Historical publications
Medicare Statistics - September Quarter 2007
Explanatory notes, information on interpretation of data and strengthening Medicare measures
- Care should be exercised in interpreting changes in the utilisation of Medicare services over time. Changes in the utilisation of services over time may reflect structural changes to the Medicare Benefits Schedule (eg the introduction of pathology patient episode initiation items to the Medicare Benefits Schedule in early 1992, has added approximately 15 million services to Medicare, with no change in the coverage of Medicare). Changes in the utilisation of services may also reflect population growth and net migration, ageing of the population, cost shifting (services previously provided by States/Territories at no charge or services which should more appropriately be performed under public patient arrangements, are being charged under Medicare), minor additions of new items to the Medicare Benefits Schedule and changes to the coverage of Medicare as a result of Government policy.
The data incorporated in this report reflect the period in which claims were processed. Care should be exercised in interpreting quarter on quarter movements in utilisation, due to the seasonal nature of use of certain types of services (eg non-referred attendances have sessional peaks in the June and September quarters each year). Furthermore, the timing of Easter each year can affect interpretation of movements in utilisation of services between the March and June quarters of successive years. Different processing rates for the same State/Territory in the same quarter of successive years, can also affect interpretation of data and may not be indicative of the rate of utilisation of services in the corresponding periods.
In the broad type of service tables, attendances involving general practitioners/vocationally registered general practitioners (GP/VRGP) are distinguished from enhanced primary care, other non-referred attendances and practice nurse services. In interpreting fee charged, Schedule fee and benefit paid, the data for GPs do not include income received from other Australian Government payments such as the Practice Incentives Program (PIP).
Fee charged data in the attached tables reflect amounts contained on accounts submitted to Medicare Australia for payment. For bulk billed services, the fee charged is equal to the benefit paid. For patient billed services paid by Medicare Australia prior to the account being settled with the medical practitioner, the fee charged will reflect the amount recorded on the account. This may not be subsequently received by the medical practitioner, since some practitioners accept the Medicare benefit as full settlement of the account and some provide discounts for early payment. Data on average patient contributions per service must be treated with caution due to uncertainty about final payment of accounts because of this discounting.
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Explanatory Notes
1. These tables contain summary data relating to Medicare for the latest quarter, together with data for earlier quarters and financial years. The 'A' series tables present data by State/Territory of patient, the 'B' series tables present data by broad type of service as defined below, the 'C' series tables present data by broad type of service and by enrolment State/Territory of patient, while the 'D' series tables present data by gender and age range and by State/Territory of patient, the 'E' series tables present data by electorate and the 'F' series tables present data for selected items by State/Territory of patient. The data have been compiled from summary files maintained by the Department of Health and Ageing.
2. Each working day Medicare Australia passes to the Department of Health and Ageing details of claims processed on the previous working day. These records are edited and aggregated into special summary files which are designed to assist with the development and review of health policy, particularly as it relates to Medicare.
Scope and Coverage of the Statistics
3. Data in the attached tables relate to services on a 'fee-for- service' basis for which Medicare benefits were paid in the period in question. The data reflect the quarter/year of processing rather than the quarter/year of service. Excluded are details of:
(a) services rendered free-of-charge in recognised hospitals;
(b) services rendered under an entitlement conferred by legislation other than the Health Insurance Act eg services covered by third party or workers' compensation, where an interim benefit has not been paid, or services rendered to repatriation beneficiaries or defence personnel;
(c) services rendered for insurance or employment purposes;
(d) health screening services; and
(e) services rendered under grant provisions such as the Health Program Grant arrangements.
Growth in Financial Aggregates including Benefit Levels and Safety Net
4. All financial aggregates in this publication are in nominal terms, i.e. not price adjusted. Percentage changes reflect amounts in aggregates in nominal terms.
