Report on the 2010 review of the Medicare provider number legislation

Chapter Three - Operation of Section 19AA

Page last updated: 15 November 2012

This section discusses the operation of s19AA, including relevant recommendations from the 2005 Biennial Review and any emerging issues.

The legislation is operating as intended but there are mixed views about whether there is the right balance between managing the workforce and quality control aspects of the legislation. Some of the recommendations of the 2005 Biennial Review have been implemented, small changes to the legislation and/or regulations are needed to address the issues that continue to affect some doctors.

3.1 Section 19AA legislation intends to ensure doctors receive continuing professional development, resulting in higher quality medical care for all Australians

Section 19AA of the Act does not allow access to Medicare benefits for medical practitioners who were qualified after 1 November 1996, unless they are Fellows of a specialist college or are doing an approved placement on a s3GA program.

The purpose of the legislation is to ensure that all medical practitioners have or are working towards vocational registration, which would help them to deliver a high standard of medical care. Section 19AA of the legislation gives formal recognition to general practice as a medical speciality, whose practitioners need specific skills and competencies.

Section 19AB is a related section of legislation, which restricts OTDs’  1  and foreign graduates of accredited medical schools  2 ’ (FGAMs) access to Medicare benefits, for a period of generally 10 years, unless the doctor is working in a district of workforce shortage (DWS). This is commonly known as the ‘10 year moratorium’. OTDs and FGAMs can access Medicare benefits for the services they provide in a DWS if they obtain an exemption under s19AB of the Act. OTDs and FGAMs who are Australian permanent residents or citizens and who have yet to gain Fellowship of a specialist college or vocational recognition are also subject to s19AA of the Act. This group of OTDs are eligible to work under s3GA programs.

As s19AB is outside the scope of this review, views were not sought on the appropriateness of the moratorium. However, there were views from some stakeholders seeking its abolition because they say it is ineffective and discriminatory. Other stakeholders view it as essential for ensuring an adequate medical workforce is available, for example, for MDSs.

The Australian Government has recently announced the establishment of a formal House of Representatives Committee inquiry into the role of Australia’s specialist medical colleges in the process of registering and supporting OTDs  3  (24 November 2010). In addition, the Health Workforce Ministerial Councils asked the Australian Health Workforce Advisory Council for independent advice to Ministers regarding the assessment requirements for registration with each of the specialist colleges.

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3.2 Findings for section 19AA

The findings of the 2010 review about the operation of s19AA largely concur with those made in 2005, including that the legislation is operating as intended and that there is unfinished business in regard to recognising doctors who qualified before 1996 and are not included on the vocational register.

One new issue identified in this review is an anomaly of the legislation that makes it hard to retain doctors in practices after they become permanent residents of Australia. The review has also identified parts of the relevant regulations that need updating.

3.2.1 Section 19AA is well accepted by the medical profession

As in other specialist areas, VR medical practitioners are now seen as the norm in general practice  4 . In 2010, the new national registration process also recognised general practice as a medical specialty accessible through Fellowship of the RACGP (FRACGP) or ACRRM (FACRRM); or on the general practice vocational register.

Industry stakeholders generally agree with the intent of the legislation, that is, to ensure medical graduates have vocational training that will develop their skills and ensure they are capable of working in unsupervised general practice or other speciality areas. Stakeholders involved in vocational medical training claim that the quality of services provided by GPs is now more consistent across Australia as a result of vocational training requirements.

The review found that the implementation of s19AA, along with other legislation that addresses access to provider numbers, is complex and there is a need to harmonise the various legislation.

3.2.2 The balance between workforce and quality policy objectives

Although supportive of the intent of s19AA, one group of general practice stakeholders feel that the legislation should try to achieve a better balance between workforce supply and quality care provision. These stakeholders argue that there are still medical workforce shortages in Australia, particularly in rural areas, and therefore more flexibility is needed to overcome shortages. Other stakeholders disagree with the policy on workforce programs and believe they are inherently discriminatory. These stakeholders say that working as a doctor in remote and rural areas is generally more challenging than other places, and that workforce programs reduce standards of practice by allowing non-qualified doctors to work in these areas, often without access to adequate supervision or sufficient support to achieve vocational qualifications. They also commented on the inconsistency of standards, which means a doctor is able to work in specific areas but not considered skilled enough to work elsewhere.

Some States now require OTDs with insufficient general practice experience to first work in a hospital in order to orient them to the Australian health system. Doctors may then transition to a supervised general practice environment. However, general practice stakeholders say that it is difficult to find in-hospital placements and that community based settings are generally a more viable training placement.

One reported issue for rural areas related to workforce objectives of the legislation, is that some OTDs are less able to provide after-hours care, emergency department services or procedural services for local hospitals. This is one of several factors that might jeopardise the operation of smaller hospitals.

