Evaluation of the Medical Specialist Outreach Assistance Program and the Visiting Optometrists Scheme

5.3 How the MSOAP currently operates

Page last updated: 28 February 2012

Allocations of MSOAP funding across jurisdictions

At the commencement of MSOAP, national allocations to the states and Northern Territory were based on the proportion of population residing in the Rural Remote Metropolitan Area (RRMA) categories 4-7. In allocating initial resources across states and the Northern Territory, populations within RRMA categories 4-5 were weighted 0.12, 1.31, 1.62 and 2.38 respectively (DoHA Unpublished). These weightings reflected factors used for the funding formulae used in funding for GP divisions. In addition to the weighted population allocations a common base allocation of $400,000 was applied to ensure smaller states and the Northern Territory received a workable allocation.

At some point the program guidelines were updated to refer to the remoteness classification based on the ARIA index, although the underlying formula for allocation between jurisdictions did not change. From 2011-12 the ASGC Remoteness Area (RA) classification will be adopted (see Table 6).

For MSOAP-ICD, funding was allocated between jurisdictions based on the number of Aboriginal and Torres Strait Islander people living in ASGC remoteness areas 2-5 (as at 2006), with an administrative allowance for Northern Territory and Tasmania No additional weights were applied. MSOAP – Maternity was allocated using the projected number of births in ASGC remoteness areas 2-5. In addition to the weighted projected number of births, a common base allocation of $75,000 was applied to ensure smaller states and the Northern Territory received a workable allocation.

Fundholders

MSOAP and its extensions principally operate under a ‘fundholder’ model. In each state/Northern Territory, a fundholder (or two fundholders in the case of New South Wales and Queensland) are appointed by the DoHA to administer the program. Fundholders were identified early in the program’s establishment and have changed only marginally since that time.

Separate agreements are negotiated between DoHA and the fundholder for each MSOAP program and related programs such as USOAP. For example one fundholder has funding agreements for MSOAP, MSOAP-ICD, MSOAP-Maternity, PSOP and USOAP. A separate funding agreement is in place with the Australian Society of Ophthalmology (ASO) with respect to MSOAP Ophthalmology, which is a national rather than jurisdiction based program. Service provision funding agreements (in contrast to fundholder funding agreements) are in place for the arrangements with ACRRM, KPOP, Baker IDI and APY Lands.
Overview of fundholder arrangements under MSOAP
Figure 6 – Overview of fundholder arrangements under MSOAP

Currently under MSOAP and USOAP there are 37 active funding agreements with fundholders and service providers (Table 31). Funding agreements with fundholders under MSOAP Core have typically been for three years with annual extensions in some instances. However, the periods of time covered by the funding agreements under the various extensions can vary. MSOAP Core funding agreements for most fundholders expired on 30 June 2011 and were extended by one year to 30 June 2012. New funding agreements from 1 July 2012 will need to reflect the arrangements established for the Rural Health Outreach Fund.

Table 31 – Funding agreements with fundholders and service providers – MSOAP and USOAP (August 2011)
Jurisd. Fundholder MSOAP Core MSOAP-ICD MSOAP Opthal-mology MSOAP Matern-ity PSOP and KOPS USOAP Total
NSW NSW Rural Doctors Network 1 1   1   1 4
NSW NSW Health 1 1   1     3
Vic. Rural Workforce Agency Victoria 1 1   1 1 1 5
Qld General Practice Queensland 1 1   1   1 4
Qld Queensland Health 1 1   1     3
WA Rural Health West 1 1   1   1 4
WA WA Country Health Services         1   1
SA Rural Doctors Workforce Agency 1 1   1     3
Tas. Tas Department of Health & Human Services 1 1   1     3
NT NT Department of Health 1 1   1     3
NT Baker IDI   1         1
SA/NT AYP Lands   1         1
National Australian College of Rural and Remote Medicine 1           1
National Australian Society of Ophthalmologists     1       1
Total   10 11 1 9 2 4 37