5. At the commencement of Medicare, on 1 February 1984, all eligible persons received 85 per cent of the Medicare Schedule fee with a maximum gap between Schedule fee and benefit of $10. With effect from 1 November 1986, the maximum gap was increased to $20. From 1 August 1987, all eligible private patients in-hospital received 75 per cent of the Schedule fee (flat). From that date out-patients continued to receive 85 per cent of the Schedule fee with a maximum gap of $20 (increased to $26 from 1 January 1991, to $26.80 from 1 November 1991, $27.20 on 1 November 1992, $27.70 on 1 November 1993, $28.10 on 1 November 1994, $29.30 on 1 November 1995, $30.20 on 1 November 1996, $50.00 on 17 March 1996, $50.10 on 1 November 1997, $50.40 on 1 November 1998, $50.90 on 1 November 1999, $52.50 on 1 November 2000, $55.60 on 1 November 2001, $57.10 on 1 November 200, $58.60 on 1 November 2003), $60.00 on 1 November 2004, $61.50 on 1 November 2005 and to $63.90 on 1 November 2006.
Over the period 1 March 1991 to 29 February 1992, the benefit level for selected non-hospital general practitioner services was reduced by $3.50, for services involving non-health care card holders. For bulk bill services involving cardholders, the medical practitioner was permitted to charge a $2.50 co-payment, with the Government making an additional payment of $1.00.
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Medicare Safety Net
6. Since the introduction of Medicare, the maximum aggregate gap expenditure (Schedule fee less benefit paid for all services up to 1 August 1987, and for non-in-patient services from that date) for an individual has been $150 in a financial year. This amount was increased to $240 from 1 January 1991, to $246 from 1 January 1992 (with the safety net changed to a family basis from that date) to $247.90 from 1 January 1993, to $253.30 from 1 January 1994, to $258.10 from 1 January 1995 and $271.20 from 1 January 1996, $276.80 from 1 January 1997, $280.30 from 1 January 1999, $285.00 from 1 January 2000, $302.30 from 1 January 2001, $309.80 from 1 January 2002, $319.70 from 1 January 2003, $328.00 from 1 January 2004, $335.50 from 1 January 2005, $345.50 from 1 January 2006 and $358.90 from 1 January 2007.
Once accumulated payments exceed the threshold amount, services for the remainder of the calendar year, for the individual or registered family, are paid up to the level of Schedule fee, or the fee charged, whichever is lower.
The Extended Medicare Safety Net
7. The original Medicare benefits safety net covers the difference between the Medicare benefit paid and the schedule fee for out-of-hospital services. Under the extended Medicare safety net, Medicare meets 80% of the out-of-pocket costs for Medicare services provided outside hospital, once an annual threshold of $500 in calendar year 2006, for families in receipt of the Family Tax Benefit Part A and concession card holders or $1,000 for all other singles and families is reached. These thresholds are indexed annually, with the respective thresholds applying in 2005 being $306.90 and $716.10. As a result of a decision taken in the May 2005 Federal Budget, the respective thresholds for calendar year 2006, were $500 and $1,000. The indexed thresholds applying to calendar year 2007 are $519.50 and $1,039.00.
Out-of-pocket costs are defined as the difference between the fees charged by the doctor and the Medicare benefits paid. The safety net covers out-of-pocket expenses for the specific Medicare service but does not cover other fees or charges levied by the doctor that are not directly associated with the service provided.
Definitions
8. Enrolment State/Territory of Patient - The 'A', 'C', 'D' and 'F' series tables present data by State/Territory. State/Territory relates to enrolment State/Territory of patient at the date of processing.
New South Wales comprises postcodes 2000-2599, 2619-2899, 1000-1999 and 2999
Victoria comprises postcodes 3000-3999 and 8000-8999
Queensland comprises postcodes 4000-4999 and 9000-9999
South Australia comprises postcodes 5000-5999
Western Australia comprises postcodes 6000-6999
Tasmania comprises postcodes 7000-7999
Northern Territory comprises postcodes 0800-0899 and 0909
Australian Capital Territory comprises postcodes 0200-0299, 2600-2618 and 2900-2998
9. Average patient contribution per service – out of hospital services only - Tables A5, A6, B5 and B6 contain data on the average patient contribution per service. For out of hospital services in all time periods this represents aggregate fees charged less aggregate benefits paid, divided by the number of services. Fee charged data in the attached tables reflect amounts contained on accounts submitted to Medicare Australia for payment. For bulk billed services, the fee charged is equal to the benefit paid. For patient billed services paid by Medicare Australia prior to the account being settled with the medical practitioner, the fee charged will reflect the amount recorded on the account. This may not be subsequently received by the medical practitioner, since some practitioners accept the Medicare benefit as full settlement of the account and some discount for early payment. Data on average patient contributions per service must be treated with caution due to increasing concerns about data reliability. It is for this reason that average patient contributions per service for anaesthetics and operations are not available.
