Aboriginal and Torres Strait Islander Access to Major Health Programs November 2006

Urbis Keys Young

Prepared for Medicare Australia and the Department of Health and Ageing

Urbis Keys Young

Prepared for Medicare Australia and the Department of Health and Ageing Reference Group Membership

• Aboriginal Health Worker representative • Australian Indigenous Doctors Association (AIDA) • Australian Medical Association (AMA) • Congress of Aboriginal and Torres Strait Islander Nurses (CATSIN) • General Practice Representative Group (GPRG) • Medicare Australia (formerly the Health Insurance Commission) • National Aboriginal Community Controlled Health Organisation (NACCHO) • Ofﬁce for Aboriginal and Torres Strait Islander Health (OATSIH) • Pharmacy Guild of Australia • Queensland Aboriginal and Islander Health Council (QAIHC) • Rural Doctors Association of Australia

Working Group Membership

• Centrelink • Department of Health and Ageing (Pharmaceutical Access and Quality) • Department of Health and Ageing (Practice Incentives and Alternative Funding Section, General Practice Programs Branch) • Department of Health and Ageing (Primary Care Policy Branch) • Medicare Australia (Indigenous Access Program and Medicare Business Support Section) • Medicare Australia (Medicare and Department of Veterans’ Affairs Branch) • Medicare Australia (Program Delivery – PBS) • Ofﬁce for Aboriginal and Torres Strait Islander Health (Policy and Analysis Branch) - Department of Health and Ageing • Ofﬁce of Indigenous Policy Coordination (Policy Innovation) - Department of Family, Community Services and Indigenous Affairs

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 Acknowledgements

The consultants gratefully acknowledge the considerable support and assistance provided by staff at the Aboriginal and Torres Strait Islander Health Services which participated in this study and the contributions made by community members consulted in the course of the research. We hope that their experiences and views are clearly reﬂected in this report.

Sincere thanks also go to the members of both the Working Group and the Reference Group who made invaluable contributions throughout the study. Finally our thanks to the hundreds of health professionals and administrators - including Aboriginal health workers, nurses, doctors, pharmacists and Medicare Australia staff - who generously contributed their time and wealth of experience to this research.

We trust and believe that this work will contribute, in some small way, to the improved health and wellbeing of Aboriginal and Torres Strait Islander peoples.

The images used for this publication have been selected from a collection of photographs that were taken for use in the Healthy for Life Program. The Department of Health and Ageing acknowledges and thanks the many people who participated in the photo shoots and gave permission for the images to be used in departmental publications.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 Table of Contents

Reference Group Membership Working Group Membership Acknowledgements Glossary Executive Summary i Recommendations v 1 This study 1 1.1 Background 1 1.2 Objectives and scope 2 1.3 Methods 4 1.3.1 Introduction 4 1.3.2 Reference to existing literature and data 4 1.3.3 Analysis of OATSIH and Medicare data 6 1.3.4 Stakeholder consultation 6 1.3.5 Field visits 7 1.3.6 Survey research 8 1.4 This report 8 2 Medicare Information and Enrolment 9 2.1 Introduction 9 2.2 Aboriginal and Torres Strait Islander Enrolment in Medicare 9 2.3 Voluntary Indigenous Identifier 12 2.4 Medicare Liaison Officers for Indigenous Access and Indigenous Specialist Information line 12 2.4.1 Medicare Liaison Officers for Indigenous Access 12 2.4.2 Specialist Indigenous Access Line 13 2.4.3 Opinions about these services 14 2.5 Summary 17 3 Use of Medicare by Aboriginal and Torres Strait Islander Health Services 18 3.1 Introduction 18 3.2 Exemption under Subsection 19(2) of the Health Insurance Act 1973 18 3.3 OATSIH and Medicare funds 19 3.4 Claiming Medicare rebates 21 3.5 Role of Medicare in Indigenous health services 2 3.6 Services provided by Practice Nurses and Aboriginal Health Workers 28 3.7 Enhanced Primary Care items 28 3.8 Practice Incentives Program 31 3.9 Immunisation 35 3.10 Hearing services 37 3.11 Point of care diabetes testing and the National Diabetes Services Scheme 40 3.11.1 Point of care testing for diabetes 40 3.11.2 National Diabetes Services Scheme 41 3.12 Rural and Remote Health Initiatives 43 3.13 Other Matters 44 3.14 Summary 44

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 4 Access to Medicare through Mainstream Health Services 46 4.1 Use of mainstream services 46 4.2 Training of practitioners 48 4.3 Use of EPC items in General Practice 49 4.4 Survey of GPs 49 4.4.1 Characteristics of the practice 50 4.4.2 Numbers of Indigenous patients 50 4.4.3 Recording of information 51 4.4.4 Charging for services 51 4.4.5 Medicare 51 4.4.6 EPC items 52 4.4.7 Practice Incentives Program 53 4.4.8 Length of appointments 53 4.4.9 Specialist referrals 54 4.4.10 Medications 54 4.4.11 Rural Health Strategy 54 4.4.12 Training or experience in Indigenous health 55 4.4.13 Possible innovations or changes 55 4.5 Specialist medical services 56 4.6 Summary 58 5 Access to Medications under the Pharmaceutical Beneﬁts Scheme (PBS) 59 5.1 Introduction 59 5.2 Section 100 of the National Health Act 1953 and the 2003 review 59 5.3 Role of community pharmacies 62 5.3.1 Community pharmacist perspectives 62 5.3.2 Survey of community pharmacies 64 5.4 The PBS Safety Net 68 5.5 Medications on discharge from hospital 69 5.6 Quality Use of Medicines 69 5.6.1 General 69 5.6.2 Home Medicines Review 71 5.7 Access to a wider range of pharmacy support 72 5.8 Medications covered by the PBS 72 5.9 Possible initiatives to improve access to the PBS 72 5.10 Summary 75 Key References 76 Case Studies 78 Appendices Located online at http://www.health.gov.au/oatsih

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 Glossary

ACCHS Aboriginal Community Controlled Health Service ACIR Australian Childhood Immunisation Register AHW Aboriginal Health Worker ATSIHS Aboriginal and Torres Strait Islander Health Service CDEP Community Development Employment Program CDM Chronic Disease Management CHSP Commonwealth Hearing Services Program DHCS Department of Health and Community Services (Northern Territory) DoHA Department of Health and Ageing EPC Enhanced Primary Care GPII General Practice Immunisation Incentives HIC Health Insurance Commission MBS Medicare Benefits Schedule MLOs Medicare Liaison Officers for Indigenous Access MSOAP Medical Specialist Outreach Assistance Program NACCHO National Aboriginal Community Controlled Health Organisation NDSS National Diabetes Services Scheme OATSIH Office for Aboriginal and Torres Strait Islander Health OMPs Other Medical Providers OTD Overseas Trained Doctor PBS Pharmaceutical Benefits Scheme PHCAP Primary Health Care Access Program PIP Practice Incentives Program QUM Quality Use of Medicines RACGP Royal Australian College of General Practitioners S100 Section 100 of the National Health Act 1953 SAR Service Activity Reporting SIP Service Incentive Payment VACCHO Victorian Aboriginal Community Controlled Health Organisation

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 Executive Summary

Nature and Purpose of this Study

This study was conducted during 2005-06 for the Department of Health and Ageing (DoHA) and Medicare Australia. Its purpose was to provide an up to date picture of Aboriginal and Torres Strait Islander people’s access to major health programs. The work included consideration of a range of Australian Government initiatives that have been implemented since the submission of an earlier report on Indigenous access to Medicare and the Pharmaceutical Beneﬁts Scheme (PBS), prepared by Urbis Keys Young in 1997.

The present study involved national stakeholder consultation, visits to twelve urban, regional and remote locations across Australia, statistical analysis and the conduct of four inter-related surveys with Aboriginal and Torres Strait Islander Health Services (ATSIHSs), community pharmacies, GPs and Medicare staff.