The fundholder organisations funded under MSOAP manage the program overall and the relationships with service providers. They are required to:
    • develop a business case (a pre-funding agreement requirement)
    • develop an annual project plan specifying the outreach services to be supported under the specific program in the coming year and navigate this through the relevant advisory forum (see below)
    • implement an annual project plan
    • develop strategies to recruit and retain specialist services
    • negotiate outreach service arrangements and contract with individual specialists/service providers or an intermediary organisation. This includes building up specific budgets in accordance with the program guidelines
    • ensure outreach services are coordinated with local care providers to ensure continuity of care with MSOAP providers and to help with integration with other programs.
    • manage contractual arrangements with service providers, resolve conflicts, manage service terminations and manage transitions when a specialist sets up a practice in an existing MSOAP service location
    • receive and process invoices and reports from service providers once outreach services are provided
    • make payments to service providers
    • monitor and manage the program including managing all relevant cash flow issues
    • collect, collate, and analyse data and report this to DoHA
    • evaluate individual outreach services on an annual basis
    • fulfil other obligations in reporting to DoHA, including progress reports, financial reports
    • inform the public and the medical community about MSOAP
    • market MSOAP and educate the public and health care sector
    • assist with the provision of upskilling sessions
    • other activities as required for MSOAP to operate properly.
There are four different types of fundholder organisation under the program (Table 32):
    • Rural workforce agencies (RDN, RWAV, RHW, RDWA) – these are not-for-profit private organisations that principally provide recruitment services as well as personal and professional support for doctors working in rural and remote areas in their state or territory.
    • A state peak body representing Divisions of General Practice (GPQ) – this body represents the 17 GP divisions in Queensland.
    • State health agencies (NSW Health, Queensland Health, Tasmanian Department of Health and Human Service (DHHS) and Northern Territory Department of Health and Families (DHF) – these agencies operate public hospitals (which are often a significant source of visiting specialists) and primary health centres (particularly in remote locations).
A medical specialty society (the Australian Society of Ophthalmologists) which manages IRIS – involves a consortium of health care providers and organisations designed to establish a national approach to the delivery of eye health services in rural and remote communities of Australia. Unlike the above, the ASO does not have responsibility for service delivery, which remains with the other jurisdictionally based Fundholders.Top of page

Table 32 – Types of MSOAP fundholder organisations
  Fundholder: Type of agency
NSW NSW Rural Doctors Network Rural workforce agency
NSW NSW Health State/territory health agency
Vic. Rural Workforce Agency Victoria Rural workforce agency
Qld General Practice Queensland State level Division of  GP
Qld Queensland Health State/territory health agency
WA Rural Health West Rural workforce agency
SA Rural Doctors Workforce Agency Rural workforce agency
Tas. Tasmanian Department of Health and Human Services State/territory health agency
NT NT Department of Health and Families State/territory health agency
Aust Australian Society of Ophthalmologists A medico-political association

The fundholder role involves creating or strengthening relationships between supply (medical specialists and other health care providers) and demand (represented by primary care services located in rural and remote localities). This is a complex landscape involving a range of stakeholders and organisations, as is schematically represented in Figure 7 below.
Schematic representation of key groups involved with outreach services
Figure 7 – Schematic representation of key groups involved with outreach services
On the supply side, MSOAP service providers are spread across the public-private spectrum, as shown in Table 33. Overall, an estimated 14% of MSOAP service providers are specialists in private practice with no or limited involvement with public hospitals and 39% are private practice specialists who have a role as a VMO at a public hospital. Around 38% are staff specialists, who are employed by a public hospital, community health service or NGO. A further 8% of service providers are allied health professionals. A slightly high proportion of MSOAP service providers based in cities are staff specialists.

Around a half of MSOAP service providers are located in major cities and a half based in regional centres, typically those with regional referral centres. On the supply side, the capacity to link with both specialists working in private practice and those working in the public hospital system is important. In some jurisdictions, specifically Tasmania and the Northern Territory, the number of specialists working outside the public hospital system is very low, and consequently the linkages with the public hospital system are a much more important issue for the MSOAP arrangements.

Table 33 Practice arrangements of MSOAP service providers
Response category Capital Other Total
1. Private practice specialist with no or limited involvement with a public hospital as a VMO 15% 13% 14%
2. Private practice specialist with some or significant involvement with a public hospital as a VMO 38% 39% 39%
3. Staff specialist working in a public hospital with rights of private practice 31% 22% 26%
4. Other staff specialist working in a public hospital 9% 12% 10%
5. Clinical academic working in a public hospital 2% 1% 1%
6. Staff specialist working in community health or NGO 1% 4% 2%
7. Allied health provider working in a public hospital 2% 2% 2%
8. Allied health provider working in a private practice 1% 6% 3%
9. Allied health provider with other arrangement 0% 2% 1%
Total excluding no response 100% 100% 100%
Split across Capital City / Other 49% 51% 100%

Source: HPA survey of MSOAP service providers, 2011


To varying extents the organisations taking on the fundholder role have different advantages in their relationships with aspects of the health system. For example, the rural workforce agencies usually have a well formed relationship with rural primary care services and are experienced in sourcing and supporting workforce coming into rural regions. They are typically involved in establishing or managing locum arrangements for GPs in rural and remote communities. State health authorities have a direct institutional relationship with staff specialists in public hospitals, and in some instances are a major provider of primary care health services, particularly in more remote regions.

These relative advantages tend to vary across the level of remoteness and the specific circumstances of a jurisdiction. This is illustrated schematically in Figure 8 across the remoteness dimension. In less remote areas in rural Australia, there is likely to be a private GP and a local hospital. Visiting these communities is more likely to be more accessible and financially viable for specialists working in private practice. Billing of patients is likely to be more feasible and common.