In calculating the average patient contribution per service post 1 February 1992, fees charged and benefits paid associated with pathology patient episode initiation (pei) items have been taken into account, but the number of pei services has been ignored. In the past the benefits associated with specimen collection (now reflected in pei items) were spread across all pathology items.
10. Schedule fee observance - Tables A9, B9 and C4 contain data on Schedule fee observance. This represents the percentage of services bulk billed and patient billed at or below the Schedule fee.
11. Part of Schedule - The 'B', ‘C' and ‘G’ series tables present data by broad Part of Medicare Benefits Schedule.
GP/VRGP non-referred attendances include Items 1 and 2 (post September quarter 1996), 3, 4, 13, 14, 19, 20, 23, 24-26, 33, 35-40, 43, 44, 47-51, 193-195, 601-602, Group A18 and Group A22.
Enhanced primary care includes Items 700-779, 900, 903, 2710, 2712 and 2713.
Other non-referred attendances include Items 1 and 2 (pre March quarter 1996), 5-12, 15-18, 21, 22, 27-32, 34, 41, 42, 45, 46, 52-84, 86, 87, 89-93, 95-98, 101, 160-173, 444-449, 697-698, 980, 996-998, Group A19, Group A20, Group A23 and Item 17600.
Practice nurse comprises Items 10993, 10994, 10995, 10996, 10997, 10998, 10999, 10988 and 10989.
Specialist attendances include Items 85, 88, 94, 100, 102-152, 154-159, 177, 189, 300-338, 342-370, 385-388, 410-417, 501-536, 820-866, 887-893, 10801 to 10816 and 17603.
Obstetrics includes Part 2 and Group T4 of the Schedule and Item 9011.
Anaesthetics comprises Parts 3 (excluding Items 82, 85, 101, 102), 4 and 5, Groups T5, T6 (excluding Items 17600 and 17603), T7, T10 and Items 9021 to 9060.
Pathology comprises Part 7 and Category 6 of the Schedule, including Items 74990 and 74991.
Diagnostic Imaging comprises ultrasound (Items 791, 793, 794, 910, 911, 913, 990-993, 995 and 999 and Group I1), CT (Part 7A and items 2960-2971 and Group I2) Radiology (Part 8 and Items 9341-9344 and Group I3), MRI (Items 2980 and 2981 and Group I5), Nuclear Medicine Imaging (Items 8712, 8713, 8716, 8717, 8720, 8721, 8723, 8724, 8727-8840, 8851-8874 and Group I4) and Item 9066, and Group I6 (Items 64990 and 64991).
Operations comprise Part 10 and Group T8 of the Schedule and Items 9401-9409, 9415-9435, 9440-9449, 9458, 9476-9850.
Optometry comprises Items 180 to 186, inclusive, and Group A10 of the Schedule.
Other comprises miscellaneous (Part 6 - other than ultrasound), radiotherapy and therapeutic nuclear medicine, dental, cleft lip and palate, assistance at operations (Part 9 and Group T9) and Categories 2, 4 and 7, Groups T1-T3, Group T11, Items 10990, 10991 and 10992, and the allied health items in MBS Groups M2 to M4 and Groups M6 to M9.
1. Tables A1 to A4, B1 to B4, C1B, C2B, D1 and D2 present data on utilisation etc per capita. The source of the population estimates in computing utilisation per capita was Australian Demographic Statistics (ABS Catalogue No. 3101.0) for all years except 2006-07. For 2006-07, the estimates are population projections supplied by ABS. Minor differences in per capita utilisation may occur in these tables due to rounding or due to updating of population estimates.