Initiatives since 1997

This study conﬁrmed that a number of initiatives that have been taken in recent years to improve Aboriginal and Torres Strait Islander access to Medicare and the PBS are widely seen as appropriate and valuable. These include:

• the appointment of Medicare Liaison Officers for Indigenous Access within Medicare Australia; • establishment of a specialist free-call Indigenous Medicare information line; • increased use of an exemption under subsection 19(2) of the Health Insurance Act 1973 that enables Aboriginal and Torres Strait Islander Health Services in certain States and Territories (remote clinics) to claim Medicare rebates for services they provide; • Additional Medicare rebates for doctors who bulk bill certain services provided to eligible patients, eg health care card holders and children under 16 years. Higher incentive payments apply in eligible area including regional, rural and remote locations, • entitlement for GPs to claim Medicare rebates relating to certain tasks performed by nurses and, in the Northern Territory, by Aboriginal Health Workers; • arrangements under S100 of the National Health Act 1953 which enable eligible approved ATSIHSs in remote areas to supply PBS medication, free of charge at the time of consultation, for the use of their patients; • creation of certain Enhanced Primary Care items intended to meet specific Indigenous health needs, such as the health assessment for Indigenous Australians aged 55 and over and the adult health check for Indigenous Australians aged 15-54; • introduction of new Medicare enrolment forms for babies and the development and implementation in the Northern Territory of an Indigenous-specific baby enrolment form and program; • other specific initiatives such as arrangements for point-of-care diabetes testing and a recent extension of entitlement to services under the Australian Hearing Services Program.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 i Medicare Information and Enrolment

The study conﬁrmed the value of a range of initiatives taken since 1997 to increase Aboriginal and Torres Strait Islander enrolment in Medicare and to support the claiming of Medicare rebates on behalf of Indigenous Australians. Notwithstanding limitations in the data available, it is widely accepted that enrolment levels have substantially increased; enrolment is particularly high in the Northern Territory.

Both the appointment of Medicare Liaison Ofﬁcers for Indigenous Access (MLOs) and the establishment of a free- call Indigenous information line were seen positively by Aboriginal and Torres Strait Islander Health Services. While some difﬁculties and delays are still encountered, these initiatives have helped to substantially reduce problems previously faced by service providers relating to Indigenous enrolment and claims.

Such initiatives were also welcomed among private GPs and community pharmacists, though awareness of them was lower in these groups.

The work of MLOs in telephone and face-to-face liaison with and training of health service staff is clearly valuable, and needs to be continued and extended. An increase in the number of MLO positions would assist. Any uncertainties about ongoing funding for such positions should be addressed, and more Aboriginal and Torres Strait Islander people need to be appointed as MLOs. There are also training and career path issues for MLOs to be addressed.

Use of Medicare by Aboriginal and Torres Strait Islander Health Services

Although most ATSIHSs now receive some income under the subsection 19(2) exemption, the total value of such income overall is relatively modest by comparison with Indigenous Health Program funding provided through OATSIH. Nevertheless Medicare rebates represent an important source of funds for many services.

At this stage health services vary considerably in their capacity to capture all the Medicare income to which they are entitled. Reasons for under-claiming include varying GP or Medical Ofﬁcer familiarity with Medicare and varying degrees of motivation to claim; limited Medicare knowledge among other ATSIHS staff; the complexity of some aspects of Medicare; the limitations of administrative systems, patient record and IT systems; variation in the ways in which services are structured and in the relationships between management and GPs; and competing pressures that may reduce staff time available for investment in Medicare.

Ongoing information and training about Medicare for ATSIHS staff is clearly important, and some services need particular assistance in making the changes necessary for more effective use of Medicare. It is also important that DoHA communications about Medicare issues and changes be as clear and straightforward as possible.

Income from Medicare cannot in itself be an adequate source of income for ATSIHSs – particularly because Medicare is GP-centred, while GPs play only a limited role in the work of health services. Numbers of changes could be considered to improve the ‘ﬁt’ between Medicare and ATSIHS modes of operation – for example further Medicare recognition of the roles played by nurses and AHWs.

Health services operating in remote and traditional communities may have difﬁculty in using the standard Medicare claims process, and options for simpler and more appropriate procedures deserve consideration in these settings.

ii Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 The introduction of Enhanced Primary Care (EPC) items has generally been positive from the perspective of Indigenous health. However, ATSIHSs report that they sometimes find it difficult to provide specific EPC services and to claim for these. While maintaining high clinical standards, ongoing review of EPC items needs to take account of practical issues that may arise in Indigenous-specific services. The new Chronic Disease Management items introduced by DoHA are intended to be simpler to use, and allow greater scope for AHW participation.

Further consumer or community education would be valuable in relation to health assessments in particular, to promote an understanding of the value and availability of these checks.

By no means all health services are accredited and thus eligible to participate in the Practice Incentives Program; this is an area where Divisions of General Practice can appropriately offer support to interested ATSIHSs. Even accredited ATSIHSs face problems in using some elements of PIP (eg the Asthma 3+ program) because of difﬁculties in achieving the structured contact with patients over time that these require. Nevertheless it is important that efforts be made to increase ATSIHS understanding and use of PIP.

Medicare rebates for immunisation seem generally to present little problem for ATSIHSs. While some services achieve the 90% immunisation level required for receipt of additional outcome payments, others ﬁnd this a difﬁcult target to reach – for example because of mobility in the communities they serve.

Point of care diabetes testing, as introduced in some ATSIHSs on a trial basis, was seen as a valuable service.

Some ATSIHSs need further assistance in taking advantage of mainstream Australian Government programs relating to rural and remote area health.

Access to Medicare through Mainstream Health Services

Some Indigenous Australians are in a position to choose between use of private GPs and ATSIHSs, or to use one or other as they prefer. Advantages typically attributed to ATSIHSs include provision of services free of charge, culturally appropriate services, supportive staff, sensitivity to gender issues (eg separate male and female clinics), availability in some cases of free medications, and other beneﬁts such as assistance with transport. GPs may be chosen, on the other hand, on the basis of greater privacy or anonymity, maintaining long term doctor-patient relationships, or simply convenience.

A number of stakeholders believed that the quality of service that Indigenous Australians receive from mainstream service is very variable. Particularly in some country towns, there may be no access to Indigenous-speciﬁc services and Aboriginal patients have to use whatever mainstream services are available, regardless of levels of empathy and expertise.

There have been past initiatives in providing GPs (and other mainstream health professionals) with some form of cultural awareness training. Such work clearly needs to continue, with NACCHO, the RACGP and Divisions of General Practice being among the relevant players. Indigenous health content in formal education and training of doctors, nurses and other health professionals has been increasing, and again this needs to continue.

A small number of general practices employ AHWs, and there have been some short-term and pilot schemes encouraging broader AHW involvement in working with GPs. Two Divisions of General Practice, in Perth (Canning) and in Port Augusta, are currently trialling schemes which involve AHWs working with private practices to support the uptake of Indigenous–speciﬁc EPC items.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 iii The availability of bulk-billing is a key factor in Indigenous access to mainstream services, and any decline in the number of bulk-billing practices will have implications for Indigenous patients. The survey of GPs that was conducted during the study showed that GPs were somewhat more likely to offer bulk-billing to Indigenous than to non-Indigenous patients.

Both survey and qualitative research indicated that appointments with Indigenous patients may take longer than those with non-Indigenous patients. Reasons for this include communication issues (eg time needed to establish conﬁdence and rapport) and the fact that Indigenous patients tend to be slower to present and therefore ultimately to present with more serious or complicated conditions.

Indigenous access to medical specialists varies considerably from place to place. Where specialists are available this is often through State and Territory Health departments. Several problems or barriers affecting access to specialists were identiﬁed, including:

• the restriction of subsection 19(2) to non-referred services • the difﬁculty of obtaining GP referrals in remote or sparsely populated areas.

The Medical Specialist Outreach Assistance Program (MSOAP) is intended to assist in meeting some of the additional costs that specialists incur in providing services in isolated areas; however stakeholders described this program as quite limited in scope.

Lack of adequate and affordable dental services was frequently identiﬁed as a signiﬁcant problem in Indigenous health.