In more remote regions, private GPs are very rare. Primary care services are often provided by community controlled Aboriginal and Torres Strait health services or state/territory managed clinics. In addition, outreach from regionally based specialists is likely to be more important. Billing of patients is likely to be less feasible, and salaried practitioners are likely to be less motivated to pursue billing. High levels of patients who do not attend for clinics is also likely to be an issue which impacts the level of income achievable from billing.
Relative involvement of primary care and specialist provider groups across the different levels of remoteness
Figure 8 – Relative involvement of primary care and specialist provider groups tends to vary across levels of remoteness along with other characteristics of communities and services.Top of page

Overview of the outreach service proposal administrative cycle


Figure 9 provides an overview of the processes through which individual outreach service proposals are developed, approved and implemented. Service proposals will initially be developed through the involvement of the service provider, fundholder and possibly an intermediate organisation. The fundholder will assist with developing a budget. The proposal will be considered by a state/territory advisory forum and if supported, approved by the DoHA.

For approved services a contract will be negotiated by the fundholder with the service provider. The service provider will then proceed to provide the outreach service. Following each visit an invoice will be submitted to the fundholder along with details of outreach services provided (e.g. numbers of patients). The fundholder will then pay the service provider. Financial and activity data will be collated by the fundholder and reported as required to DoHA. On an annual basis the service proposal will be reviewed by the fundholder and submitted again for consideration by the advisory forum and approval by DoHA. More details on each of these steps are provided below.
Processes for developing, approving and implementing service proposals under MSOAP
Figure 9 – Processes for developing, approving and implementing service proposals under MSOAP
A text description of the Overview of the outreach service proposal administrative cycle Flowchart is available on a separate page.
  • Service proposals are initially developed through three main pathways. These are:A service provider develops and submits a proposal to the fundholder. Fundholders typically have an on-line application form that can be accessed by potential service providers.
  • The fundholder identifies a need for an outreach service as a result of planning and/or consultation with local primary care providers. The fundholder uses its networks and/or communication mechanisms to find an appropriate service provider who could meet that need. The fundholder develops the proposal in consultation with the service provider.
  • Another organisation (e.g. a regional health authority or GP divisions) identifies a need and develops a proposal. This will usually occur through consultation with the fundholder, or actually be developed by the fundholder. The organisation is responsible for finding a suitable service provider to actually provide the outreach service, but this may not have occurred at the time the proposal is developed. Once approved, the organisation negotiates arrangements with a provider or advertises for a service provider. The organisation receives and manages the MSOAP funding.
Proposals are typically drafted using a standard service proposal form as specified in the MSOAP guidelines, or using a local adaptation. The fundholder will work with the service provider/ organisation to develop a budget for the proposal (see section below). Local organisations and primary care will be consulted about the proposal. The fundholder will present the worked-up proposal to the advisory forum usually as part of a draft annual project plan. In some instances details of proposals are circulated by email prior to formal consideration at a meeting of the advisory forum. The presentation of the proposal will include an assessment against the relevant criteria discussed below.

A final evaluation of a proposal is presented to the Department. If the decision is not unanimous, documentation around the decision to support or not support the proposal must be provided. The chairperson of each forum is a DoHA officer from the state/territory office. The chairperson has a delegation to make all final decisions on proposals.

Service proposal budgets

For each proposal a budget will be developed based on the types of costs that can be supported according to the program guidelines. The categories of eligible costs are specified in the Guidelines for each of the MSOAP programs. These are summarised in Table 34 with more details provided in Appendix G. The rates of re-imbursement for certain categories are either set in the MSOAP guidelines, related to other public sector arrangements or determined on a case by case basis. Where a cost category relates to the time of a private specialist, then the rate of reimbursement is typically related to the fee-for-service equivalent hourly rates paid by the relevant state/territory health authority or local hospital (e.g. for cultural training and familiarisation, absence from practice allowance and workforce support payments). Allowances for meals and incidentals are related to the rates set for the Commonwealth Public Service. Private vehicle costs are reimbursed at a standard rate per kilometre based on engine size.