Bulk Bill Incentive Items, Practice Nurse Items and Allied Health Items
13. An outline of the consequences of the bulk bill incentive items and the practice nurse items on the production of Medicare statistics is available on Page 4 of this publication.
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Strengthening Medicare
The introduction of the $5.00 and $7.50 bulk billing general practice incentive items and the introduction of four new practice nurse items have had implications for the way Medicare Statistics are presented in publication tables.
$5.00 and $7.50 Bulk Bill Incentive Items (Items 10990, 10991, 10992, 64990, 64991, 74990 and 74991)
Three $5.00 bulk billing general practice incentive items were introduced into the Medicare Benefits Schedule (MBS) on 1 February 2004. Three $7.50 bulk billing incentive items were introduced into the MBS on 1 May 2004, with a further item taking effect from 1 January 2005. Items 64990 ($5.00) and 64991 ($7.50) apply to diagnostic imaging services, Items 74990 ($5.00) and 74991 ($7.50) apply to pathology services and Items 10990 ($5.00) and 10991 ($7.50) apply to all other services in the MBS, when rendered by general practitioners. Item 10992 ($7.50) applies to selected non-referred (gp) attendance items. In broad type of service statistics, Items 64990 and 64991 are included in ‘Diagnostic Imaging’ and Items 74990 and 74991 are included in 'Pathology'. Since Items 10990 and 10991 can apply to other relevant services in the MBS provided by general practitioners, they are included in 'Other Services'. Statistics relating to Item 10992 have also been included in ‘Other Services’.
The $7.50 incentive items apply to bulk billed services provided by general practitioners, to persons under 16 years of age or Commonwealth concession card holders in Tasmania or in Rural, Remote and Metropolitan Areas 3-7, and with effect from 1 September 2004, to a number of eligible metropolitan areas. The $5.00 incentive items apply to bulk billed services provided by general practitioners to persons under 16 years of age or to Commonwealth concession card holders in other parts of Australia.
From 1 November 2006, the bulk billing incentives increased to $5.30 and $8.00 in line with indexation of Medicare Benefits Schedule fees.
Since the incentive items are supplementary payments for general practice bulk billed services to Commonwealth concession card holders and persons under 16 years, the number of items processed by Medicare Australia are not included in service counts or in bulk billing statistics. To do so, would involve double counting. However, benefits paid etc for these items, are included in 'Diagnostic Imaging', 'Pathology' and 'Other Services', as outlined above.
Tables F1 and F2 provide details of the number of items claimed and benefits paid, by bulk bill incentive item number and by patient State/Territory.
Practice Nurse Items (Items 10993, 10994, 10995, 10996, 10997, 10998 and 10999) and Aboriginal Health Worker Items (Items 10988 and 10989) – on behalf of a General Practitioner
With effect from 1 February 2004, two practice nurse items (10993 and 10996) were introduced into the MBS covering relevant services on behalf of a general practitioner. An additional item (10998) was introduced into the MBS on 1 January 2005 with a further item (10999) introduced into the MBS on 1 May 2005 and a further two items (10994 and 10995) introduced into the MBS on 1 November 2006. Two items (10988 and 10989) covering relevant services performed by aboriginal health workers on behalf of a general practitioner, were introduced into the MBS with effect from 1 May 2006. An additional item (10997) covering services provided to a person with a chronic disease by a practice nurse or aboriginal health worker was introduced into the MBS on 1 July 2007. The availability of these items can free up general practitioners for other important tasks. These items have been separately identified as a component of the broad type of service group 'Non-referred (GP) attendances', in Medicare Statistics.
Allied Health Items (Items 10950 to 10977 and 80000 to 81125)
With effect from 1 July 2004, a number of items were introduced into the MBS covering selected services by allied health practitioners to persons with chronic and complex conditions which are being managed by a medical practitioner under an Enhanced Primary Care multidisciplinary care plan. Additional items covering psychological therapy, focussed psychological strategies and pregnancy support counselling were introduced into the MBS on 1 November 2006, with new group services for diabetes education, exercise physiology and dietetics introduced on 1 May 2007. These services are included in the broad type of service group ‘other’.