3.2.3 Supporting non VR GPs to achieve vocational recognition

Non VR GPs and their patients are financially disadvantaged by receiving significantly lower Medicare rebates than their VR colleagues. In 2010, the rebates for non VR GPs are almost the same as nurse practitioners rebates, a situation that some stakeholders find unfair given the differences in training of the two professional groups  5 

More needs to be understood about the characteristics of non VR doctors working in general practice. There are an estimated 5,800 non VR GPs  6 , approximately half of these are OTDs. Many non VR GPs work in metropolitan areas in specialist general medicine, for example: skin cancer medicine or cosmetic medicine; or in Aboriginal Medical Service; or in Family Planning clinics.

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Non VR doctors who graduated before 1996

One group identified in previous reviews as being unfairly affected by s19AA, and subsequent changes to the way doctors are recompensed for services, is GPs who graduated before 1996 and who are not currently on the vocational register.

Although the group is difficult to define, there are four types of these pre-1996 graduates who are non VR:

  • doctors who objected to the idea of vocational recognition and who have remained non VR
  • doctors who missed the cut off date for grandfathering because they were overseas or on leave and have since chosen to not work towards a Fellowship
  • doctors working in an area of general medicine that doesn’t require them to be FRACGP/FACRRM, for example: skin cancer medicine or cosmetic medicine; Aboriginal Medical Service; or in Family Planning Clinics
  • OTDs who came into Australia before 1996 or in the early 2000s and who have continued to work in DWS as part of s3GA programs and have not needed vocational recognition to access Medicare.

Across these groups, there are an estimated 600 GPs who graduated before 1996 and have at least five years experience in general practice who would be interested in having their skills recognised formally, or who could work towards a Fellowship  7 . It’s believed that many of the doctors in this group are highly experienced doctors working in solo practices. Some stakeholders suggested that the cost of attaining Fellowship, both in terms of exam fees and the time cost of studying for the exams, might be the biggest barrier to Fellowship. Others surmise that factors including fear of failure, uncertainty about how to prepare for the exams and the effort it will take to pass the exams, are the reasons why these non VR doctors hesitate to do their Fellowship exams.

The 2005 Biennial Review recommended that the Australian Government ‘provide one more opportunity for doctors who meet the necessary criteria to be grandfathered onto the Vocational Register’, but this opportunity wasn’t provided. In 2010, there are different views about how to assist and encourage non VR doctors to obtain recognition.

One view is that, because the opportunity to be grandfathered wasn’t provided after the last review and because there is no reason to believe that these doctors’ standards of care are any different than their peers who graduated at the same time, another round of grandfathering should be offered. Stakeholders who support grandfathering argue that the new national registration arrangements will provide reassurance about the ongoing quality of their practice, similar to other medical practitioners.

Because more than half of the non VR GPs already have access to higher Medicare rebates through workforce programs, it’s argued that the move to grandfather the non VR doctors would have a limited cost impact. The stakeholders argue that the move could help to retain this cohort of highly experienced GPs in the medical workforce and encourage them to increase their working hours.

Other stakeholders do not support grandfathering. This group suggests that because Fellowship is now the industry standard to ensure quality of care, and because grandfathering does not include an assessment of doctors’ skills, that an additional round of grandfathering could jeopardise the credibility of vocational recognition. Another common argument against grandfathering is that most of non VR GPs who qualified before 1996, that are likely to do their Fellowship exams, have done them.

The regulatory landscape has changed since the last round of grandfathering for non VR GPs. If grandfathering occurred as the result of the current review, one issue to consider is whether this group of GPs would be eligible for specialist registration and hence able to access specialist rebates for services. Our initial advice is that this group could be outside s58 of the Health Practitioner Regulations, National Law Act 2009 because they do not hold a ‘qualification’ and that an alternative administrative mechanism may have to be established.

In line with the argument that non VR GPs and their patients are financially disadvantaged, some stakeholders made suggestions for improving remuneration for non VR GPs.

  • Allow non VR GPs to access higher Medicare rebates for a defined time period if they can show they are working towards Fellowship.
  • Increase the ‘other non-referred medical practitioner’ Medicare items to 93 per cent of the VR Medicare rebate and ensure an indexation of Medicare rebates for all non VR GPs, in line with the current GP indexation arrangements.

Currently, there are programs available which offer medical practitioners the same access to the higher rebate as is available to GPs on the Vocational Register. The Medicare Plus for Other Medical Practitioners (MOMPs) Program provides access to the higher Medicare rebate for services provided by pre-1996 non VR GPs who provide services in DWS. After these practitioners have been on the program for a period of five years, their services will continue to attract the higher rebate regardless of where they subsequently practice. Although there is the condition to work in a DWS, this program affords this cohort of pre-1996 doctors the opportunity to access the higher rebate without obtaining vocational recognition.

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Non VR GPs who graduated after 1996

General practice stakeholders indicated that all doctors who graduated after 1996 and who are working in general practice settings should have VR or be working towards this qualification.

