Health Insurance Commission Regulations (Amendment) (Cth)

Statutory Rules 1996

No. 159 1

__________________

Health Insurance Commission Regulations 2(Amendment)

I, The Governor-General of the Commonwealth of Australia, acting with the advice of the Federal Executive Council, make the following Regulations under the Health Insurance Commission Act 1973.

Dated 17 July 1996.

 WILLIAM DEANE

 Governor-General

By His Excellency’s Command,

MICHAEL WOOLDRIDGE

Minister for Health and Family Services

____________

1.   Commencement

1.1   These Regulations commence on 1 August 1996.

2.   Amendment

2.1   The Health Insurance Commission Regulations are amended as set out in these Regulations.

3.   Regulation 3P (Additional functions of the Commission: the Better Practice Program)

3.1   Subparagraph 3P (1) (b) (i):

Omit “Program;”, substitute “Program, and to cancel participation in the Program by general medical practices that cease to comply with the relevant criteria under subregulation (2);”.

3.2   Subparagraph 3P (1) (b) (ii):

Omit “to make decisions”.

3.3   Paragraph 3P (2) (a):

Omit “make”, substitute “subject to subregulation (2A), make”.

3.4   Subparagraph 3P (2) (a) (ii):

After “30 November 1995”, insert “and before 1 August 1996”.

3.5   After paragraph 3P (2) (a), insert:

• “(aa)

  in relation to applications lodged with the Commission after 31 July 1996—make the decisions:

  • (i)

    in the case of decisions made under subparagraph (1) (b) (i)—in accordance with criteria stated in the document known as ‘Eligibility Criteria for the Better Practice Program’ published by the Department in July 1996; and

  • (ii)

    in the case of decisions made under subparagraph (1) (b) (ii)—in accordance with the formula set out in Schedule 2A; and”.

3.6   After subregulation 3P (2), insert:

 “(2A) The Commission must calculate amounts payable for any payment quarter after 31 July 1996 in accordance with the formula set out in Schedule 2A.

 “(2B) During the period after giving notice of a decision under paragraph (2) (b) and before receiving any application under subregulation (3), the Commission may reconsider a decision it has made under paragraph (1) (b) to correct a decision on the basis of:

• (a)

  further information received by it; or

• (b)

  an error that has been made in making a decision.”.

3.7   Subregulation 3P (4):

Omit “On receiving”, substitute “In reconsidering a decision under subregulation (2B), or on receiving”.

3.8   Paragraph 3P (4) (a):

Omit the paragraph, substitute:

• “(a)

  reconsider or review the decision in accordance with the relevant criteria and formula mentioned in subregulation (2) that applied for the purposes of the decision; and”.

3.9   Paragraph 3P (4) (b):

Omit “review” (wherever occurring), substitute “reconsideration or review”.

3.10   Subregulation 3P (5):

Omit the subregulation, substitute:

 “(5) Where the Commission makes a reconsidered decision under subregulation (2B) or (3), the Commission must promptly give a notice of the decision to the nominated persons who lodged the application to which the decision relates, being a notice that contains:

• (a)

  the terms of the decision; and

• (b)

  statements to the effect that:

  • (i)

    a copy of the reasons for the decision may be obtained from the Commission on request in writing; and

  • (ii)

    in the case of a decision made following a reconsideration under subregulation (2B)—application may be made under subregulation (3) for internal review of the decision by the Commission; and

  • (iii)

    in the case of a decision made following an internal review under subregulation (3)—application may be made under subregulation (7) for a review of the decision by the Administrative Appeals Tribunal.”.

3.11   Paragraph 3P (6) (b):

Omit “subparagraph 5 (b) (i) or (ii)”, substitute “sub-subparagraph (5) (a) (ii) (A) or (B) or paragraph (5) (b)”.

3.12   Subregulation 3P (7):

Omit

 the subregulation, substitute:

 “(7) Application for review of a reconsidered decision may be made:

• (a)

  in the case of a decision that is made following a reconsideration under subregulation (2B)—under subregulation (3) to the Commission; or

• (b)

  in the case of a decision that is made following a review under subregulation (3)—under the Administrative Appeals Tribunal Act 1975 to the Administrative Appeals Tribunal.”.

3.13   Add at the end:

 “(9) A general medical practice is not eligible to participate in the Program if a medical practitioner who currently provides services at the practice has refused consent to the use of data held by the Commission for the purposes of assessing eligibility under subparagraph (1) (b) (i).

 “(10) Subject to this regulation, a decision that a general medical practice is eligible to participate in the Program has effect for the 4 payment quarters following the decision.

 “(11) In this regulation, a reference to a ‘general medical practice’ is taken to be a reference to:

• (a)

  all medical practitioners who are providing services at the practice; and

• (b)

  all medical practitioners who:

  • (i)

    have provided services at the practice during the period of 18 months immediately before the application is made in respect of the practice; and

  • (ii)

    whose details are included in the application or information later provided to the Commission.

“(12) In this regulation:

‘lodged’, in relation to an application, means received by the Commission.”.

4.   New Schedule 2A

4.1   After Schedule 2, insert:

 “SCHEDULE 2ASubparagraph 3P (2) (aa) (ii)

BETTER PRACTICE PROGRAM PAYMENT FORMULA

Interpretation

 1. In this Schedule:

‘all practices’ means all general medical practices for which an amount is payable in respect of the quarter in which the amount payable is to be paid;

‘patient’ means a patient who has had an attendance, for which a benefit has been claimed under the Health Insurance Act 1973, at a general medical practice within a period of 1 year ending 4 months before the start of the quarter in which the amount payable to the practice is to be paid;

‘relevant practice’ means a general medical practice that has the same RRMA category as the practice for which the amount payable is calculated;

‘RRMA category’ means the rural, remote or metropolitan area category referred to in Rural, Remote and Metropolitan Areas Classification, 1991 Census Edition, published by Australian Government Publishing Service, November 1994;

‘schedule fee’ means the fee applicable to an attendance on the date of the attendance as set out in a table of medical services made by regulations under subsection 4 (1) of the Health Insurance Act 1973.