In MSOAP-ICD and for some very remote services provided under MSOAP Core, payments can be made to specialists for services provided in lieu of billing patients or Medicare. Justification for this funding could include cultural or other events, such as high rate of patient no show, if they impact the delivery of services.
Table 34 – Categories of cost eligible for re-imbursement under MSOAP, MSOAP-ICD and MSOAP Maternity 
Cost category Eligibility
Travel costs for specialists Cost of travel by the most efficient and cost effective means to and from the outreach service location. This may include commercial air, bus or train fares, charter flights, and/or expenses associated with the use of a private vehicle or hire care (see Appendix G). Other incidental costs such as fuel for hire cars, parking and taxi fares may also be covered.
Travel costs for other health professionals Travel costs for registrars, who accompany visiting specialists.  Technical staff who assist specialists with procedures (excluding nursing or allied health personnel) are considered on a case by case basis.  Salary/backfilling not covered.
Accommodation Costs of overnight accommodation for visiting specialist (see Appendix G)
Meals and incidentals Meals and incidentals for visiting specialists and approved accompanying staff may be paid at a set rate (see Appendix G).
Administrative support
for visiting specialists
MSOAP Core: Administrative costs associated with the delivery of outreach services, such as the organisation of appointments, processing of correspondence and follow up with patients, at the outreach location
MSOAP-ICD:  May pay for one administrative support person associated with the delivery of outreach services, such as the organisation of appointments, processing of correspondence and follow up with patients, at the outreach location.  May be a member of the multidisciplinary team (e.g. a GP) or an administrative officer.
MSOAP-MS:  May pay for one administrative support person associated with the delivery of outreach services, such as the organisation of appointments, processing of correspondence and follow up with patients, at the outreach location.
Equipment lease and equipment transport Assisting with equipment lease arrangements. Purchase of equipment is not covered.  Transport of equipment will be considered
Facility fees Fees incurred in hiring appropriate venues or facilities to support either outreach service provision or upskilling activities
Cultural training and familiarisation Cultural training and familiarisation for visiting specialists who provide outreach services, which may include: formal cultural awareness courses; self-learning cultural awareness education program.  For MSOAP Core non-salaried private specialists can claim MSOAP benefits for the time they attend cultural training and familiarisation. Cultural training and familiarisation is a requirement for all services supported under MSOAP-ICD and MSOAP Maternity.
Absence from Practice Allowance Payable to non-salaried private specialists to compensate for ‘loss of business opportunity’ due to the time spent travelling to and from a location where they are delivering an outreach service and/or upskilling.  Salaried specialists, registrars and any accompanying health professionals are not eligible.
Workforce support Private specialists who provide outreach in remote and very remote (ARIA > 5.8), mainly Aboriginal and Torres Strait Islander communities where access to Medical Benefits Schedule (MBS) payments is not assured; and/or patient compliance with appointments is uncertain. Visiting specialists who accept a workforce support payment are precluded from claiming MBS payments in the designated outreach location. Medical specialists who receive a workforce support payment are ineligible to receive the Absence from Practice allowance.
Backfilling for salaried specialists The salary costs of backfilling salaried medical staff who provide approved MSOAP outreach services.  Claims made against the MBS by salaried specialists for outreach services supported under the MSOAP would render void any claim to cover backfilling costs. Registrars are not eligible for backfilling payments.
Upskilling Covers the cost of non-salaried private specialists for the time required to present the agreed upskilling activity. Can cover costs of the venue/facility/ room hire.
Professional support Informal support provided by non-salaried private specialists to local medical and health professionals through, for example, lunchtime meetings and/or telephone/email support once the specialist has returned to their principal practice.
Telemedicine MSOAP supports the use of telemedicine services as a supplement to usual face-to-face consultation between patients and specialists. MSOAP may cover costs, such as hire of venue and equipment, associated with consultations using this medium, but it does not support the capital costs associated with the establishment of telemedicine services.
Services for public hospital patients Not eligible

Budgets for proposals will be developed (almost always by the fundholder in consultation with the service provider) using the program guidelines and other information. For example, quotations for commercial and charter flights may be obtained. Outreach services may be bundled in a variety of ways, for example, where a service provider undertakes a circuit involving several communities. However, the program requires that the budget be constructed to reflect the cost of each individual visit by the service provider to a particular community. This will require appropriate apportioning of costs across locations where necessary, such as in the example of a circuit. The dollar cost of a single visit to a location is combined with the proposed number of visits to establish an annual budget for the service proposal. It is this annual budget that is considered by the relevant advisory forum and approved under the program.

In most instances the budget sets the amount per visit that will be paid to the service provider. This amount will be paid without further reference to receipts or actual costs involved. In early years of MSOAP, service providers were required to submit full details of costs (including receipts) in support of their claim for funding. However, some fundholders still require submission of details of expenditure with claims under the program. 

Advisory fora

An advisory forum for MSOAP has been established in each state and the Northern Territory. The program guidelines define the principal role of the advisory fora as “to evaluate all proposals for MSOAP funding as they are presented [in order] to:
  • identify whether the selected region has the need and the capacity to support for a proposed new service
  • determine gaps in services
  • advise on the appropriate types of services to be delivered; and - link (when appropriate) with the planning mechanisms of other programs to explore possibilities for integrated program implementation”.
(DoHA 2010a)
The specific terms of reference are that advisory fora will:
  • Analyse, consider, evaluate and provide impartial advice on proposals received from the fundholder(s) for funding of services under MSOAP in their respective state or territory.
  • Ensure that the MSOAP aims and guidelines are fully met in the consideration of each proposal.
  • Ensure that each proposal fulfils the Australian Government priority of providing value for money and, if the level of funding requires it, advise on priorities between services.
  • Ensure that MSOAP funding contributes to an improved access to specialist services in the selected community/area, and that new services in one area are not established at the expense of services in another.
  • Ensure that capacity exists in the region/community to support and sustain a specialist service (e.g. available infrastructure, clinical supports and/or networks and client base).
  • Use the Evaluation Matrix as supporting documentation as required.
  • Provide written advice to the secretariat on proposals that are worthy for funding in their respective state or territory under MSOAP.
(DoHA 2010a)

Advisory fora are chaired by an officer from the state/territory office of DoHA. The Secretariat is also provided by the state/territory office of DoHA. Fundholders are required to report on the activities to each forum, and prepare materials, such as draft annual project plans for consideration by the forum. 

