National Health Reform

National Health Reform Agreement

Schedule G - Business Rules for the National Health Reform Agreement

The following Business Rules are for service providers required to operate under the National Health Reform Agreement. These rules may be amended at any time with agreement in writing by all the parties or on behalf of the parties by the Commonwealth, State and Territory Health Ministers.

Public Patient Charges

G1. Where an eligible person receives public hospital services as a public patient no charges will be raised, except for the following services provided to non-admitted patients and, in relation to (f) only, to admitted patients upon separation:

1. dental services;


2. spectacles and hearing aids;


3. surgical supplies;


4. prostheses – however, this does not include the following classes of prostheses, which must be provided free of charge:
   1. artificial limbs; and
   
   
   2. prostheses which are surgically implanted, either permanently or temporarily or are directly related to a clinically necessary surgical procedure;
5. external breast prostheses funded by the National External Breast Prostheses Reimbursement Program;


6. pharmaceuticals at a level consistent with the PBS statutory co-payments;


7. aids, appliances and home modifications; and


8. other services as agreed between the Commonwealth and States.

G2. States can charge public patients requiring nursing care and accommodation as an end in itself after the 35th day of stay in hospital providing they no longer need hospital level treatment, with the total daily amount charged being no more than 87.5 per cent of the current daily rate of the single aged pension and the maximum daily rate of rental assistance.

Charges for Patients other than Public Patients

G3. Private patients, compensable patients and ineligible persons may be charged an amount for public hospital services as determined by the State.

G4. Notwithstanding clause G3, pharmaceutical services to private patients, while they receive services as admitted patients, will be provided free of charge and cannot be claimed against the PBS.

Pharmaceutical Reform Arrangements

G5. States which have signed bilateral agreements for Pharmaceutical Reform Arrangements may charge the PBS for pharmaceuticals for specific categories of patients as provided for in the Arrangements.

Public Health Services

G6. States and the Commonwealth will deliver public health services in accordance with the objectives, principles, roles and responsibilities, and any applicable standards, agreed in relevant national strategies, programs or initiatives.

Public Patients’ Charter and Complaints Body

G7. States agree to:

1. continue the commitment under the previous health care agreements to preparing and distributing a Public Patients’ Hospital Charter (the Charter), in appropriate community languages to users of public hospital services; and


2. maintaining complaints bodies independent of the public hospital system to resolve complaints made by eligible persons about the provision of public hospital services received by them.

Public Patients’ Hospital Charter

G8. States agree to:

1. review and update the existing Charter to ensure its relevance to public hospital services. The review should be conducted with the ACSQHC;


2. develop the Charter in appropriate community languages and forms to ensure it is accessible to people with disabilities and from non-English speaking backgrounds;


3. develop and implement strategies for distributing the Charter to public hospital service users and carers; and


4. adhere to the Charter.

G9. States agree to the following minimum standards:

1. the Charter will be promoted and made publicly available whenever public hospital services are provided; and


2. the Charter will set out:
   1. how the principles included in this Agreement are to apply to the provision of public hospital services in States;
   
   
   2. the process by which eligible persons can lodge complaints about the provision of public hospital services to them;
   
   
   3. that complaints may be referred to an independent complaints body;
   
   
   4. a statement of the rights and responsibilities of consumers and public hospitals in the provision of public hospital services in States and the mechanisms available for user participation in public hospital services; and
   
   
   5. a statement of consumers’ rights to elect to be treated as either public or private patients within States’ public hospitals, regardless of their private health insurance status.

Independent Complaints Body

G10. States agree to maintain an independent complaints body to resolve complaints made by eligible persons about the provision of public hospital services to them.

G11. States agree to the following minimum standards:

1. the complaints body must be independent of bodies providing public hospital services and State health departments;


2. the complaints body must be given powers to investigate, conciliate and/or adjudicate on complaints received by it; and


3. the complaints body must be given the power to recommend systemic and specific improvements to the delivery of public hospital services.