Data

 2.(1)The amount payable to a practice is calculated from data held by the Commission that:

• (a)

  concern claims for benefits under the Health Insurance Act 1973 or the Veterans’ Entitlements Act 1986 for attendances as set out in items numbered not greater than 98 in a table of medical services made by regulations under subsection 4 (1) of the Health Insurance Act 1973; and

• (b)

  in the case of a decision made under subparagraph  3P (1) (b) (ii):

  SCHEDULE 2A—continued

  • (i)

    relate to claims for benefits in relation to attendances during the period of 12 months ending 4 months immediately before the start of the quarter in which the payment is to be made; and

  • (ii)

    have been processed by the Commission, and extracted for the purposes of calculating the amount payable, before the decision is made; and

• (c)

  in the case of a decision made following a reconsideration or review:

  • (i)

    relate to claims for benefits in relation to attendances during the period of 12 months ending 4 months immediately before the start of the quarter in which the payment that is the subject of the reconsideration or review was, or would have been, made; and

  • (ii)

    have been processed by the Commission, and extracted for the purposes of calculating the amount payable, before the decision is made.

 (2) For the purposes of calculating the amount payable the Commission may use data relevant to the general medical practice that is not data for which the relevant medical practitioner has refused consent for its use by the Commission.

Formula

 3. The amount payable to each eligible general medical practice is the amount worked out using the formula:

• [Practice size]  

   [Continuity] [Rural loading]

($0.50 x SWPE) + ($2.00 x x SWPE) + ($2.50 x RLF x SWPE)

where:

 ‘SWPE’ (standardised whole patient equivalent) is the sum of:

 FC x weighting factor

SCHEDULE 2A—continued

 for each patient who has claimed a benefit in relation to the practice under consideration.

 ‘FC’ (fraction of care) is the amount worked out by dividing the schedule fee value of attendances by the patient with the practice by the schedule fee value of attendances by the patient with any medical practitioner who has been allocated a provider number within the meaning of the Health Insurance Regulations.

 The ‘weighting factor’ relevant to each patient is the amount set out in the following table:

Sex	Age of patient on the last day of the reference period (years)
< 1	1–4	5–14	15–24	25–44	45–64	65–74	≥75
Male	0.867	1.109	0.616	0.593	0.703	0.932	1.483	2.088
Female	0.806	1.035	0.625	0.913	0.999	1.162	1.596	2.342

 

  ‘APCI’ (adjusted patient continuity index) is an amount calculated according to clause 4.

 ‘RLF’ (rural loading factor) for a practice is the amount set out in the following table opposite the RRMA category applicable to the practice:

RRMA category	Rural loading factor
Capital city	0.00
Other metropolitan centre	0.00
Large rural centre	0.15
Small rural centre	0.20
Other rural area	0.40
Remote centre	0.25
Other remote area	0.40

SCHEDULE 2A—continued

Adjusted Patient Continuity Index

 4.(1) Subject to subclauses (2) and (3), APCI is the amount worked out using the formula:

+ 0.5

where:

 ‘PCI’ (patient continuity index) is the sum of the FC of each patient in respect of the practice under consideration who is the subject of more than 1 attendance at the practice, divided by the number of those patients who are the subject of more than 1 attendance at the practice.  If the number of those patients is 0, PCI is 0.

 ‘MPCI’ (weighted mean patient continuity index) is the amount worked out in the following manner:

• (a)

  sum, for all relevant practices, the SWPE for each practice multiplied by the PCI for that practice;

• (b)

  divide by the sum, for all relevant practices, of the SWPE for each practice.

 ‘standard deviation’, for the practice under consideration, is the weighted standard deviation of the PCIs for all relevant practices, worked out in the following manner:

• (a)

  sum, for all relevant practices, the square of the PCI for each practice multiplied by the SWPE for that practice;

• (b)

  multiply the square of MPCI of the practice under consideration by the sum, for all relevant practices, of the SWPE of each of those practices;

• (c)

  subtract the amount obtained under paragraph (b) from the amount obtained under paragraph (a);

• (d)

  sum, for all relevant practices, the SWPE of each of those practices;

• (e)

  subtract 1 from the amount obtained under paragraph (d);

SCHEDULE 2A—continued

• (f)

  divide the amount obtained under paragraph (c) by the amount obtained under paragraph (e);

• (g)

  take the positive square root of the absolute value of the amount obtained under paragraph (f).

 (2) If the APCI is more than 1, it is reduced to 1.

 (3) If the APCI is less than 0, it is increased to 0.”.

_______________________________________________________

NOTES

1. Notified in the Commonwealth of Australia Gazette on 24 July 1996.

2. Statutory Rules 1975 No. 27 as amended by 1976 Nos. 21 and 146: 1982 No. 249: 1983 Nos. 88 and 152; Act No. 54, 1983; Statutory Rules 1984 No. 321; 1985 Nos. 41 and 70; 1986 No. 127; 1987 No. 165; 1989 Nos. 55, 96 and 195; 1991 No. 443; 1992 No. 241; 1993 Nos. 81, 89, 197 and 217; 1994 Nos. 102, 257, 404 and 450; 1995 Nos. 24, 286, 375 and 440.