Access to Medications under the Pharmaceutical Beneﬁts Scheme

Arrangements under S100 of the National Health Act 1953 have greatly improved access to PBS medications for Aboriginal and Torres Strait Islander people living in remote areas, and this scheme represents one of the major advances of recent years. It is clear, however, that access to medications remains a major concern in areas not covered by the S100 arrangements; here the cost of medications is the greatest single barrier. In particular, the study team was consistently told that the cost of PBS medicines was a major problem for many Indigenous families and individuals who do not qualify for a health care concession card. Other problems include physical access (eg lack of transport) and communication/cultural barriers.

Two key issues emerged from the study in relation to access to the PBS – ﬁrst, the need to strengthen the existing S100 arrangements in remote areas by appropriate initiatives to improve Quality Use of Medicines; and, second, to address cost and other barriers in non-remote areas. Key QUM measures in remote areas will involve medication training for AHWs and nurses, and increased advice and support to ATSIHSs on the part of community pharmacies supplying medications under S100.

Community pharmacists indicate that, particularly in light of the Indigenous-speciﬁc services now provided by Medicare Australia, it is in most cases reasonably straightforward for them to solve problems that arise in relation to missing Medicare cards or enrolment details.

Both qualitative research and data provided by DoHA show that few Indigenous Australians obtain the beneﬁt of the PBS Safety Net arrangements.

Correct storage and use of medications is a signiﬁcant and ongoing problem, and there is a need to address this through community education and other measures. It would be desirable, for example, to develop alternatives to the existing Home Medicines Review that would better meet the needs of Indigenous Australians. iv Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 Recommendations

Aboriginal and Torres Strait Islander Enrolment in Medicare

1. The initiatives taken over recent years to increase Indigenous enrolment in Medicare are appropriate and should continue and be further developed. Among other things there should be a continuing focus on the timely enrolment of newborn babies. 2. Medicare Australia and OATSIH should monitor the implications for Indigenous enrolment of possible moves towards a ‘smart card’ covering Medicare and other programs. 3. Work should continue on promoting take-up of the Voluntary Indigenous Identiﬁer and effective use of the data it yields to improve health services for Aboriginal and Torres Strait Islander people. Medicare Liaison Ofﬁcers for Indigenous Access and the Indigenous Specialist Information line

4. Both the appointment of MLOs and the establishment by Medicare Australia of a specialist free-call Indigenous information line have been positive initiatives, and funding for both should continue. Medicare Australia should ensure that all existing MLO positions are funded on an ongoing basis. 5. Medicare Australia and OATSIH should review the present number and location of MLOs, with a view to making additional appointments where this is likely to lead to improved services. 6. Medicare Australia should review training needs and career opportunities for MLOs, and should continue its efforts to attract suitable Indigenous candidates to these positions as vacancies occur. 7. DoHA should provide further support for NACCHO afﬁliates in their work on improving levels of Indigenous enrolment in Medicare and the use of Medicare by their member services. 8. Medicare Australia, in consultation with relevant parties such as the AMA, ADGP, the Pharmacy Guild and NACCHO, should take further steps to increase awareness among mainstream health service providers of the role of MLOs and the availability of the specialist Indigenous information line. Access to Medicare through Aboriginal and Torres Strait Islander health services

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 v 12. Divisions of General Practice should specifically consider how they can best assist ATSIHSs in their area to make optimal use of the MBS. 13. Once review of the special Medicare claim arrangements that have been in operation at the Nganampa Health Service has been completed, Medicare Australia and OATSIH should consider options for making more flexible claiming arrangements available in other remote areas. 14. In introducing or amending Medicare items (including EPC and PIP items), DoHA should ensure that relevant information is provided to ATSIHSs in as clear, simple and effective a manner as possible. The same should apply to any other aspects of Medicare where uptake by ATSIHSs may be affected by communication barriers. Information packages should be ‘market tested’ with relevant target groups in advance. 15. Consideration should be given to further practical changes to Medicare which reflect the models of health care used within ATSIHSs and the circumstances in which they operate. Examples could include further recognition of the roles played by health professionals other than GPs, consideration of the role of GP services provided by telephone, increased rebates for services provided in remote locations, and increasing the number of allied health services provided for in Chronic Disease Management plans. 16. DoHA should promote awareness and education initiatives for Indigenous communities on the purpose and value of periodic health assessments. 17. DoHA should implement a strategy designed to increase ATSIHS use of the Practice Incentives Program (PIP). In future consideration of the scope of the PIP, consideration should be given to the inclusion of items that reflect particular needs in Indigenous health – including possible incentives to mainstream practices to employ Indigenous staff. 18. All Divisions of General Practice should consult with ATSIHSs within their area on whether those services would value assistance with the accreditation required for participation in PIP. 19. DoHA and State and Territory Governments should provide appropriate registration systems for AHWs. Pending the introduction of such systems across Australia DoHA, in consultation with other relevant parties, should take steps to ensure that AHWs with appropriate skills can claim rebates for tasks such as wound care, immunisations and ante-natal checks. 20. DoHA should put in place a system for obtaining timely feedback from ATSIHSs on difficulties and limitations that they encounter in the use of Medicare, with a view to responding promptly to problems identified. Immunisation

21a. Divisions of General Practice should consider ways of increasing the support they provide for Aboriginal and Torres Strait Islander Health Services in relation to immunisation. 21b. Immunisation should be a high priority in future information and education initiatives for Indigenous communities. Hearing services

22. Consideration should be given to further extending beneﬁts under the Australian Government Hearing Services Program to people aged under 50.

vi Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 Point of care diabetes testing and the National Diabetes Services Scheme

23. Subject to review of the trial program, facilities for point-of-care diabetes testing should be made as widely available as possible. 24. DoHA should continue to support efforts to improve Indigenous Australians’ access to the National Diabetes Services Scheme. Rural and remote health initiatives

25. In consultation with NACCHO and other relevant stakeholders, DoHA should take steps to ensure that Aboriginal and Torres Strait Islander Health Services are well informed about Australian Government programs supporting health service delivery in rural and remote areas, and are supported in making use of these to improve services available to Indigenous Australians. Mainstream services

26. DoHA should monitor pilot schemes involving use of AHWs in general practice, such as those currently being managed by the Division of General Practice in Port Augusta and by the Canning Division in Perth, with a view to building on initiatives of this kind. The outcomes of the Canning Division pilot program linking patients discharged from hospital into mainstream health services should be similarly reviewed. 27. DoHA should work with relevant parties such as NACCHO, Divisions of General Practice and the RACGP on ongoing initiatives to offer training in cultural awareness and cultural safety to GPs and to ‘frontline’ staff working in general practices. 28. DoHA should continue to promote strategies for delivering speciﬁc training in Indigenous health care for nurses and medical practitioners. 29. DoHA should support initiatives to encourage GPs to establish whether their patients identify as Aboriginal or Torres Strait Islander, and to explain to patients why this is useful. 30. Given limited Indigenous access to specialist medical care, especially in remote areas, DoHA should explore options for: (i) overcoming the problem that shortages of GPs, especially in remote areas, create a barrier to specialist referrals for Indigenous patients; (ii) modifying the current exemption under subsection 19(2) to allow Medicare claims in relation to referred attendances as well as non-referred; and (iii) providing further ﬁnancial assistance and incentives for specialists to provide outreach services to Indigenous patients in isolated areas. DoHA should also review the operation of the Medical Specialist Outreach Assistance Program (MSOAP) with a view to extending its scope.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 vii Access to the PBS

31. DoHA should pursue the possibility of PBS Safety Net entitlements being triggered automatically from Medicare records, as with the MBS Safety Net. 32. In the context of current negotiations relating to the Australian Health Care Agreements, DoHA should address the issue of Aboriginal and Torres Strait Islander patients needing larger quantities of medication on discharge from hospital. 33. DoHA should consider options for providing medication review services better suited to the needs of Aboriginal and Torres Strait Islander people in varying locations. 34. The S100 arrangements operating in remote areas should be retained, but strengthened from a QUM perspective by measures designed to ensure substantially increased professional support from community pharmacies and by delivery of appropriate training for AHWs and nurses. Funds available under the Fourth Community Pharmacy Agreement could be used to support such improvements. 35. DoHA should review progress relating to other recommendations that were made in the Australian Government’s evaluation of the S100 arrangements in 2003, and should report on this by the end of 2006. 36. In consultation with relevant stakeholders, DoHA should develop speciﬁc strategies to substantially improve Indigenous Australians’ access to the PBS in areas which do not beneﬁt from the current S100 arrangements. These strategies need to address cost barriers for both holders and non-holders of health care cards, and also cultural and physical/transport barriers. 37. DoHA should develop community education and other strategies (such as funding towards the cost of dose administration aids) to address the problems of suboptimal use of medication among Indigenous Australians. Review and Implementation

38. DoHA should make specific arrangements for examination of the findings and recommendations flowing from this study; the National Aboriginal and Torres Strait Islander Health Council, for example, could play a significant role in that process.

viii Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 1 This study

1.1 Background

Medicare and the Pharmaceutical Beneﬁts Scheme are key pillars of the national system of health care from which all Australians are entitled to beneﬁt.

