.85 rebate.

    I hope that my understanding of how the Medicare rebate under and EPC plan is correct.

    Also of note is that the plan covers a TOTAL of a max of 5 appts in 1 year for all AHP's NOT FOR EACH.

    So maybe our pts have elected to see a physio dietitian instead of US.:bash:

    regards David:drinks
     
  9. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    David

    There were many reasons CDMP/EPC was developed, the least of all was probably for finding a place to discharge tertiary patients into the community.

    To quote DoHA, "The Enhanced Primary Care (EPC) program was introduced to provide more preventive care for older Australians and improve coordination of care for people with chronic conditions and complex care needs. The program provides a framework for a multidisciplinary approach to health."

    ...whatever that means.

    However, if you read between the political lines on this decision, there was a conscious effort from the Commonwealth to introduce non-medical health professionals into the Medicare funding mix. This had to be done as a gradual, subordinate approach so as to keep the AMA, RACGP and others onside on not threaten them with a 'loss of control', or more importantly 'reduced economic benefit'.

    In reality we all know tht 5 visits per year across about 15 professions for a "chronic or complex condition" is tokenistic at best. To then pay GPs a bucket to rationalise a referral decision they would have already made without EPC being around reads to me as just another 'incentive' to keep them happy whilst the 'feds' slip allied health gradually into the Medicare funding pool.

    Please remember that the Medicare rebate is an arbitrary figure determined by the Commonwealth, that is *typically* based on 85% of the scheduled fee (also determined by the Commonwealth). Interestingly, the *sheduled fee* for allied health services under EPC mysteriously 'dissapeared' at the last published update in November 2007. Call me a conspiracy theorist, but I feel there is a reason for this...Allied health, being as apolitical and subservient to medicine as ever has not even made any mention of this very peculiar anomaly.

    Lets see what federal Labor starts to do with this quirky little project.

    LL
     
  10. ely

    ely Member

    Really????
    I was under the impression it was the generic, doesn't resolve in x number of weeks/months definition they were using... from memory it was 6 weeks or 3 months or 6 months (I have the fact sheet at work). I don't see how being under the care of 2 specialists would be workable in rural areas, given the lack of specialist cover (where I work, we have no endocrinology, rheumatology, vascular or orthopaedic visiting service). And I think for over 75s I wasn't sure if the chronic disease thing applied?
    Sorry to run off topic a touch.
    Regards,
    E.
     
  11. Stuart Blyth

    Stuart Blyth Active Member

    Yep, the plans have nothing to do with age, the patient needs to have a chronic health condition that has been or is likely to be present for longer than 6 months.

    The plan must be made up by the GP/practice nurse etc by adding 2 other members i.e. a Pod and a diabetes educator or another health practitioner,even a pharmacist will do if they are talking multiple medications.

    cheers
    Stuart
     
  12. pgcarter

    pgcarter Well-Known Member

    I'm in Lakes Entrance......EPC'S are all about how organized the GP is. One local practice has two family members as GP'S, they have a nurse who expedites all the paperwork.......they get alot done.....the other practice....hardly ever.....same population base.
    regards Phil
     
  13. RStone

    RStone Active Member

    I'm in a rural area and we have a lot of GPs across the very large area we cover. I have found several things with the EPC plans

    1. Those doctors that normally use computer software packages and normally supply careplans or printed referrals tend to refer quite a lot of EPCs - probably because their programs and staff are used to this type of work.

    2. Once my receptionist and I got our heads around the referral system (ie pt sees GP and signs a 721 and then returns a week later for review and signs a 723 which allows allied health involvement and then sends referral with pt to podiatrist etc) it was much easier because we could explain it ad nauseum to the GP support staff.

    3. We and the GPs received a lot of conflicting information from Medicare - I guess with all the paperwork that they receive it simply wasn't worth the hassle trying to sort out the mess for a lot of GPs initially - they also received less information in relation to EPCs than we did.

    4. As a practice we only charged the $47.85 rebate, not the full amount but what really helped with the paperwork was telling, first the GPs and then the patients when they made an appointment, that the patient would pay us up front for the consultation and then claim it back at medicare. This helped for several reasons:
    i) it meant we received our money immediately instead of waiting 6 weeks only to find that payment was rejected,
    ii) patients were happy to pay because they were in effect getting a free consult once they received the rebate back - however they still made an effort with treatment because it cost them something up front.
    iii) if a patient didn't get their rebate from Medicare (and we make absolutely sure we have all the appropriate information like referral date/expiry, GP and provider number and correct code - 10962 on our receipts) it meant they chased it up with the GP rather than us having to deal with the GP (besides which the GPs can't back date a care plan if it wasn't filled out correctly initially which means we didn't get paid!). GPs seem to learn things when patients complain, not necessarily when the podiatrist doesn't get paid :)
    iv) If a GP has mistakenly referred a patient to us for 5 visits and the dietitian for a further 3 (obviously more than the 5 allowed across all disciplines) we still get paid for our consult and the GP gets to explain to the patient why medicare won't pay for the extra three consultations.

    We have a number of GPs who are quite worried about being audited so we always send our reports on our medicare consultations to the GP on the same day we see the patient - we have seen quite an increase in EPC referrals since they receive reports quickly.

    We also do NOT EVER tell the patient that they are eligible for and EPC from the GPs (particularly as some of the GPs WILL NOT take part in the EPC process) - we tell the patient that it is entirely up to the GP to determine whether they are eligible and that they must discuss it with their GP - I find the GPs prefer this because they don't feel railroaded into referring. In addition if the GP gets audited I'm not responsible for any referral they send me that is inappropriate.

    Several other points with EPCs to remember
    - medicare insists on a minimum 20 minute appointment for patients under EPC plans - if you are audited can you prove that you have spent 20 minutes with them? (An appointment schedule/day list showing you allow 30 minutes is one way to help prove this)
    - reports must be submitted covering each visit with you the patient has
    - dentists have lost their EPC status as patients were receiving a much higher rebate on items (such as dentures) then any of the private health funds were giving (a bit rough on the dentists since they didn't determine the medicare rebate)

    Above all - patient (as in time consuming, temper keeping, non-frustrating communication) with patients, GPs and Medicare is required initially with GPs new to the EPC concept.

    Anyway this is my experience with and understanding of EPCs - as far as I know it's correct but more than willing to be corrected if I'm in the wrong :)

    RStone
     
  14. Stuart Blyth

    Stuart Blyth Active Member

    Hi Rstone

    In our experience they learn not to do EPC's anymore!
    This requirement was dropped in 2006 you only have to report after the first and last visit on a referral or after a significant event in patient care

    Cheers

    Stuart
     
    Last edited by a moderator: May 20, 2008
  15. RStone

    RStone Active Member

    Hi Stuart

    Cheers for that - you are right - what I actually meant to say is that the report has to cover what treatment you have performed (ie you can't send a report off after the initial appointment and then not send any further reports at the end)

    Your way of saying is so much clearer :eek:

    RStone
     
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