The fora are made up of stakeholders that have knowledge and expertise on issues of remote and rural health care. Their purpose is to provide advice to DoHA and the fundholders on how to allocate and provide resources, prioritise projects and evaluate proposals. Members can include:
  • DoHA (state/territory office)
  • state/territory health authorities
  • rural workforce agencies
  • representatives of specialist medical practitioners provider outreach services
  • medical colleges
  • GP divisions/state based organisations
  • Aboriginal and Torres Strait Islander organisations/communities
  • allied health disciplines
  • local hospitals, community-based services and local communities.
(DoHA Department of Health and Ageing 2010a)
Table 35 shows the distribution of membership of the various advisory fora as at May 2011.
Table 35 – Membership of MSOAP advisory fora, May 2011

Jurisd.

DoHA

Fund-holder

State health authority

Aboriginal health org.

Division of GP

Spec-ialist

GP

Allied health prof.

Other

Total

NSW

3

2

FH

3

1

2

1

 

2

14

Vic.

3

3

3

 

1

2

 

 

1

13

Qld

3

4

FH

1

FH

3

1

1

4

16

WA

3

4

3

3

1

 

 

1

 

15

SA

3

3

2

3

2

1

1

1

 

16

Tas.

2

3

1

2

1

 

1

1

2

13

NT

1

2

 

1

1

1

 

3

1

10


FH = Fundholder
While there are national ‘terms of reference’ set under the program guidelines, the function and organisation of advisory fora varies significantly across states/Northern Territory. There are several key areas where variation in how advisory fora are established and how they approach their roles differs. Some ways in which the advisory fora vary include the frequency of meetings, communication outside meetings and perceived roles of members and the group as a whole.

Some advisory fora have at least two meeting per year. Typically there is a meeting in May or June to consider the annual plans for the coming year. In most cases meetings are held face to face with some members attending by teleconference, although for one advisory forum most meetings are held by teleconference. One advisory forum has adopted a schedule of meetings every two months. Approval of proposals may also occur out of session by email exchange, particularly where issues may not be resolved in the formal meeting.

There are typically regular meetings between the state DoHA office and the fundholder outside the formal advisory fora meetings. In one jurisdiction a working group involving the state DoHA office, the fundholder, the state health authority and the state Aboriginal and Torres Strait Islander health organisation has been established to undertake work prior to formal advisory forum meetings.

Assessment of proposals and priority setting


The program is targeted at rural and remote areas. The various MSOAP programs have now moved to ASGC Remoteness Area (RA) system for determining eligibility (see discussion in Chapter 3).

In addition to the broad guidelines that establish the overall eligibility of particular service proposals, other factors are used to determine the priority of specific service proposals. The program guidelines identify eight criteria, including that the proposal:
    • is putting forward a service that is of high medical need in the community
    • assures that the local workforce and facilities can support the treatment performed/provided
    • will increase access to medical specialist services for local and regional residents
    • has linkages with other state/Northern Territory and Australian Government health service programs in the region
    • identifies a service provider
    • has support from all medical professionals in the region
    • assures that the provider has capacity to meet the requirements of the MSOAP
    • provides value for money.
(DoHA 2010b)
The advisory forum is required to assign a score for each of these criteria across a scale as follows:
    • 0 – Not acceptable
    • 2 – Marginal
    • 3 – Acceptable
    • 4 – Very good
    • 5 – Excellent.
However, within this broader framework, advisory fora in each jurisdiction have considered more specific issues impacting priorities. Specific disciplines have been identified as important priorities by several advisory fora (e.g. psychiatry and mental health outreach has been a priority in South Australia and Queensland). Other fora have adopted other approaches. In Victoria in the early years of MSOAP, a higher priority was allocated to service proposals involving specialty disciplines involving consultation based services (‘consultationists’) rather than procedural based disciplines (‘proceduralists’), as gaps in consultationist based services were considered more significant across the State.

The methods used for evaluation of need vary by state/Northern Territory. Evaluation of need and planning has been carried out by fundholders and then presented to the advisory fora for review. In jurisdictions where there is more than one fundholder, this requires co-ordination between the fundholders.

The majority of fundholders appear to have conducted an initial assessment of need when the program was initiated (Morey Australia 2003). However, it was also reported that in the initial establishment of the program many outreach services were identified more on an opportunistic basis, that is, based on where specialists were willing to travel. Subsequently changing the pattern of outreach services has been a relatively slow process, based on the availability of expansions of the program and/or specialists themselves deciding to discontinue providing an outreach service.

