EXPLANATORY STATEMENT HS/4/1998
SUBJECT: HEALTH INSURANCE ACT 1973
DETERMINATION UNTIER SUBSECTION 3C(1) TO PROVIDE MEDICARE BENEFITS FOR PERCUTANEOUS TRACHEOSTOMY
Subsection 3C(1) of the Health Insurance Act (the Act) provides that the Minister may, by writing, determine that a health service not already included in the general medical services table (the table) is to be treated as if it were included in the table. Such a determination shall specify a fee in respect of the health service and shall be subject to the provisions of the Act and Regulations as if it were a health service included in the table.
The table, which is prescribed by Regulations under section 4 and section 133 of the Act, contains item numbers for descriptions of and fees in respect of medical services which are, among other things, recognised for the purposes of the payment of Medicare benefits.
A restructure of head and neck surgery services in the table, including a revision of items covering tracheostomy, was introduced from 1 July 1998. The new structure was designed to reflect changes in clinical practice in this area and to recognise the emergence of head and neck surgery as a specialty area of medicine. The review of these services was undertaken in consultation with the Australian Society of Otolaryngology Head and Neck Surgery, the Royal Australian College of Surgeons and the Australian Medical Association under the auspices of the Medicare Benefits Consultative Committee (MBCC).
The Australian and New Zealand Intensive Care Society (ANZICS) subsequently advised that the revised items for tracheostomy did not cater for the percutaneous technique performed in the main by intensivists for the purpose of long term mechanical ventilation of intensive care patients. The previous item covering all tracheostomies regardless of the approach had been changed to specify the open approach, with amendment to a further item to cater for the direct stab or dilatation technique using a Minitrach or similar device. However, ANZICS advised that neither item accurately described the percutaneous procedure which was performed using a dilatation or trachea splitting technique.
At a subsequent MBCC meeting, it was agreed that the percutaneous procedure described by ANZICS is not adequately covered by existing items in the table.
This Determination will provide for the payment of Medicare benefits for percutaneous tracheostomy pending its inclusion in the table at the next amendments to the health insurance regulations.
Overview
The Health Insurance Act 1973, enacted by the Australian Parliament, was introduced to address the need for a comprehensive health insurance scheme in Australia, providing access to essential medical services and financial protection against health-related expenses. The Act establishes a framework for the administration of Medicare, Australia’s universal health care scheme, and allows for the inclusion of various medical services through the general medical services table. The explanatory statement for the 1998 determination under subsection 3C(1) of the Act clarifies that the Minister may determine specific health services not previously included in the table to be recognised for Medicare benefits, pending their formal inclusion through regulation amendments. This particular determination was introduced to rectify a gap in the coverage of tracheostomy services, specifically to recognise and provide Medicare benefits for percutaneous tracheostomy, a technique predominantly used by intensivists for long-term mechanical ventilation in intensive care patients. This decision was made in response to feedback from medical professional bodies, ensuring that the evolving practices in medical care are adequately reflected in the benefits provided.
Scope and Application
The Health Insurance Act 1973 (the Act) applies to the provision of health services, particularly medical services, within the Medicare system in Australia. The Act allows the Minister to determine specific health services to be included in the general medical services table, which outlines the fees for medical services recognised for the payment of Medicare benefits. This legislation impacts all medical practitioners and patients who engage in Medicare-covered services, including those involving tracheostomy procedures. The Act operates on a national level across Australia, as it is a Commonwealth Act. The Determination, issued under subsection 3C(1) of the Act, aims to address a specific gap identified in the medical services table by providing for Medicare benefits for percutaneous tracheostomy. This ensures that the service, which is performed primarily by intensivists for long-term mechanical ventilation of intensive care patients, is adequately recognised and compensated. The Determination will remain in effect until the next scheduled amendments to the health insurance regulations incorporate the service into the table.
Key Provisions
The Health Insurance Act 1973 (the Act) includes provisions that allow the Minister to determine the inclusion of certain health services in the general medical services table (subsection 3C(1)). This determination allows for the specification of a fee for such health services and subjects them to the provisions of the Act and the Regulations as if they were already listed in the table. In this instance, the determination pertains to the provision of Medicare benefits for percutaneous tracheostomy, which was not adequately covered by the existing items in the table.
The Act imposes several obligations and requirements on the parties it governs. Firstly, the Minister is responsible for making the determination under subsection 3C(1), ensuring that the fee for the specified health service is appropriate and that the service is subjected to the relevant provisions of the Act and Regulations. Secondly, healthcare providers are required to follow the guidelines and fees specified in the determination for the provision of percutaneous tracheostomy services. Additionally, the determination must be made in consultation with relevant professional bodies and committees, such as the Medicare Benefits Consultative Committee (MBCC), to ensure that the services accurately reflect current clinical practice and standards.
The Act also includes provisions for civil and criminal consequences for breaches of its provisions. Although the specific penalties are not detailed in the explanatory statement, it is common for breaches of health legislation to incur fines or other penalties as determined by the courts. These penalties are designed to enforce compliance with the Act and ensure the proper administration of Medicare benefits.
In summary, the Health Insurance Act 1973 allows the Minister to determine the inclusion of health services not already covered in the general medical services table, specifying fees and subjecting the services to the relevant provisions of the Act. The determination for percutaneous tracheostomy was made to address the inadequacy of existing items in the table, reflecting current clinical practices. The Act imposes obligations on the Minister and healthcare providers to ensure proper implementation of the determination, and includes provisions for civil and criminal consequences for breaches.