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Health Insurance Amendment (Diagnostic Imaging Services) Bill 1999
Bills Digest No. 24 1999-2000
Health Insurance Amendment (Diagnostic Imaging Services) Bill 1999
This Digest was prepared for debate. It reflects the legislation as introduced and does not canvass subsequent amendments. This Digest does not hav e any official legal status. Other sources should be consulted to determine the subsequent official status of the Bill.
Health Insurance Amendment (Diagnostic Imaging Services) Bill 1999
The Health Insurance Amendment (Diagnostic Imaging Services) Bill 19 99 will amend the Health Insurance Act 1973 to change the mandatory requirements regulating the provision of diagnostic imaging services by medical practitioners.
Diagnostic imaging services range from the f amiliar X-rays and ultrasound to the more high-tech magnetic resonance imaging (MRI), computerised tomography (CT) and nuclear medicine services.
The Health Insurance Act 1973 (the Principal Act) requires that in order for a Medicare benefit to be paid, diagnostic imaging services must only be provided on written request by another medical practitioner. Several exemptions are provided by the Principal Act. Medical practitioners providing diagnostic imaging services under two of these exemptions (remote areas exemption and pre-existing diagnostic imaging practices) are affected by amendments in this Bill. While less than 350 medical practitioners in total are expected to be affected by these changes, a considerable proportion of these are general practitioners operating under the 'remote areas exemption'.
All services, procedures and interventions for which rebates are paid under the Medicare arrangements are contained in the Medicare Benefits Schedule (MBS). Each prof essional service included in the MBS is assigned a unique item number. Each item in the MBS also includes the fee which the Commonwealth Department of Health and Aged Care has assessed as appropriate for each service or procedure. This fee is known as the 'schedule fee' and is important because it is this fee (rather than the fee charged by the practitioner) which is used when the Medicare rebate is calculated.
The MBS comprises several distinct categories or tables:
- General Medical Services: this category includes professional attendances by general practitioners and medical specialists, diagnostic services such as tests for glaucoma and electrocardiography (ECG), and therapeutic procedures such as anaesthetics and surgery.
- Approved Dental Practitioner Ser vices: this category includes the small number of dental services for which a Medicare rebate is payable, including oral surgery.
- Diagnostic Imaging Services: this category includes x-ray, ultrasound, mammography, MRI, CT and nuclear medicine services.
- Pathology Services: this category includes all pathology services covered under Medicare.
A new edition of the MBS takes effect on 1 November each year and updates are issued through the year as required.
'R-type' services, 'NR-type' services and the MBS
Changes to the Principal Act which took effect from 1 May 1991 restricted, except in certain circumstances, the payment of Medicare benefits for diagnostic imaging services. Services affected included diagnostic radiology, CT scanning, ultrasound and nucle ar scanning. These changes required that a Medicare benefit only be payable for a diagnostic service if it is provided following a written request for that service by another medical practitioner. For certain services such as X-rays of particular parts of the body, a medical practitioner may also be a dental practitioner, physiotherapist or podiatrist. The changes also established a separate Diagnostic Imaging Services Table within the MBS. Items of service which are subject to the requirement for a written request are classified as 'R-type' (requested) and the items not subject to the requirement are classified as 'NR-type' (not requested) services.(1)
Certain important exemptions to these requirements were provided for by the legislative changes which took effect in 1991. These included a remote areas exemption and an exemption for pre-existing diagnostic imaging practices. Practitioners operating under either or both of these exemptions are subject to measures proposed by the Health Insurance Amendment (Diagnostic Imaging Services) Bill 1999.
The remote areas exemption aims, predictably, to encourage the establishment of radiology services in areas where they are scarce. A 'remote area' is defined at paragraph DIC.1.1 of the MBS to be one that is more than 30 km by road from a hospital or free-standing radiology service, or one where services are such that patients in the area would suffer physical or financial hardship in accessing them.
The pre-existing diagnostic imaging practices exemption is designed to enable practices which provided 'R-type' services on a regular basis before the 1991 legislative changes to continue to do so. In order to qualify for this exemption, a practitioner must have rendered at least 50 'R-type' diagnostic services, attracting a medicare benefit, in the period 17 October 1988 - 16 October 1990, and in the same location as he or she now practices. The exemption only applies if the practitioner is treating their own patient.(2)
The measures proposed in the Health Insurance Legislation (Diagnostic Imaging Services) Bill 1999 continue moves by successive Commonwealth Governments during the 1990s to enhance the quality of medical services. For example, recognition of the importance of continuing medical education by both government and the profession has resulted in the introduction of the vocational register for general practitioners. Enhancement of quality has also underpinned a variety of initiatives directed towards the prescribing, dispensing and consumption of pharmaceutical drugs as well as measures to improve patient care within public hospitals.
Medical practitioners who have been providing diagnostic imaging services under exemptions conferred by legislative changes which took effect in May 1991 have not been required to participate in quality assurance and continuing medical education activities. Changes proposed in this Bill will now require these practitioners to enrol and participate in an approved continuing medical education and quality assurance program in the field of diagnostic imaging in order for a Medicare benefit to be provided for their services. Ultimately, the aim of such programs is the achievement and maintenance of high quality services for patients. Much is asserted about the high quality of Australia's health system, however it can be argued that in order to assure the provision of quality services in all aspects of medical practice and in all parts of the country, continuing medical education and quality assurance programs need to be in place and need to be compulsory.
