The issue of accountability for the delivery of methadone services and the costs incurred in their provision has been a major focus of this study. Accountability is appropriate at all levels of service delivery, ranging from individual service providers through to entire organisations, whether they be in the public or private sectors. Secondly, accountability also applies to different aspects of services, including the quality of the clinical service provided, and the costs incurred in service provision. Thirdly, accountability also requires that service providers are responsible to the people to whom they provide services - namely their clients. Finally, accountability also applies at the program level, and requires that a process be established for regular monitoring of the performance of methadone programs and the extent to which they are meeting their objectives. Each of these issues are addressed in this section.
11.1 Financial accountability
11.2 Clinical accountability
11.3 Accountability to clients
11.4 Program accountability
11.1 Financial accountabilityFinancial accountability requires that persons or organisations incurring costs for service delivery are held responsible for these costs, and can demonstrate to the entity providing the funds that they have been expended in an appropriate and effective manner. This principle applies in both the public and private sectors.
This review has sought to identify and quantify the costs incurred in both the public and private sectors in the provision of methadone services. Throughout this process, access to the required information has been made difficult by an inability in both sectors to identify the costs specific to methadone programs.
11.1.1 The public sectorIn the public sector, State health authorities were asked to complete a questionnaire which identified basic activity levels and their associated costs. In virtually all cases, the questionnaire could only be completed by estimation, since public methadone programs and their costs are largely subsumed in more general drug and alcohol programs, or within general hospital budgets. All questionnaires were completed with caveats concerning the reliability of the estimates provided.
If true accountability for the expenditure of public funds on methadone programs is to be provided, it is essential that the costs incurred be separately identified within the accounting records of public methadone providers. It is recognised that this entails a greater level of specificity than is currently provided for in the accounting records of service providers. Consequently, additional costs will undoubtedly be incurred in establishing and maintaining these records. Equally, seeking to aggregate these costs across a range of service providers including specialist clinics, more general drug and alcohol clinics and public hospitals will also incur additional costs. The complexity of this task should not be underestimated.
Ultimately, the issue becomes whether or not the costs incurred in establishing and maintaining the additional accounting records required for full financial accountability in the planning and delivery of methadone services are justified in terms of the use to which the information is to be put. An alternative view is that methadone services are part of a suite of drug and alcohol treatment services provided in all jurisdictions for which there is joint funding from State and Commonwealth governments. Consequently, financial accountability at this broader level may meet the requirements of those funding the services. This is a matter for the Commonwealth and State governments to determine as part of the negotiations for the shared funding of services. While the requirement for financial accountability is recognised, the issue to be determined is the level at which this requirement is to be exercised.
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11.1.2 The private sectorIn the private sector, costs of medical consultations and pathology tests for methadone clients are paid by the Commonwealth under Medicare. However, services provided within methadone programs are not separately identified within the Medicare Schedule (CMBS), and consequently cannot be separately accounted for with confidence from this source alone.
Efforts to identify costs in the private sector during the course of this study have proved difficult to date, because of an unwillingness by State health authorities to provide information identifying participants in private methadone programs (both approved practitioners and clients), which might then be used to identify the costs incurred through Medicare. An alternative approach of relying on survey data from medical practitioners suffers from subjectivity and potential bias because of the vested interest this group has in the provision of services.
This has highlighted one of the fundamental impediments to proper financial accountability under the current administrative and funding arrangements in the private sector. The responsibility for approval and regulation of methadone prescribers and clients rests with State health authorities. However, the funding of services rests with the Commonwealth. While the States have administrative procedures in place ostensibly to monitor activities in the private sector, these vary between States, and indeed are limited in the information they provide. Consequently, little information is available in State health authorities on activities (and hence costs) in the private sector. Conversely, while the Commonwealth has these data available through the HIC data base, it is unable to identify those activities relevant to methadone programs, their clients and practitioners. As long as this dichotomy between the regulators of services and the funder of services exists, then financial accountability in the private sector cannot be achieved.
In this regard, there are several options available:
- States could collect data on a routine basis on the volume of services provided in the private sector as part of their regulatory procedures, which could be done independently of the funding system used. This option would necessarily entail additional data collection, processing and reporting, with an increased workload for all participants in the program and increased infrastructure costs. It is therefore likely to lead to additional costs of administration, and deter medical practitioners from participating in methadone programs.
- States could provide information to the Commonwealth on a regular basis on the identities of approved methadone prescribers and their clients, which might then be used as a basis for monitoring services and costs on the Medicare data base. This approach would not require any additional data collection or reporting, and would use existing data sources for the extraction of the required information. However, other primary health care services provided to clients by these doctors could not be separated from services associated with methadone treatment, leading to a potential overstatement of methadone costs. This approach is expected to be opposed by many medical practitioners, and may act as a deterrent to their participation.
- Methadone services funded under Medicare could be separately identified in the CMBS, and monitored on the Medicare data base. This would enable the use of existing data bases for the required information, and isolate costs of methadone services from other primary health care costs. However, the use of a separate CMBS item may be resisted by consumer representatives because of issues of privacy and confidentiality.
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11.2 Clinical accountabilityClinical accountability refers to the quantity and quality of services provided, the extent to which they conform to guidelines for service provision, and the outcomes achieved.
During the course of this study, information has been sought on each of these dimensions of accountability with limited success. All States have administrative data collections in place in both the public and private sectors, but the quality of the information collected is suspect, and has proved difficult to access. For example, in Victoria one of the main complaints received during our consultations was the onerous nature of the bureaucratic forms and procedures associated with registration and participation in the private methadone program. Yet these procedures have translated into minimal data on the quantity and quality of the services provided.