The two general practice colleges, RACGP and ACRRM, both have pathways to Fellowship for non VR GPs that take into account their commitment to the profession, their past experience, and their involvement in continuing professional development. The RACGP offers a Practice Eligible Route to Fellowship, which is open to doctors who have at least four years of fulltime general practice experience with at least one of these years in Australia. Doctors following the Practice Eligible Route do a three-part practice-based assessment of their skills before being awarded FRACGP. Likewise, ACRRM offers an Independent Pathway to Fellowship for experienced GPs, which is delivered to doctors enrolled in the RVTS.

3.2.4 The impact of s19AA on OTDs’ ability to practise

Once an OTD becomes a permanent resident or citizen of Australia, they are subject to s19AA of the Act and, if they don’t have appropriate postgraduate qualifications, they need to be placed on a s3GA program in order to access Medicare benefits. The logic of this requirement is to ensure that doctors who remain permanently in the country have appropriate levels of qualifications.

Anomalies under s19AA mean that OTDs can suffer hardship and find it difficult to practice. Stakeholders described situations where a recent Australian permanent resident doctor, with a well established practice, may no longer be able to access Medicare rebates in that location due to becoming subject to the restrictions of s19AA of the Act. The result of situations like this is that doctors might need to leave their practice, or be unable to earn a satisfactory living unless they can access a suitable s3GA program.

Stakeholders expressed concern that maintenance of recognition on the vocational register can be influenced by the rules of individual Colleges, outside the need to keep up continuing professional development points. This issue has been raised with the Australian Medical Board who are currently developing a policy to address it.

3.2.5 Other issues

One result of s19AA is that doctors are less able to acquire training and skills to work in different but related work contexts or change their career pathways than was possible prior to 1996, for example, being able to move between emergency medicine and general practice. In regional Australia, where the bulk of emergency services are provided by GPs, this has led to challenges which ACRRM is addressing through its Fellowship program. The Australasian College of Emergency Medicine is considering offering additional diplomas that improve emergency medicine skills of other medical practitioners as a way of addressing this issue. Queensland Health has also introduced advanced specialist training in emergency medicine for generalists in the Queensland Health workforce.

An unintended consequence of s19AA is that many junior doctors have not had experience in general practice settings as part of their postgraduate training. Until the recent introduction of PGPPP, there has not been a dedicated workforce program that allows junior doctors’ access to Medicare rebates while working in general practice.

This has meant it is more difficult to attract graduates to general practice. Instead, junior doctors tend to follow a hospital based training pathway and have limited experience in general practice settings in their first or second postgraduate years. General practice stakeholders are hopeful that by expanding PGPPP, most junior doctors will be able to get general practice experience in their first few years of practice. PGPPP is discussed further in chapter 6.

3.2.6 Changes needed to legislation and/or regulations to support vocational training in the private hospital sector

There are inconsistencies across medical specialist areas about access to Group T8 rebates. Currently, only supervising surgical specialists can bill for Group T8 items, that is, surgical procedures their registrars do under supervision. Non-surgical supervising specialists cannot bill in this way, which is a barrier to getting vocational training placements in private hospitals because of a potential loss of income.

The review understands that DoHA are considering the issue and are seeking advice as to whether changes are required to the relevant legislation or regulations to address this issue.

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3.3 2010 Recommendations for section 19AA

Recommendation 1

DoHA to review all relevant Medicare Provider Number Legislation to address issues in access to provider numbers and the ability of doctors to practice.

Recommendation 2

The Government to review eligibility criteria for access to vocational training programs so that OTDs’ access to these is assessed on the basis of clinical skills and not on the basis of their residential status.

Recommendation 3

Eligibility for grandfathering of non VR GPs who were qualified before 1996 to be determined in consultation with the profession and the Medical Board of Australia:

Provide one last opportunity to be grandfathered onto the vocational register because this recommendation was not actioned in 2005. If grandfathering is not possible because of the establishment of the national registration system; allow this group to access A1 rebates for a defined period whilst working towards Fellowship with ACRRM or RACGP.

Recommendation 4

For other non VR doctors working in general practice:

DoHA and industry stakeholders to investigate the barriers for non VR doctors in obtaining vocational recognition and how to provide better support to them, and act on the findings of the investigation.

Recommendation 5

DoHA to amend the relevant regulations and/or legislation to allow supervisors to bill for T8 items for specialist trainee doctors performing procedures in private settings.

1 OTDs are doctors whose primary medical qualification was not obtained from an AMC accredited medical school in Australia or New Zealand.
2 Foreign graduates of accredited medical schools are doctors whose primary qualification was obtained at an AMC accredited medical school in Australia or New Zealand, and who was not a permanent resident of citizen of Australia or New Zealand at the time when they first enrolled.
3 http://www.aph.gov.au/house/committee/haa/overseasdoctors/index.htm
4 In 2010, the ratio of GP Fellows to GP’s on the Vocational Register was about fifty-fifty (Source: AMA personal communication).
5 Doctors on s3GA workforce programs in districts of workforce shortage are an exception, because they can access higher rebates (A1) by virtue of being on these programs.
6 5,800 non-VR doctors participate in RACGP Continuing Professional Development Program
7 RACGP estimates