In 1997 the Health Insurance Commission (HIC) engaged Keys Young Pty Limited to undertake a major research project on Aboriginal and Torres Strait Islander access to Medicare and the Pharmaceutical Benefits Scheme (PBS). Keys Young’s report identified a number of significant access issues, including the fact that there were many Indigenous Australians not enrolled in Medicare, that Aboriginal Community Controlled Health service (ACCHS) claims on Medicare were low, and that there were significant limitations on Aboriginal and Torres Strait Islander access to the PBS. The report made a total of 48 recommendations relating to such matters as Medicare enrolment, the Medicare claims process, voluntary identification for Indigenous Australians, communications with Indigenous Australians and their health service providers, improved Medicare response to the nature and range of services provided by ACCHSs, and improved access to medications in remote areas.

In response to the 1997 report the HIC developed an Indigenous strategic framework and action plan, and the Department of Health and Ageing (DoHA) set up a working group of relevant agencies and other stakeholders in Indigenous health to consider health funding models and future policy development. Changes and new initiatives that have followed include the following:

• more systematic use of an exemption under subsection 19(2) of the Health Insurance Act 1973 that enables Aboriginal and Torres Strait Islander health services (including specified Queensland and Northern Territory government-operated health services in rural and remote areas) to bulk bill Medicare for services they provide – regardless of the fact that their GPs are salaried; • introduction of certain Enhanced Primary Care (EPC) items designed to meet particular needs among Aboriginal and Torres Strait Islander people; • development of a new Indigenous enrolment form for Medicare which allows relevant community members to vouch for an individual’s identity; • introduction of a voluntary Indigenous identifier for people enrolling in Medicare; • establishment within the HIC (now Medicare Australia) of a network of Medicare Liaison Officers for Indigenous Access (MLOs) with a range of responsibilities relating to such matters as promoting Medicare enrolment, facilitating the processing of Medicare claims, and training and support for health service providers and communities; • introduction of an Aboriginal and Torres Strait Islander access line (1800 number) for Medicare enquiries, serviced by the MLOs and their support staff; • development by the HIC of an Indigenous communication strategy, including such initiatives as an Indigenous Medicare Toolkit and production of Well and Good magazine;

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 1 • use of S100 of the National Health Act 1953 to enable supply of PBS medicines free, at the time of consultation to clients of eligible and approved Aboriginal and Torres Strait Islander health services in remote areas; • provision for pharmacists, where necessary, to dispense medications to Indigenous customers who are unable to present a Medicare card.

The HIC (now Medicare Australia) and DoHA believe that initiatives such as those described above have had positive impacts on Indigenous Australians’ access to the Medicare and PBS systems. However, they saw a need for new independent research to consider such impacts and to provide an up-to-date picture of Medicare and PBS issues from the perspective of Indigenous Australians and their health service providers. Accordingly, in 2005, they called for tenders for a research project designed to review the impact of changes since 1997 and to identify needs and opportunities for further improvement. Urbis Keys Young, in association with Professor Ian Anderson and Dr Margaret Kelaher of the University of Melbourne and the survey research ﬁrm instinct and reason, was commissioned to undertake the new project.

1.2 Objectives and scope

The underlying premise of this research is that the health of Indigenous Australians remains poor relative to that of non-Indigenous Australians, with substantially higher levels of morbidity and mortality.

The study was designed to examine the effectiveness of Australia’s major health benefits programs - specifically Medicare and the PBS – in supporting Aboriginal and Torres Strait Islander people’s access to Australian and State Government health services. The project was commissioned jointly by Medicare Australia and by the Office for Aboriginal and Torres Strait Islander Health (OATSIH) within DoHA. It has involved a range of qualitative and quantitative research tasks, including analysis of relevant data held by Medicare Australia and OATSIH, survey research with various groups, and consultation with Aboriginal and Torres Strait Islander people living in urban, rural and remote areas, with their health service providers and with other relevant organisations and individuals.

The speciﬁc objectives of the study, as outlined in the Terms of Reference and reﬂected in Urbis Keys Young’s research proposal, were to:

• examine Aboriginal and Torres Strait Islander people’s attitudes, perceptions and experiences in using the major health programs • identify and distinguish between service-related issues (such as availability of services) and the operation of major health programs (such as enrolment in Medicare) • examine the views and perceptions of health service providers regarding factors affecting Aboriginal and Torres Strait Islander Australians’ access to health care • consider Medicare participation and patterns of Medicare claiming by Aboriginal and Torres Strait Islander people and identify features of the major health programs which enhance or impede Indigenous access • report on the effectiveness of changes to the major health programs instituted by the Australian Government since 1995 (when the Health portfolio became responsible for health programs speciﬁcally for Aboriginal and Torres Strait Islander peoples) • suggest strategies to improve the effectiveness of the major health programs to support Indigenous Australians’ access to and use of health services.

2 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 The study was intended to assist DoHA and Medicare Australia in further developing program policies and initiatives which would improve access to services, with the ultimate aim of improved health outcomes for Indigenous Australians.

The focus of this research is on access to major health programs, services and entitlements. There are of course other major issues that impact on Indigenous Australians’ access to health care, such as workforce problems and shortages (in particular the recruitment and retention of health professionals in rural and remote areas), and the broader issue of funding levels and funding models for Indigenous health. Stakeholder views and concerns around these issues are referred to in various sections of the report.

Medicare Australia and DoHA identiﬁed a range of services and programs that were to be considered within the scope of this study. These included:

• Medicare Benefits Schedule (MBS) • Pharmaceutical Benefits Scheme (PBS) • Enhanced Primary Care (EPC) items, including Indigenous-specific items • Practice Incentives Program • Medicare Plus • Point Of Care Testing for diabetes • Hearing Services Program for Aboriginal and Torres Strait Islander peoples • Programs supporting service delivery in rural and remote locations such as the Medical Specialist Outreach Program (MSOAP) • General Practice Immunisation Incentives Scheme (GPII) • Other Medical Practitioners (OMPs).

A Reference Group involving key stakeholder representatives was set up to provide project advice and practical support; members of the Reference Group made signiﬁcant contributions at various stages of the study – for example in the design of survey questionnaires (see section 1.3.6 below). Members of the Reference Group are listed at the front of this report.

A Working Group, representing a sub-group of the Reference Group DoHA, MA and OIPC, provided project advice, information and support on behalf of Medicare Australia, DoHA, Centrelink and the Ofﬁce of Indigenous Policy Coordination. The Project Manager for Medicare Australia and the Department of Health and Ageing was Rob Mercer of the consultancy Uncommon Knowledge.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 3 1.3 Methods

1.3.1 Introduction

This research was conducted between November 2005 and March 2006.

The main components of the research were as follows:

• review of existing reports and other relevant materials; • analysis of statistical data on a range of matters, made available by DoHA and Medicare Australia (this work was carried out by Professor Ian Anderson and Dr Margaret Kelaher of the University of Melbourne); • consultation with a total of approximately 50 stakeholders or key informants nominated by OATSIH and Medicare Australia; • face-to-face consultations with relevant individuals and organisations in twelve locations across Australia, nominated by DoHA and Medicare Australia (of these 12 locations, seven had been visited in the course of the 1997 study); • survey research with Aboriginal and Torres Strait Islander health services and with Australia-wide samples of community pharmacies, General Practitioners and Medicare staff (survey ﬁeldwork, data analysis and reporting were carried out by the survey company instinct and reason).