Items 1 and 2 amend section 16B of the Principal Act, which deals with the payment of Medicare benefits for 'R-type' diagnostic services. Section 16B provides that, subject to specified exemptions, a benefit will only be payable when the service is requested in writing by a medical practitioner, or in respect of certain 'R-type' services, by a dental practitioner, a chiropractor, a physiotherapist or a podiatrist. Subsection 16(7) contains the remote areas exemption and subsection 16(11), the pre-existing diagnostic imaging practices exemption.
Each item inserts in the respective subsection(3) a new paragraph which makes the exemption conditional on the practitioner being registered as a participating practitioner in the Register of Participating Practitioners. The subparagraph allows a period of grace for a practitioner to register initially: the exemption will continue to apply for a month after the commencement of the new provision, or such further period as the Health Insurance Commission (HIC) may allow.
Item 3 then inserts new Division 1A in Part IIB of the Principal Act, establishing a framework for the approval of continuing medical education and quality assurance programs in the area of diagnostic imaging, and a register of practitioners who participate in such programs (known as the Register of Participating Practitioners).
New section 23DSB provides that the Minister for Health may approve a continuing medical education program or a quality assurance program in respect of providers of diagnostic imaging services. In giving approval, the Minister may specify a standard that a practitioner has to reach, or requirement that a practitioner has to satisfy, within the program. New subsection 23DSB(3) provides that approvals given under the section are disallowable instruments within the meaning of the section 46A of the Acts Interpretation Act 1901 . This means that the programs must be tabled in Parliament and are subject to disallowance by either House.
New section 23DSC concerns the Register of Participating Practitioners. The register is to be maintained by the HIC. New paragraphs 4(a), (b) and 5(a) require the HIC to register upon commencement of the new Division, all practitioners who held either a remote areas or pre-existing diagnostic imaging practices exemption under the Principal Act prior to the commencement of the new Division. The HIC is also required under new paragraphs 4(c) and 5(b) to register upon receipt of notice, any practitioner in respect of whom either the Royal Australian College of General Practitioners (RACGP) or the Australian College of Rural and Remote Medicine (ACRRM), gives notice of participation in a program approved under new section 23DSB. The HIC is obliged to give a practitioner written notice of their registration and the date upon which it commenced (new subsection 6) and the HIC may also make this information available to either the RACGP or ACRRM (new subsection 7).
New section 23DSD deals with the removal of practitioners from the Register of Participating Practitioners. Deregistration can occur in three different ways:
- the RACGP and ACCRM inform the HIC that a practitioner ceases to be enrolled in, or participate in, an approved program, or has not reached a specified standard or sa tisfied a specified requirement within the program: new paragraph (1)(a); or
- a practitioner fails to enrol or participate in an approved program after the expiry of the period of grace: new paragraph (1)(b); or
- a practitioner requests to be deregistered: n ew paragraph (1)(c).
New subsections (2) - (4) set out the procedure which the HIC must follow in deregistering a practitioner. The HIC must give the practitioner written notice of their deregistration, specifying in the notice that they will no longer be included on the Register of Participating Practitioners, from a date at least 14 days after the date of the notice. The HIC must then enter in the Register a statement stating the practitioner has ceased to be registered, and the date when that occurred.
An important issue in relation to the Bill is unresolved at the time of writing. The quality assurance program and standards which the Bill proposes to be established by regulation are still under development by the ACRRM, the RACGP and the Royal Australian and New Zealand College of Radiologists. Tension (or at least poor communication) between the ACRRM and the RACGP was apparent as recently as June 1999 over the issue of mandatory continuing medical education for non-specialist providers of diagnostic imaging services. For example, the ACRRM reportedly claimed in a recent newsletter that the RACGP had 'attempted to close a deal' with the Royal Australian and New Zealand College of Radiologists on the issue and that 'once again, there was no consultation with ACRRM'.(4)
1. Department of Health and Family Services, Medicare Benefits Schedule book: operating from 1 November 1998 , Canberra, Department of Health and Family Services, 1998, p. 338.
2. Section 16B(7) of the Health Insurance Act 1973 .
3. Item 1 inserts new paragraph (e) into section 16B(7) and item 2 replaces paragraph (d) in subsection 16B(11).
4. K Murphy, 'RACGP denies secret rural radiology deal', Australian Doctor , 18 June 1999.
Andrew Grimm an d Paul Mackey
4 May 1999
Bills Digest Service
Information and Research Services
This paper has been prepared for general distribution to Senators and Members of the Australian Parliament. While great care is taken to ensure that the paper is accurate and balanced, the paper is written using information publicly available at the time of production. The views expressed are those of the author and should not be attributed to the Information and Research Services (IRS). Advice on legislation or legal policy issues contained in this paper is provided for use in parliamentary debate and for related parliamentary purposes. This paper is not professional legal opinion. Readers are reminded that the paper is not an official parliamentary or Australian government document. IRS staff are available to discuss the paper's contents with Senators and Members and their staff but not with members of the public.