This option represents no change to the way in which methadone services are currently funded between the States, the Commonwealth and clients. As such, the comments made in respect to the relative advantage and disadvantages of this option may provide a benchmark for comparison with the other options presented.
Public programs under this option would continue to be funded by State governments, either through traditional resource-based funding of public services, or through contracting arrangements with private practitioners for specific services of the type currently being established in Victoria. The preferred approach would be left to the discretion of State health authorities. Funding provided by the Commonwealth under the NDS could be used to assist in funding these services.
In the private sector the existing fee for service structure inherent in the CMBS would continue, whereby medical practitioners are remunerated for each occasion of service provided to clients. There is no statutory limitation on the number of occasions of service which may be provided in a given period, and the frequency of service is left to the individual practitioner's judgement. Under the current CMBS structure, services provided within methadone programs are not separately identified from other services. Fees charged are generally commensurate with the CMBS Schedule Fee, with the large majority of medical practitioners bulk-billing for their services. These fees vary according to the qualifications of the medical practitioner, with specialists and psychiatrists generally charging considerably higher fees than GPs.
Clients would continue to pay a fee for methadone dispensing, whether at a specialist methadone clinic, a public pharmacy or a community pharmacy. The fee charged for these services would be unregulated, and left to the discretion of the dispenser.
12.1.1 Advantages of this option
12.1.2 Disadvantages of this option
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12.1.1 Advantages of this option
- The fee for service principle inherent in the current Medicare structure provides a remuneration to medical practitioners proportional to the quantum of services provided. In particular, it caters for the considerable differences that exist in regard to the service needs of methadone clients, and for variations in intensity of services provided at different stages of treatment. These are distinct from any differences in approach between medical practitioners for clients with similar needs. This option caters for and encourages appropriate levels of service for more difficult clients. Failure to do so may result in these clients being diverted to public clinics (which may not have the capacity to cater for them) or to be excluded from services altogether.
- This approach avoids the need to differentiate between methadone services and other health care services provided contemporaneously. Considerable reference has been made by those consulted, particularly medical practitioners in private practice, of the comorbidities treated at the same time as methadone consultations. Using a common CMBS item and fee structure overcomes the problem of differentiating these treatments for billing purposes.
- The payment structure is consistent with the funding of other primary health care services to the wider community. As such, it reinforces the concept that methadone treatment is akin to other forms of care provided by private practitioners, and avoids any stigma that might be generated by a payment method which differs from that for other primary care services.
- This approach provides for client mobility, a factor which has been identified as being important among methadone clients. While movement of clients between medical practitioners providing methadone treatment is sometimes difficult to arrange, this is due primarily to the administrative arrangements in place rather than to any barriers caused by the payment structure. Alternative payment systems of the types described below may act as a further obstacle to client mobility.
- This payment structure is likely to encourage more general practitioners to participate in methadone programs. This is due to the range of reasons described above, particularly its ease of administration and the fee for service structure.
- This option would result in minimum disruption to existing practices which have generally proven successful. Familiarity with the existing fee structure and levels among medical practitioners facilitates their involvement, and requires no changes to administrative arrangements relating to billing and payment methods.
12.1.2 Disadvantages of this option
- The failure under this option to distinguish methadone services separately from other primary care services inhibits financial and clinical accountability for methadone services. Throughout the course of this study, difficulties in obtaining financial and clinical data through Medicare or other sources relating to methadone services provided in the private sector has highlighted the deficiencies of this approach.
- The fee for service structure provides an incentive for over-servicing. Information provided by medical practitioners in New South Wales has demonstrated the significant variations that exist in service provision both within and between disciplines. It is unreasonable to consider that these differences can be attributed solely to differences in client needs. This has been reinforced by the concerns raised by many about excessive levels of service in some instances. In the absence of improved accountability procedures, this approach fails to provide a structure which identifies such instances, and continues to reward such practices.
- While catering for more complex cases, this approach fails to provide incentives for best practice for clients with less complex needs. An open ended fee for service system with little clinical or financial accountability does not encourage medical practitioners to review their service levels.
- The differential fee structure is based on the qualifications of the practitioner rather than the nature of the service provided. There is a strong view that the fee differential between GPs and psychiatrists is not justified in regard to the normal range of methadone treatment services provided. While recognising that some clients in the care of psychiatrists require specialist care, this payment structure does not differentiate between these clients and those whose needs are less complex.
- This approach exposes the Commonwealth to an unlimited funding liability for methadone services provided in the private sector without the capacity to differentiate methadone treatment services from other primary health care services.