The information provided by a sample of medical practitioners in New South Wales demonstrates the high degree of variability that exists in the frequency of consultations. This variability is evident among GPs and psychiatrists through different phases of client treatment. There is, however a systematic difference between GPs and psychiatrists, whereby the latter group have a higher frequency of consultation than GPs. This may be due to a higher level of complexity among clients treated by psychiatrists than those treated by GPs, or simply reflect different attitudes among different groups of medical practitioners as to what constitutes an appropriate level of intervention as part of their models of practice. In the absence of information about either of these possibilities, it is not possible to draw any definitive conclusions. However, the variability in practices and the absence of information as to the reasons for such variability highlight the need for improved information and a program of clinical review.
We have previously recommended the implementation of quality assurance and accreditation programs for methadone clinics, both public and private as a requirement for their approval as providers of methadone services. Such a process will facilitate peer review of these services, one of the fundamentals of clinical accountability. At the same time, the identification of methadone services on the CMBS distinct from other primary health services will enable the quantity of services provided in the private sector to be monitored. While these measures will assist in improving clinical accountability, neither provides a reliable indicator of the outcomes achieved by general practitioners.
In this regard, there is a need for the establishment of a national data collection of basic performance indicators of methadone services. The nature of these indicators were outlined previously in this report, and include retention in treatment, continuing heroin use, use of non-opioid drugs, and psychological well-being. These data could be collected by State health authorities (or be required to be collected) as part of their regulatory procedures. If undertaken in lieu of some of the existing data collection and recording procedures (which have proven largely ineffective to date), little additional effort would be required to collect the data. However, some investment would be required to record the data, and to produce regular reports on outcomes.
While indicators may reveal differences in service outcomes, they do not necessarily reveal the causes for such differences. In order to further investigate these issues, and to continue to identify and promulgate models of best practice, there is a need to establish a regular program for the clinical evaluation of methadone services and the means by which they are delivered. The National Methadone Committee should therefore be responsible for monitoring of performance indicators at a State and national level as an integral part of its evaluation and planning processes, and for the establishment of a regular program of clinical review.
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11.3 Accountability to clientsClient accountability refers to the accountability of service providers to their clients. This relates to both the quality of the clinical services provided, and the relationship between service providers and their clients. The analysis of public and private clinics in NSW by NDARC described previously in this report demonstrated the differences in outcomes achieved when different approaches were adopted in the provision of services. A more therapeutic approach with open communication was associated with improved clinical outcomes.
Other anecdotal evidence gathered in the course of this study highlighted differences in the approach by treating doctors. Some adopt an approach whereby clients are given significant input to their program, including variations to dosage levels, self-reporting of opioid use and use of takeaways. Other practitioners adopt a more punitive approach, using urinalysis, dosage levels and takeaway availability as reward/punishment mechanisms for compliance/non-compliance. While generalisations on this issue should be treated with caution, our observation is that the punitive approach appears more prevalent than the client empowerment approach. In some instances, the approach taken is affected by the regulatory environment. Clients also expressed concern about the lack of empowerment in many programs, which in some instances was accompanied by a lack of concern about clients' rights.
Many of these concerns could be addressed by inclusion of clients' rights as part of the quality assurance and accreditation procedures previously recommended. At the same time, the availability of a fast, effective appeals mechanism for clients against decisions of prescribers and dispensers would be of value.
Concern was also expressed by client representatives about the lack of participation by clients in the design and implementation of methadone programs at both the national and state level.
11.4 Program accountabilityThe final dimension of accountability refers to accountability of methadone programs in meeting their defined objectives. We are aware of a proposal before the National Methadone Committee to develop a national system of performance indicators to monitor and evaluate the performance of methadone programs across all jurisdictions in Australia.
A draft document has been prepared for discussion by the Committee in which the objectives of the performance indicator system are stated as:
- to define the Australian methadone treatment population and describe trends.
- to measure the performance of methadone treatment in Australia against the following objectives of the National Methadone Policy:
- to reduce unsanctioned opioid use;
- to improve the health status of clients;
- to help reduce the spread of infectious diseases associated with illegal opioid use, especially HIV, Hepatitis B and Hepatitis C; and
- to reduce crime associated with illegal opioid use;
- to assess access to, and acceptability of, methadone treatment in Australia; and
- to monitor risks associated with methadone treatment.
- participation rates in methadone programs by different age, gender and ethnic groups;
- the duration of treatment;
- the number of clients being treated in public and private medical and pharmacy programs;
- changes in clients outcomes across a number of dimensions;
- the incidence of blood borne viral infection among clients; and
- the number of deaths where methadone was the primary cause.
The future development of these indicators and their means of collection is the subject of further consideration by the Committee. Nevertheless we consider it appropriate to indicate our support for this program, and to endorse the principles behind the proposed indicators. At the same time, we recognise the need to ensure that the data collected for the purposes of evaluation at the program level are consistent with the data proposed for clinical evaluation at the individual clinic level. Such an approach will be essential if the costs of data collection are to be kept to a reasonable minimum and the onus of reporting by service providers is to be contained.
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- That Commonwealth and State governments negotiate the minimum level at which financial reporting of expenditure on public methadone programs be provided on an ongoing basis
- That a national minimum data set be established for the collection of performance indicators in all States on a regular basis, and that such data collection requirements be considered as part of a streamlining of existing reporting and regulatory procedures in the States.
- That a regular program of clinical review be established as the basis for developing and promulgating models of best practice.
- That provision be made for client representation to relevant State and Commonwealth committees responsible for the development and delivery of methadone programs.
- That a charter of client rights be included in the quality assurance programs proposed for the accreditation process for methadone clinics.
- That a fast effective appeals mechanism be established in each State to deal with client complaints.
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