Fundholders indicated that in most assessment of need a starting point was information about where populations were located, the remoteness of the populations (in terms of either the ARIA index or the remoteness area), and the distribution of the Aboriginal and Torres Strait Islander populations. In some instance socio-economic status has also been considered (generally assessed in terms of the ABS SEIFA indices). Indicators related to health status have been considered but more as an additional overall consideration rather than informing variability in need between locations. Other information used in assessing needs by some fundholders have been the relative level of potentially preventable hospitalisations.

This analysis has then been supplemented by local information about gaps in service delivery. Gaps in service delivery have generally been assessed by gathering information from more local organisations or service providers, for example, GP divisions who may in turn consult with local GP chapters, regional state/territory health managers, or regional health service fora. In one state (Victoria) there are Regional Steering Groups (RSGs) that advise of needs (and will examine proposals from their local area). In another state where there are two fundholders (Queensland), a regional forum is convened at which both fundholders will be represented as well as all local service providers. These sources will typically identify which particular specialist outreach services are of the highest priority for a region. In some instances, fundholders will also develop a database/map of all visiting services being provided in a locality. Two fundholders (both state health authorities), indicated that analysis of information from the local patient assisted travel schemes (PATS) was used in assessing needs.

Advisory fora have also played an important role in considering needs. Advisory fora may identify particular specialities which they consider to be priorities for the development of outreach services. However, the major ways in which advisory fora have had input is through providing input to draft annual plans and service proposals. In considering service proposals, some members of advisory fora reported that they felt that the process was ad hoc.

In our consultations there has been little mention of planning ‘benchmarks’ that might be referred to in deciding what the level of need might be across various specialties (e.g. compared with metropolitan areas). One exception has been work in the Northern Territory to develop a list of core (outreach) visits that would be expected to be provided for communities of different sizes (see Table 36).Top of page

Table 36 – Visiting services required for communities of various sizes – MSOAP-ICD Annual Plan, Northern Territory, 2011-12

Specialty

Days per visit

Community population

100-300

300-500

500-1000

> 1000

Physician

3

1-2

2

4

4+

Paediatrician

3

1-2

3

4

5+

Surgeon

2

1

2

2

2+

O&G

2

1

2

3

4

Psychiatrist

3

1

1-2

2

3+

ENT

2

1

2

3

4

Ophthalmologist

2

1

2

2

3

Cardiologist

2

Nil

Nil

2

2


The feedback received on MSOAP-ICD is that a needs assessment has taken place in most states/Northern Territory to coincide with the introduction of the program. While the exact methodologies of assessment were not discussed in detail, two distinct outcomes are occurring in different states/ Northern Territory that would indicate significant variation in how needs assessment is functioning. In the first group there are jurisdictions that have significantly more applications for MSOAP-ICD funds then they have available. This situation is most likely due to a combination of needs assessment, program awareness and pre-existing engagement in Aboriginal and Torres Strait Islander communities. The other situation is an inability to get enough proposals to distribute the ICD funding. While the same factors are likely to contribute to a lack of proposals, the approach taken does not seem to generate enough opportunities for groups to apply.

Contracts with service providers

Once a proposal has been endorsed by an advisory forum and approved by DoHA, the fundholder will develop or finalise a contract with the service provider or an intermediary organisation. The contract will specify the period, outreach services to be provided, the amount of funding to be provided in relation to the outreach service, reporting and invoicing requirements and other matters.

Where an intermediary organisation is contracted (e.g. a regional health service or a GP division) the intermediary is responsible for organising or sub-contracting services with the actual service provider.

Depending on local arrangements, different aspects of the budget may be split between different parties. For example, in some arrangements the fundholder takes responsibility for directly booking and paying for airfares.

Approval of service proposals is only for one year at a time. Most fundholders have interpreted that this means that contracts with service providers can only be for a period of one year. However, some fundholders have developed multi-year contracts with services that are likely to continue into the future. These contracts have provision for review or termination if ongoing approval is not provided by DoHA and/or where the service provider does not or is unable to provide the service specified in the contract. Under the multi-year contracts, ongoing support under MSOAP can be confirmed annually by letter or email communications.

Payment of service providers

Once an outreach service is delivered, most fundholders require the service provider to submit a valid tax invoice related to the visits to the specified community, together with a report on activity. In most instances the budget sets the amount per visit that will be paid to the service provider. This amount will be paid without further reference to receipts or actual costs involved. Several fundholders have established or are working towards systems that allow the submission of invoices and activity reports electronically. Once an invoice is received, along with the relevant activity report, payment will be made to the service providers.
Payment arrangements within state health authorities, where the fundholder is also the state health authority are more complex. These arrangements are sometimes dictated by the financial and accounting regulations in place for the health authority. In some instances, the organisation unit in the health authority is required to report actual expenditures. At times this appears to have resulted in delays in reporting and release of MSOAP funds.