These various elements of the research are further discussed in the following subsections.

1.3.2 Reference to existing literature and data

Over the course of the project OATSIH and Medicare Australia provided the study team with copies of or references to a number of existing reports and other relevant material. Service providers visited and stakeholders who were consulted also made available to the study team written information of various kinds which they believed might be helpful. Such materials were not the subject of a formal literature review, but they informed the study team on a range of relevant issues and helped provide the framework for the research. References to several key documents appear through this report.

Professor Anderson and Dr Kelaher made a search for information relating to trends in use of health services among Indigenous Australians, and in particular for information on the use of health programs funded by the Australian Government from 1997 to the present. Sources that were searched included the Medline database, the NACCHO website, publications by the Australian Institute of Health and Welfare (AIHW) and the Google Internet search engine.

4 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 This work revealed little data relating to Indigenous Australians’ use of Australian Government funded health services. Data were identiﬁed, however, relating to

• trends in expenditure on health services for Aboriginal and Torres Strait Islander people (Deeble et al 1998; AIHW 2001; AIHW 2005); • trends in the uptake of health assessment items for Aboriginal and Torres Strait Islander people compared to other Australians (Kelaher et al 2005); and • use of the Asthma 3+ plan (Couzos & Davis 2005).

The last of these is considered in section 3.7 of this report, relating to the Practice Incentives Program; the other two are discussed below.

Trends in expenditure

Although the relevant data are subject to a number of qualiﬁcations and limitations, information collated by the AIHW points to an increase, between 1995/96 and 1998/99 and between 1995/96 and 2001/02, in the ratio of various expenditures on the health of Indigenous Australians relative to non-Indigenous Australians. These included increases relating to MBS and PBS items claimed by Indigenous Australians. As noted by Dr Margaret Kelaher, however, the trends in expenditure have been contested; in particular, concerns about data quality and estimation measures have been discussed at length in the most recent AIHW Expenditure Report1. Relevant ﬁgures are set out in Table G1 in Appendix G.

Table G2 (Appendix G) provides information on the make-up of health expenditures on Indigenous and non- Indigenous Australians over time. It shows that the proportion of expenditure on medical and pharmaceutical beneﬁts and community and public health increased between 1995/96 and 2001/02 compared to expenditure on hospital admissions.

Table G3 (Appendix G) provides a breakdown of the types of health services used by Aboriginal and Torres Strait Islander people in 1998/99 and 2001/02, and the MBS or PBS beneﬁts paid for these services as a proportion of the total beneﬁts paid for such services. While Indigenous Australians’ use of all services is lower than for the non- Indigenous population, this is particularly true of the use of specialist services.

Overall, the data suggest that there has been some increase in the use of health services by Aboriginal and Torres Strait Islander people over time, although a large disparity still exists in the use of services by Indigenous Australians compared with non-Indigenous Australians. There is also some evidence of a shift from hospital-based expenditure towards primary care expenditure. However, Indigenous use of specialist services remains relatively low, which is seen as particularly signiﬁcant in light of the high prevalence of chronic conditions in the Indigenous population2.

Uptake of health assessment items

Analysis previously undertaken by Kelaher et al (2005) indicated that while uptake of the EPC health assessment for older Australians has been generally low, there has been even less uptake in relation to Indigenous Australians3.

1 These issues are explored in greater detail in Section 8 of the separate data analysis report provided to DoHA. 2 See Section 8 of the data analysis report. 3 As noted elsewhere, this EPC Aboriginalitem is available and Torres to Indigenous Strait Islander Australians Access aged to Major 55+ Healthand to Programsother Australians - Urbis Keysaged Y75+.oung - 2006 5 Further analysis showed that, in the ﬁrst three quarters of its use, uptake of the new adult health check for Aboriginal and Torres Strait Islander Australians (ages 15-54) was lower than uptake of the older persons’ health check in the general population (though higher than uptake of the older persons’ health check among Indigenous Australians).

Kelaher et al have noted that provision of assistance to doctors to promote conduct of health assessments may be particularly important in Aboriginal and Torres Strait Islander health services, where the ratio of walk-in consultations to appointment-based consultations is far higher than in mainstream services. These conditions can often make it difﬁcult for doctors to block out the time required for health assessments.

1.3.3 Analysis of OATSIH and Medicare data

OATSIH and Medicare Australia made available to the study team statistical data on various matters relevant to Medicare and PBS access by Indigenous Australians. Analysis of most of the data provided was undertaken by Professor Ian Anderson and Dr Margaret Kelaher; instinct and reason also contributed to this aspect of the study. Information that was made available included data on the following:

• Pharmaceutical Beneﬁts Scheme – S100 • Medicare Beneﬁts Schedule items for Indigenous Australians • Overseas Trained Doctors (OTDs) in ATSIHSs with an exemption under subsection 19(2) of the Health Insurance Act 1973 • Practice Incentives Program (PIP) • Service Activity Reporting (SAR) • MBS data relating to ATSIHSs with an exemption under subsection 19(2) of the Health Insurance Act 1973.

References to the results of these analyses are included at relevant points through this report.

1.3.4 Stakeholder consultation

DoHA and Medicare Australia provided the study team with names and contact details for a range of over 50 individuals with whom they suggested the team consult. These included, for example, relevant representatives of State or Territory Health Departments, OATSIH representatives in the various jurisdictions, Medicare Liaison Ofﬁcers for Indigenous Access, and representatives of relevant organisations such as NACCHO and its afﬁliates, Australian Government agencies, and peak bodies such as the Australian Divisions of General Practice and the Royal College of Nursing.

The study team developed a schedule of questions to provide a framework for the stakeholder interviews; this was in most cases forwarded to stakeholders in advance, so that they would have a sense of the range of issues to be discussed. The interview outline is set out in Appendix A, and a list of the stakeholders consulted is provided in Appendix B.

6 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 1.3.5 Field visits

A two-person team, consisting in each case of one Indigenous and one non-Indigenous researcher, visited twelve separate locations across Australia to conduct detailed interviews about aspects of Indigenous access to Medicare and to the PBS. The locations visited were as follows:

• Western Sydney • Moree • Wagga Wagga • Brisbane • Townsville/Cairns • The Torres Strait and Northern Cape York • Darwin • Nhulunbuy • Perth • Halls Creek • Port Augusta • Echuca.

Thus metropolitan, regional and remote locations in various States and in the Northern Territory were included. Seven of the 12 locations (namely Western Sydney, Moree, Torres Strait, Nhulunbuy, Perth, Halls Creek and Port Augusta) had been the subject of similar research visits during the 1997 study.

The ﬁeld visits conducted for the present study typically involved the following:

• interviews with a range of staff members at one or more Aboriginal or Torres Strait Islander health services • interviews with one or two local pharmacists • interviews with one or more local GPs • consultations (usually involving one or two small group meetings in each location) with local Indigenous Australians in their capacity as health care consumers • interviews with relevant staff-members at local hospitals or health centres – for example nurses, pharmacy staff or Medicare Liaison Ofﬁcers • in some cases, representatives of the local Division of General Practice • other individuals or organisations seen as relevant and/or knowledgeable in a given location.

In conducting these interviews in each location, study team members were guided by lists of appropriate topics and questions reﬂecting the scope and emphasis of the study. However, the speciﬁc focus of the interviews naturally varied, both from individual to individual and from place to place.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 7 1.3.6 Survey research

Between February and April 2006 the study team carried out telephone surveys with the following three groups:

• community controlled and State/Territory Government funded Aboriginal and Torres Strait Islander health services; • a sample of community pharmacies in areas of relatively high Indigenous population; and • a sample of general practitioners in areas of relatively high Indigenous population (in most cases involving an interview with both the GP and his/her practice manager).