G12. The Commonwealth and the States agree that the powers of the complaints body will not interfere with or override the operation of registration boards or disciplinary bodies in States and that the exercise of powers by the complaints body will not affect the rights that a person may have under common law or statute law.

G13. To assist in making recommendations and taking action to improve the quality of public hospital services, States agree to implement a consistent national approach, agreed with the ACSQHC or any successor, to collecting and reporting health complaints data to improve services for patients.

Patient Arrangements

G14. Election by eligible patients to receive admitted public hospital services as a public or private patient will be exercised in writing before, at the time of, or as soon as possible after admission and must be made in accordance with the minimum standards set out in this Agreement.

G15. In particular, private patients have a choice of doctor and all patients will make an election based on informed financial consent.

G16. Where care is directly related to an episode of admitted patient care, it should be provided free of charge as a public hospital service where the patient chooses to be treated as a public patient, regardless of whether it is provided at the hospital or in private rooms.

G17. Services provided to public patients should not generate charges against the Commonwealth MBS:

1. except where there is a third party payment arrangement with the hospital or the State, emergency department patients cannot be referred to an outpatient department to receive services from a medical specialist exercising a right of private practice under the terms of employment or a contract with a hospital which provides public hospital services;


2. referral pathways must not be controlled so as to deny access to free public hospital services; and


3. referral pathways must not be controlled so that a referral to a named specialist is a prerequisite for access to outpatient services.

G18. An eligible patient presenting at a public hospital emergency department will be treated as a public patient, before any clinical decision to admit. On admission, the patient will be given the choice to elect to be a public or private patient in accordance with the National Standards for Public Hospital Admitted Patient Election processes (unless a third party has entered into an arrangement with the hospital or the State to pay for such services). If it is clinically appropriate, the hospital may provide information about alternative service providers, but must provide free treatment if the patient chooses to be treated at the hospital as a public patient. However:

1. a choice to receive services from an alternative service provider will not be made until the patient or legal guardian is fully informed of the consequences of that choice; and


2. hospital employees will not direct patients or their legal guardians towards a particular choice.

G19. An eligible patient presenting at a public hospital outpatient department will be treated free of charge as a public patient unless:

1. there is a third party payment arrangement with the hospital or the State or Territory to pay for such services; or


2. the patient has been referred to a named medical specialist who is exercising a right of private practice and the patient chooses to be treated as a private patient.

G20. Where a patient chooses to be treated as a public patient, components of the public hospital service (such as pathology and diagnostic imaging) will be regarded as a part of the patient’s treatment and will be provided free of charge.

G21. In those hospitals that rely on GPs for the provision of medical services (normally small rural hospitals), eligible patients may obtain non-admitted patient services as private patients where they request treatment by their own GP, either as part of continuing care or by prior arrangement with the doctor.

G22. States which have signed a Memorandum of Understanding with the Commonwealth for the COAG initiative “Improving Access to Primary Care Services in Rural Areas” may bulk bill the MBS for eligible persons requiring primary health care services who present to approved facilities.

G23. In accordance with this Agreement, public hospital admitted patient election processes for eligible persons should conform to the national standards set out in this schedule.

Public Hospital Admitted Patient Election Forms

G24. States agree that while admitted patient election forms can be tailored to meet individual State or public hospital needs, as a minimum, all forms will include:

1. a statement that all eligible persons have the choice to be treated as either public or private patients. A private patient is a person who elects to be treated as a private patient and elects to be responsible for paying fees of the type referred to in clause G1 of this Agreement;


2. a private patient may be treated by a doctor of his or her choice and may elect to occupy a bed in a single room. A person may make a valid private patient election in circumstances where only one doctor has private practice rights at the hospital. Further, single rooms are only available in some public hospitals, and cannot be made available if required by other patients for clinical reasons. Any patient who requests and receives single room accommodation must be admitted as a private patient (note: eligible veterans are subject to a separate agreement);