The requirement that an invoice is submitted for each visit results in a high level of financial transactions. One advantage of this approach, emphasised by some fundholders is that it creates a direct incentive for service providers to submit the required activity statistics in a timely manner. Nevertheless service providers are not always vigilant in submitting invoices, which creates problems for fundholders in terms of potential underspends. Delays in reporting of activity and expenditure was noted as a problem in some cases where state and territory health services were the service provider.

Annual review


As mentioned above, every service proposal is reviewed annually by the relevant advisory forum and re-approved by DoHA. This occurs even where the service is a long standing proposal which is very unlikely to be de-funded. Table 37 provides an estimate of the total number of service proposals included in the annual plans for MSOAP Core for 2010-11 and the number that related to services that had been included and approved in the previous year. Of a total of 1,710 service proposals mentioned in the annual plans 1,289 (75%) were for services that were approved in the previous year. However, many of these had variations in the amounts approved. Around 35% of service had variations of less than 10% in allocations between the final approved budget for 2009-10 and the proposed budget for 2010-11.
Table 37 – Number of service proposals including in annual plans for 2011-12 including continuing services
State Fundholder Proposed Services Temporarily funded Reserve Cancelled Transferred to ICD Total % Continuing proposals from 2009-10
Funded in 2009-10 Newly funded in 2100-12
NSW NSWH 106 6     7   119 89
  RDN 101 2 21   9 6 139 73
Vic. RWAV 255       7   262 97
Qld GPQ 98 1   24 9   132 74
  QLDH 175 10   123 18   326 54
WA RHW 145 5     32   182 80
SA RDWA 183 4     4   191 96
Tas. DHHS 38   6   9   53 72
NT NT* 187 18   101     306 61
Total   1,288 46 27 248 95 6 1,710 75

* The split between previously funded and new services was problematic for the Northern Territory
Source: HPA analysis of Annual Project Plans for MSOAP Core 2010-11


Variations to service proposals

Under the program guidelines fundholders must obtain approval for changes in service proposals including: commencement of a new service not detailed in the approved annual plan, a change the location of a service as detailed in the approved annual plan and a change in the budget to an approved services of greater than 10% or $2,000. Changes must be endorsed by the relevant advisory forum and then approved by DoHA. A change in service frequency or service provider does not require advisory forum endorsement. However, the advisory forum needs to be informed of changes. These provisions mean that there is typically a reasonably high level of administrative processes required through the year to obtain approval for variations.

Arrangements between DoHA and fundholders

Under MSOAP Core, fundholders have mostly been appointed for three years with a one year extension for 2011-12. Other funding periods have applied for the MSOAP extensions. Funding agreements are usually negotiated between the state/territory DoHA Office and the fundholder, with the national DoHA office involved with final approval and actual signing of the funding agreement. Figure 10 describes some of the broad administrative processes required under the funding agreements.
As above this flowchart describes the processes involved under funding agreements between DoHA and fundholders under MSOAP.
Figure 10 – Processes involved under funding agreements between DoHA and fundholders under MSOAP
A text description of the processes involved under funding agreements between DoHA and fundholders under MSOAP Flowchart is available on a separate page.

Fundholders are required to prepare a number of reports to DoHA. Table 38 summarises the key reporting requirements for MSOAP Core and MSOAP-ICD. Within any one financial year there are around 24 documents reported under these two programs, with additional reports at the commencement and end of funding agreements. MSOAP-MS will add to reporting requirements and fundholders managing other programs (e.g. USOAP) have additional reporting requirements. In jurisdictions with two fundholders, reporting is doubled for the jurisdiction as a whole. In addition to these standard reports, other paper work is required to manage variation in service proposals.

Reports and related paperwork are transmitted from the fundholder to the state/territory DoHA office. Officers at that level will scrutinise reports and service proposals and will often raise questions with fundholders. Reports are then forwarded to the Rural and Indigenous Health Outreach Section of DoHA in Canberra. Additional questions may be raised by officers at that level. The Chair of the relevant MSOAP advisory forum, who is typically a senior officer from the state/territory office, has a delegation to approve service proposals and variations to service proposals.
Table 38 – Reporting requirements under MSOAP Core and MSOAP-ICD
Report MSOAP Core MSOAP ICD Number of reports
Business Case   Start of contract 1
Annual Project Plan (Attachment A) Annual Annual 2
Service Data Reports (Attachment B) Six monthly Quarterly 6
Financial Summary (Attachment D) Six monthly Annual 3
Income and expenditure statement (Attachment E) Quarterly Quarterly 8
Progress Report (Attachment C for financial year; Unspecified for mid year) Six monthly Annual 3
Audited statement Annual Annual 2
Final Report (Attachment F) End of contract End of contract 1
    Total 26

Note: Attachments refer to attachment to the respect MSOAP funding agreements

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Outreach service activity reporting

Reporting on outreach services occurs through two mechanisms. Firstly, details of a service proposal and its budget are included in the Annual Project Plan. These are provided to DoHA as MS Word or portable document format (pdf) documents by the fundholder. Secondly, fundholders submit a spreadsheet (referred to as Attachment B) to DoHA on either a quarterly (MSOAP-ICD) or six-monthly (MSOAP Core) basis. Table 39 shows the data items specified for reporting. Some data items for the Annual Project Plans are only reported by (or relevant to) some fundholders.