Among 265 health services approached to participate in the ATSIHS survey, interviews were completed with 251 (a response rate of 95%).

Both the GP and the community pharmacy surveys involved samples from the various States and Territories, in each case focused on postcode areas with relatively large numbers of Aboriginal or Torres Strait Islander residents. In the GP survey, 685 practices were contacted for a yield of 407 completed interviews (response rate 59%). In the community pharmacy survey, 301 pharmacies were contacted for a yield of 244 completed interviews (response rate 81%).

The study team also conducted a national online survey of Medicare staff in each State and Territory. Out of a possible 787 respondents, 165 staff-members completed the online questionnaire within the timeframe available – a response rate of 21%.

The four questionnaires used in the conduct of these surveys were developed by Urbis Keys Young and Rob Mercer, with valuable input from members of the Reference Group and Working Group. The questionnaires are set out in Appendices C to F.

1.4 This report

Section 2 of this report discusses a range of issues concerning Medicare enrolment and initiatives relating to Medicare information, advice and support. Section 3 goes on to consider the current use of Medicare by Aboriginal and Torres Strait Islander Health Services (ATSIHSs)4, while section 4 focuses on Indigenous access to Medicare through mainstream health services. Section 5 is concerned with the Pharmaceutical Beneﬁts Scheme.

4 The report uses ‘ATSIHS’ as a general term to cover both community controlled health services and services funded/managed by State or Territory governments.

8 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 2 Medicare Information and Enrolment

2.1 Introduction

The 1997 Urbis Keys Young report on Indigenous Australians’ access to Medicare noted that at that time there were large numbers of Aboriginal and Torres Strait Islander people who were not enrolled in Medicare; it reported estimates of Indigenous enrolment ranging between around 60% and 85% in various locations. The HIC subsequently introduced a series of measures designed to promote and to simplify the enrolment of Aboriginal and Torres Strait Islander people. As noted in section 1.1 above, such measures included:

• creation of a network of Medicare Liaison Officers for Indigenous Access (previously known as Indigenous Liaison Officers) in the various States and Territories, whose task is to work with Aboriginal and Torres Strait Islander health services to support enrolment and to assist in the process of claiming appropriate Medicare rebates; • establishment of a free-call (1800 number) Aboriginal and Torres Strait Islander access line – serviced by the Medicare Liaison Officers for Indigenous Access and their support staff – to deal with enquiries and requests for assistance specifically relating to Indigenous Australians’ use of Medicare; • various steps to facilitate Medicare enrolment by Aboriginal and Torres Strait Islander people – such as more appropriate and flexible methods of identification; • a communications campaign, launched in 2003, which involved such steps as the provision of a Medicare Toolkit publication for use by Aboriginal and Islander health service staff5. 2.2 Aboriginal and Torres Strait Islander Enrolment in Medicare

Consultations with Medicare Liaison Ofﬁcers (MLOs), other Medicare staff and workers in Aboriginal and Islander health services revealed agreement that, notwithstanding limitations in the data available, rates of Indigenous enrolment in Medicare are now considerably higher than in 1997.

In the Northern Territory, for example, it was estimated that over 95% of Aboriginal and Torres Strait Islander people are now enrolled. In the Territory, the MLO and support staff play an active role in keeping population records up to date for all Aboriginal health services, both community controlled and Territory-operated6.

In other States it was more difficult to obtain estimates of current enrolment levels, although a range of parties who were consulted were confident that enrolment numbers had significantly increased over recent years. A number of ATSIHS staff-members, for example, said that it was now relatively rare for them to encounter Indigenous patients who were not enrolled in Medicare. Despite the reported increase in enrolments, some of those consulted emphasised that they still encountered some errors and delays in enrolments and issue of Medicare cards.

5 Information on the communications campaign is set out in Appendix H. An updated version of the Toolkit was in preparation at the time of this study. 6 The Aboriginal Medical Service Alliance Northern Territory (AMSANT) has estimated that over 80% of the Aboriginal population in the Northern Territory are health care card holders (letter to Health Minister Tony Abbott, 15 November 2005).

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 9 Some of those interviewed during the study nominated particular groups who were less likely to be enrolled – for example transient and homeless people, and young people who had recently left school and/or moved away from home. There also remained some practical difﬁculties in ensuring that all newborns are enrolled – although the strong trend towards hospital births has been helpful in this respect.

Medicare Australia staff-members who took part in the online staff survey believed that Indigenous groups which were less likely to be enrolled in Medicare or were more likely to have enrolment problems included the following:

• ‘traditional’ people or people living in remote or isolated areas (this was much the most common answer) • people who have literacy problems • people living far from a Medicare ofﬁce • people who move around a lot • teenagers who have dropped out of school • homeless people • newborn babies.

While numbers of Medicare personnel thought that ‘traditional’ people and others living in remote areas were less likely than most to be enrolled, some of the stakeholders consulted by the study team pointed to the effective enrolment drives that had been conducted in some small and discrete communities – especially those served by an ATSIHS that can offer support in providing enrolment forms and assisting in their completion and in meeting identiﬁcation requirements.

It seems to be general practice now for hospitals to provide new mothers with an information pack, which includes the Medicare enrolment form for their newborn. Practice does vary, however, in terms of the level of assistance available to parents to complete and lodge the enrolment form. In some areas maternity nurses take the view that their role does not include assisting with such forms and that their workload simply does not allow for this. In other areas, for example at Royal Darwin Hospital, the common practice is for administrative staff to assist people requiring assistance to complete the enrolment form. It is not clear which enrolment form is usually included in the information pack, and it may be that including the Indigenous-speciﬁc form would promote more timely enrolment.

A small number of babies who are not enrolled in Medicare continue to present to ATSIHSs. (However, at least two Medicare staff members who were consulted during the study reported that it was more common for non- Indigenous than Indigenous babies to be registered at the Medicare Ofﬁce at six months of age or more.) When unenrolled babies do present, the ATSIHS is likely to provide the Indigenous-speciﬁc enrolment form as well as any assistance required by the parent or carer to complete it. It can happen, however, that clinical services (for example immunisation) are provided to babies without a Medicare number, as the opportunity to immunise there and then would not be foregone by the ATSIHS.

MLOs or their staff-members nominated various factors which they believed had been inﬂuential in increasing overall Medicare enrolment – for example:

• increasing awareness among ATSIHS staff of the signiﬁcance of Medicare rebates as a source of funding, which led them to emphasise to patients the need to be enrolled (some health services were reported to be moving towards a no card/no service policy);

10 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 • Medicare publicity campaigns and enrolment drives conducted by MLOs and their staff – for example through Indigenous community organisations such as Legal Services, CDEPs, housing co-operatives and health services themselves; • simplified procedures for identifying people for the purpose of Medicare enrolment, and the development of an Indigenous-specific enrolment form (Medicare staff-members who responded to the online survey regarded the introduction of simplified procedures for Medicare enrolment as having been a very beneficial initiative); • availability of the Indigenous-specific access line.

In Brisbane, for example, it was reported that MLO outreach visits to a growing number of localities had generated a perceptible increase in calls to the 1800 Indigenous access line over the past six months – from around 60-70 calls a day to over 100.

Recent Australian Government announcements relating to the possible introduction of a single ‘smart card’ for Medicare and other purposes may be welcomed by Indigenous Australians who currently have to keep track of a number of different cards – eg cards for Centrelink and Medicare, health care card and the like. However the possible introduction of a ’smart card’ does raise the question of whether Aboriginal and Torres Strait Islander people will be affected by more demanding requirements for identiﬁcation. Medicare Australia and DoHA will need to monitor the progress of these proposals to ensure that they work to the beneﬁt and not the disadvantage of Indigenous Australians.

There are some examples of Centrelink and Medicare working actively together on issues relating to identiﬁcation and entitlements, and there is scope for further co-operative work of this kind.

Having achieved what appears to be a high level of enrolment by Indigenous Australians in Medicare, one ongoing issue is clearly maintaining the currency of the card. ATSIHSs, private GPs and pharmacists all reported that it is quite common for people to present with an expired Medicare card. Cards expire about every seven years, and are automatically renewed and posted to the cardholder if ‘Medicare Australia’ is conﬁdent the address is correct (Medicare – The Basics, p5). Change of address is reportedly more frequent for Indigenous Australians, and this may result in new cards being less likely to be issued and or received.