3. a statement that a patient with private health insurance can elect to be treated as a public patient;


4. a clear and unambiguous explanation of the consequences of public patient election. This explanation should include advice that admitted public patients (except for care and accommodation type patients as referred to in clause G2):
   1. will not be charged for hospital accommodation, medical and diagnostic services, prostheses and most other relevant services; and
   
   
   2. are treated by the doctor(s) nominated by the hospital;
5. a clear and unambiguous explanation of the consequences of private patient election. This explanation should include advice that private patients:
   1. will be charged at the prevailing hospital rates for hospital accommodation (whether a shared ward or a single room), medical and diagnostic services, prostheses and any other relevant services;
   
   
   2. may not be fully covered by their private health insurance for the fees charged for their treatment and that they should seek advice from their doctor(s), the hospital and their health fund regarding likely medical, accommodation and other costs and the extent to which these costs are covered; and
   
   
   3. are able to choose their doctor(s), providing the doctor(s) has private practice rights with the hospital;
6. evidence that the form was completed by the patient or legally authorised representative before, at the time of, or a soon as practicable after, admission. This could be achieved by the witnessing and dating of the properly completed election form by a health employee;


7. a statement that patient election status after admission can only be changed in the event of unforeseen circumstances. Examples of unforeseen circumstances include, but are not limited to, the following:
   1. patients who are admitted for a particular procedure but are found to have complications requiring additional procedures;
   
   
   2. patients whose length of stay has been extended beyond those originally and reasonably planned by an appropriate health care professional; and
   
   
   3. patients whose social circumstances change while in hospital (for example, loss of job);
8. in situations where a valid election is made, then changed at some later point in time because of unforeseen circumstances, the change in patient status is effective from the date of the change onwards, and should not be retrospectively backdated to the date of admission;


9. it will not normally be sufficient for patients to change their status from private to public, merely because they have inadequate private health insurance cover, unless unforeseen circumstances such as those set out in this Schedule apply;


10. a statement signed by the admitted patient or their legally authorised representative acknowledging that they have been fully informed of the consequences of their election, understand those consequences and have not been directed by a hospital employee to a particular decision;


11. a statement signed by admitted patients or their legally authorised representatives who elect to be private, authorising the hospital to release a copy of their admitted patient election form to their private health insurance fund, if so requested by the fund. Patients should be advised that failure to sign such a statement may result in the refusal of their health fund to provide benefits; and


12. where admitted patients or their legally authorised representatives, for whatever reason, do not make a valid election, or actual election, these patients will be treated as public patients and the hospital will choose the doctor until such time as a valid election is made. When a valid election is made, that election can be considered to be for the whole episode of care, commencing from admission.

Multiple and Frequent Admissions Election Forms

G25. A State or hospital may develop a form suitable for individuals who require multiple or frequent admissions. The form should be for a specified period, not exceeding six months, and nominate the unit where the treatment will be provided. Further, the form should be consistent with the national standards and provide patients with the same information and choices as a single admission election form.

Other Written Material Provided to Patients

G26. Any other written material provided to patients that refers to the admitted patient election process must be consistent with the information included in the admitted patient election form. It may be useful to include a cross reference to the admitted patient election form in any such written material.

Verbal Advice Provided to Patients

G27. Any verbal advice provided to admitted patients or their legally authorised representatives that refers to the admitted patient election process must be consistent with the information provided in the admitted patient election form.

G28. Admitted patients or their legally authorised representatives should be referred to the admitted patient election form for a written explanation of the consequences of election.

G29. To the maximum extent practicable, appropriately trained staff should be on hand at the time of election, to answer any questions admitted patients or their legally authorised representatives may have.

G30. Through the provision of translation/interpreting services, hospitals should ensure, where appropriate, that admitted patients, or their legally authorised representatives, from non-English speaking backgrounds are not disadvantaged in the election process.