Fundholders reported a range of difficulties in meeting the activity data reporting requirements including an inability to populate the data collection spreadsheet as a whole due to in-built macros that check each data item one at a time. This means each data item needs to be entered manually, unless a password is used to disable the macros. This can require weeks to manually enter data for a single reporting period. Almost all fundholders have automated aspects of their data but are unable to export their data to the data collection instrument. Issues with the data structure and inconsistencies in interpretation make this process more problematic. DoHA reported that they had issues with the quality and timeliness of data provision by some fundholders. Provision of data, in particular consistency with the Attachment B format, was mentioned as a significant issue.

As indicated in the table the data items reported typically fall into one of three broad types of data (see Figure 11):
    • Project description including project ID – these are items that are fixed for the life of the project.
    • Project annual approval – these data items reflect the approved status of a project in a given financial year. This includes the annual budget for the project and intended number of visits. As approvals can change during a financial year these data items can be separated further into original, previous and current approvals.
    • Reporting period – these data items related to the reporting period (three months or six months).
While these concepts are relatively straight forward, the current reporting mechanisms group the concepts into a single level, which creates redundancies and difficulties in reporting and analysis of the data.
Table 39 – Data items reported under MSOAP Core and MSOAP-ICD

* These data items are implied in the structure of the annual project plan


This diagram illustrates the data types reported under MSOAP Core and MSOAP-ICD
Figure 11 – High level structure of reported data

How outreach services are organised

Outreach services themselves are organised and supported in a variety of ways. Key dimensions include:
    • Whether the outreach service is delivered by service providers based in a regional health service (a hub), or whether the service is provided from a provider not associated with the regional health service (e.g. they come from a capital city). The former arrangement is typically referred to as the hub and spoke model. The advantages of the hub and spoke model were explored in an earlier evaluation of MSOAP ( Morey Australia 2003). They include that there will be greater continuity between the outreach and regional setting for patients where they need to move across these settings, specialists based in hubs will be able to provide a higher level of back up to primary care providers and will have a greater understanding of issues for local communities. While many services supported under MSOAP reflect the hub and spoke model, one of the challenges for this model is the high level of demand on specialists in regional settings, which can limit their capacity to provide outreach.
    • Whether the outreach service is contracted in relation to an individual service provider or an organisation. In general, outreach services provided by specialists working in private practice are contracted directly with the private practice, whereas services provided by staff specialists are contracted with a health (generally regional) organisation employing the staff specialist. Where the contract is with an organisation, alternative clinical service providers may be involved at different times.
    • A closely related dimension is whether the outreach service is delivered by a specialist in private practice or an employed service provider. This factor can effect the provider’s motivation to ensure patients are billed under Medicare, and also whether there is a capacity to charge a gap fee. Staff specialists are less likely to bill Medicare when seeing patients as their salary costs are generally covered for the visit. They are also unable to charge above the schedule fee. Private practice specialists have a stronger motivation to ensure services are billed, as this is the only way their core costs are covered during the outreach service. They also have a capacity to charge above the schedule fee, although this is not common in outreach settings. The availability of administrative staff to assist with billing is also a consideration.
    • How bookings of travel and accommodation are managed. A variety of models exist across the country, including:
        • Centralised booking services. Some fundholders take on the role of booking all travel and accommodation and directly pay for these costs. In these instances, the service provider does not need to be paid for these costs.
        • Regionalised booking services. In some cases, all travel and accommodation costs related to outreach services to a region are held by a regional health organisation, and this organisation manages all bookings.
        • Service provider. In other cases the service provider takes responsibility for all bookings and associated expenses.
    • Whether the outreach service is in a hospital outpatient setting, a GP, a primary health centre operated by the state/territory health service or an Aboriginal and Torres Strait Islander health service. A related issue is whether a facility fee is paid for the use of consultation rooms.
    • The level of interaction between GPs and primary care health providers and the visiting specialist. Specialists visiting regional hospital settings are more likely to have a lower level of interaction with GPs and primary care health providers. A variety of formal and informal links are likely to occur where the outreach service occurs in a primary care setting.
    • How referrals to specialists are managed. For example, who manages appointments and develops patient lists, how patients are reminded and/or assisted to attend the clinic.
    • The extent to which the visiting service directly uses and records information on the local primary care health service’s patient information system/patient charts.Top of page