If someone with an expired card attends an ATSIHS that has HIC online access, the expired status is automatically detected and staff (eg the worker responsible for Medicare matters) can ensure the card is renewed. Without online access this required a manual check of the card which, if defective, can lead to rejected claims. While ATSIHSs can usually deal with an expired card in a timely way, other providers such as radiology, pathology or a private GP are not obliged to accept an expired card.

Recommendations:

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 11 2.3 Voluntary Indigenous Identiﬁer

In November 2002 a Voluntary Indigenous Identiﬁer (VII) was added to the Medicare database. This relies on information that Indigenous Australians choose to provide at the time they enrol in Medicare or update their details with Medicare, and is regarded as valuable in terms of providing better statistical information relevant to Indigenous Australians’ health. DoHA and Medicare Australia are considering further options to enable people to identify themselves as Indigenous – for example as part of the process of re-issuing Medicare cards or registering for Safety Net entitlements.

OATSIH reports that as at April 2006 around 122,000 people had identiﬁed themselves as Aboriginal or Torres Strait Islander through the VII – that is, over 40% of the estimated Indigenous population.

Discussions with Aboriginal and Torres Strait Islander people over the course of this study suggested that there was little objection to the adoption of the VII; people typically said that they were accustomed to giving such information, and some acknowledged that it could be of value in generating more reliable information on Indigenous health issues.

NACCHO (2005) has expressed some concern about privacy issues in relation to the VII – for example that ‘the structure of the form leads people to identify as Aboriginal prior to providing information as to their individual choice to voluntarily identify’. This point should be considered in future redesign of enrolment forms.

Recommendation:

3. Work should continue on promoting take-up of the Voluntary Indigenous Identiﬁer and effective use of the data it yields to improve health services for Aboriginal and Torres Strait Islander people.

2.4 Medicare Liaison Ofﬁcers for Indigenous Access and Indigenous Specialist Information line

2.4.1 Medicare Liaison Ofﬁcers for Indigenous Access

Medicare Australia has set up a network of Medicare Liaison Ofﬁcers for Indigenous Access (MLOs) who have speciﬁc responsibility for supporting Indigenous access to Medicare, for example by promoting Medicare enrolment and providing information to community members and health service providers. As at March 2006 there were ten MLOs in place, in the following locations:

• New South Wales (2) • South Australia/ Northern Territory (2) • Queensland (2) • Tasmania (1) • Victoria (1) • Western Australia (2)

MLOs are managed by a National Ofﬁce Team based in Canberra.

12 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 2.4.2 Specialist Indigenous Access Line

One of the responsibilities of the MLOs and their co-workers is to staff the special 1800-number access line that has been established to handle Medicare enquiries from or about Aboriginal and Torres Strait Islander people. Qualitative research indicated that calls to the access line come most often from ATSIHSs, but that the service is also used by individual Aboriginal or Torres Strait Islander people and by GPs, pharmacists, hospitals and other health service providers.

Among MLOs, MLO support staff and other Medicare staff who spent at least some of their time on matters relating to ATSIHSs, the online staff survey indicated that enquiries or requests for assistance most commonly related to:

• Medicare enrolment or obtaining Medicare card numbers • enquiries about registration and entitlements/claims/payments.

Less common tasks involved:

• enquiries about how to make a claim or obtain a payment • correcting or following up a particular claim • issues about other regulations or procedures, eg referral to a specialist.

The continuing need for the specialist Indigenous access line is indicated, among other things, by the fact that both the community pharmacists and the GPs who were surveyed during this study indicated that it was more common for Indigenous than non-Indigenous customers or patients to be unable to produce a Medicare card when required7.

Results of the ATSIHS survey conducted during this study likewise indicated that many ATSIHS patients were unable to produce their Medicare card or provide their Medicare number: 68% of services receiving Medicare rebates under subsection 19(2) said that this occurred either very often or quite often. The usual course of action taken in this situation was for the health service to contact Medicare or to check its own records; among those who gave this response, 95% said it was easy or very easy to obtain the details required8.

7 Some 25% of the pharmacists said that Indigenous customers were either very often or quite often unable to produce a Medicare card, compared with 10% who said this was the case among non-Indigenous customers. Among the GPs or their practice managers 17% reported that Indigenous patients were very often or quite often unable to produce a Medicare card, compared with 8% who said this applied to non-Indigenous patients. 8 Among ATSIHSs which received S19(2) income, 61% said it happened either very often or quite often that the patient was unable to produce a health care concession card when required.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 13 2.4.3 Opinions about these services

ATSIHS perspectives

ATSIHS representatives interviewed in the course of this study generally spoke highly of the role and work of the MLOs they were familiar with, and of the service available to them through the special 1800 access line. Most indicated that they were frequent users of the telephone service, both as a means of solving Medicare enrolment and identity problems and more generally as a source of advice on Medicare entitlements and procedures. They described the service provided as quick and responsive, and said that the availability of the information line represented a great step forward in resolving the sorts of problems relating to Medicare numbers, patient identity and the like which were highlighted in the 1997 Keys Young report.

Among health services which were covered by the ATSIHS survey, 62% said that they had at some time contacted an MLO for assistance, and 72% said that they had used the special Indigenous access line. Among those with experience of either or both of these, 94% said they had found the services either very helpful (80%) or fairly helpful (14%).

Medicare staff

The Medicare staff online survey asked respondents (excluding MLOs or their support staff) what sort of difference they believed the introduction of MLOs had made. Answers included the following:

• improved level of service for Indigenous Australians and better lines of communication • improved information and access for remote areas in particular • provides a ‘face’ for Medicare • provides a consistent and culturally aware point of contact and information source for Indigenous health services • increased Medicare enrolment and greater accuracy in enrolments • simpliﬁes and reduces the workload of other Medicare staff • improves the image of Medicare.

Some respondents believed that the impact of the introduction of MLOs had varied from area to area, but a number of respondents stated that MLOs had made ‘a major difference’ or ‘a huge difference’.

The impacts that Medicare staff attributed to the introduction of the special Indigenous access line included the following:

• availability of well-informed, specialist staff to handle enquiries and problems • direct and appropriate source of assistance and accurate information (‘help is only a free phone call away’) • has relieved pressure on other Medicare staff • speedy problem-solving; ‘huge help in sorting out claims issues’.

‘It is obviously fantastic to have this available’, said one staff-member.

14 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 It was interesting to note that a number of respondents to the Medicare staff survey referred specifically to the work of the Northern Territory Regional Office as providing a positive model of what could be achieved. ‘I think the Northern Territory Regional Office have a great setup’, said one; another described the staff in that office as ‘a shining light’.

Pharmacists and GPs

Qualitative research involving community pharmacists and GPs suggested that these groups tended to be less familiar than ATSIHS staff with the existence of MLOs and the availability of the special Indigenous access line (a number of pharmacists and GPs were interested to hear about the access line from members of the study team). The survey research later conducted with community pharmacists and GPs conﬁrmed that there was limited awareness among these groups of the MLOs and of the special 1800-number service. Among the pharmacists surveyed, for example, only 27% said that they were aware that there were MLOs within Medicare whose job it is to assist with matters relating to Indigenous access to Medicare and the PBS. The percentage of pharmacists who said they knew of the special 1800 access line was just below this, at 23%. Corresponding levels of awareness were a little higher among GPs who had at least some Indigenous patients, with 46% saying that they knew of the existence of MLOs, and 37% that they were aware of the special Indigenous access line.

Despite limited awareness of the Indigenous-specialist services, responses from both community pharmacists and GPs indicated that the current arrangements for solving problems relating to Indigenous enrolment were working effectively. In both surveys questions were asked about the ease with which Medicare information, when required, could be obtained from Medicare Australia (whether or not the Indigenous-speciﬁc information was used). Over three out of four relevant pharmacy respondents (77%) said that they found it either easy or very easy to obtain a Medicare number in this way. Among relevant GPs (or their practice managers), 87% said this process was either easy or very easy.

Outreach and education work by MLOs

While ATSIHS staff consulted by the study team were very positive in their assessments of the MLOs’ role in handling Medicare enquiries and resolving enrolment and claims issues, some reservations were expressed about their role in providing Medicare information and training for health services. Those who were consulted generally reported ﬁnding such training very helpful, but a number said that MLO visits were too few and/or too brief to provide the level of support required. For one thing, staff turnover within health services created a need for ongoing training. Several health services that were contacted in the course of the study reported having had more intensive assistance from Medicare representatives, and indicated that they had found this very valuable.

Reservations about the operation of some MLOs were noted in a draft report on barriers and enablers to improving access for ACCHS to Medicare Australia programs (NACCHO 2005), which states:

Individual relationships and the approach taken by individual Medicare Australia liaison officers … was identified as a barrier, as individual states reported that the relationships and perceived lack of available engagement of … liaison officers needed to improve. The idea of liaison officers regularly contacting ACCHS and developing supportive relationships need to be supported and improved.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 15 It has been suggested that linkages between MLOs and community controlled health services could be strengthened, and ACCHS responsiveness to Medicare issues and opportunities increased, by the appointment of Medicare project officers in the various NACCHO State and Territory affiliates, and more generally by coordination of NACCHO and Medicare Australian initiatives. In Queensland a Working Agreement has been signed by the NACCHO affiliate QAIHC and to Queensland Office of Medicare Australia, with the aim of establishing ‘cooperation, partnership and commitment between the Parties to improve the access of Australian Government health initiatives administered by Medicare Australia for Aboriginal and Torres Strait Islander people’. VACCHO, the Victorian NACCHO affiliate organisations, has a Medicare Enhancement Officer with responsibilities for promoting understanding and use of Medicare among its member services. Among other things he has worked closely with the Melbourne-based MLO in delivering Medicare information and education to AMS personnel. There is also a joint initiative to deliver cultural awareness training for regional Medicare managers across Victoria. VACCHO expects in the near future to sign a Memorandum of Understanding with Medicare Australia that sets up a clear framework for ongoing cooperation.

Some MLOs themselves made the point that they were ‘stretched thin’ and faced difﬁculties in fulﬁlling their roles and responsibilities over wide geographical areas. The Sydney-based MLO, for example, emphasised that there were limits to what he could achieve in terms of community and health service education and support. MLO staff in Brisbane commented that, for practical reasons, health services in the south-east of Queensland were more likely to receive a visit than those in more remote or isolated locations.

Other issues

It is understood that at this point not all the existing MLO positions are fully funded; this issue needs to be addressed, as well as the desirability of creating additional positions9.

Some of the MLOs noted that effective performance of their roles requires not only a thorough knowledge of Medicare, but also some familiarity with relevant medical terminology; they saw a need for further training to enable them to work as productively as possible with health service providers. It was also said that there was a need for clearer documentation of policy issues affecting the MLO role.

It was noted that Medicare had had some difﬁculty in recruiting Indigenous Australians to the MLO positions – although numbers of support positions are ﬁlled by Aboriginal or Torres Strait Islander workers. It was seen as desirable to increase the number of Indigenous appointments. For example, it has been suggested that in its recruitment processes, Medicare Australia could make more active use of the NACCHO member network. It was also argued that further consideration of potential career paths for MLOs would both assist the individuals currently occupying these positions, and also make the positions more attractive for the future.

9 In Tasmania it was reported that the level of stafﬁng of the 1800 line is currently insufﬁcient to reliably meet demand.

16 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 Recommendations:

2.5 Summary

Both the appointment of Medicare Ofﬁcers for Indigenous Access (MLOs) and the establishment of a free-call Indigenous access line were seen positively by Aboriginal and Torres Strait Islander health services. While some difﬁculties and delays are still encountered, these have helped to substantially reduce problems previously faced by service providers relating to Indigenous enrolment and claims.

Such initiatives were also welcomed among private GPs and community pharmacists, though awareness of them was lower in these groups.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 17 3 Use of Medicare by Aboriginal and Torres Strait Islander Health Services

3.1 Introduction

This section of the report considers Indigenous access in terms of issues relating to ATSIHS use of Medicare, including a range of factors that tend to support or to limit access and possible changes that could beneﬁt health services and their patients.

3.2 Exemption under Subsection 19(2) of the Health Insurance Act 1973

In general, Commonwealth or State Government salaried medical practitioners are not eligible to make Medicare claims for the services they render, since to do so is regarded as ‘double dipping’. Historically this created a barrier to Aboriginal and Torres Strait Islander Health services claiming Medicare rebates for the services provided by GPs whom they employed.

Action under subsection 19(2) of the Health Insurance Act 1973, however, has provided an exemption that allows doctors employed by eligible Aboriginal and Torres Strait Islander community controlled health services to claim Medicare beneﬁts for the ‘non referred’ services they provide. Providers are required to have a separate provider number for each location at which they provide services. All income derived from Medicare rebates is to be used to improve primary health care for Aboriginal and Torres Strait Islander people. As at 1 July 2005 there were 112 community controlled services across Australia which were entitled to this exemption under subsection 19(2) of the Act.

The subsection 19(2) exemption also allows access to Medicare benefits by specified State and Territory funded health services for Aboriginal and Torres Strait Islander people located in rural and remote areas of Queensland and the Northern Territory – which again typically employ doctors (usually referred to as Medical Officers or MOs) on a salaried basis. These exemptions are granted on the understanding that the resulting savings to the State or Territory Government are to be re-invested in provision of primary health care for Indigenous communities. In the Northern Territory the current arrangement is that Medicare income derived from the work of Territory-run clinics (around $1 million a year) is used to fund District Medical Officer services and administrative support services in such clinics – including the administrative work involved in claiming Medicare rebates. In Queensland such income is allocated to Indigenous primary health care at Area Health level.

The general Medicare model provides rebates to patients under the Medical Beneﬁts Schedule. A patient can choose to assign such rebates to the service provider by signing a bulk billing voucher. Subsection 19(2) makes it possible for Medicare beneﬁts rebates to be paid for services provided by medical practitioners employed by Aboriginal and Torres Strait Islander health services as long as the medical practitioner accepts the Medicare rebate as full payment for that service. Medicare rebates are paid via a paygroup link directly to the Aboriginal and Torres Strait islander health service. In general the Medicare bulk billing voucher is required to be signed by the patient after receipt of the service, in the standard fashion.

18 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 In recent years there has been a different process in use, on a trial basis, in two remote area services (Nganampa Health in Central Australia and Ngaanyatjarra Health Service in Western Australia). This makes bulk billing possible without the requirement of a patient signature or the patient receiving a copy of the bulk billing voucher. Instead claims require an Assigned Beneﬁt Provider Claim Form and an Assigned Beneﬁts Provider Claim Declaration. The doctor providing a service to a community member completes the Claim Form with all relevant details, and then signs and has witnessed the Claim Declaration. Separate Forms and Declarations are used by each doctor; the documentation is required to be checked and countersigned by an appropriate staff-member of the health service.

These arrangements were agreed to on the basis that there are insufﬁcient resources within the local clinics to administer Medicare Australia’s standard requirements, and that individual sign-off of every Medicare forms is not practical in these situations (for instance in light of low literacy levels). The appropriateness and effectiveness of the trial arrangements have not yet been reviewed.

Health service providers in some other remote locations (eg East Arnhem Land) emphasise that they experience similar practical difﬁculties in using standard Medicare procedures, and it may well be that more ﬂexible arrangements should in due course be extended to a number of other remote locations.

Particularly in the Northern Territory and remote areas elsewhere, numbers of individuals and organisations raised the larger issue of the models used to fund community controlled health services and approaches involving ‘cashing out’ of Medicare entitlements. Among other things it was emphasised that the Primary Health Care Access Program (PHCAP) represents an essential strategy that is complementary to improved Medicare and PBS access, and clearly needs to be retained.

3.3 OATSIH and Medicare funds

Table 3.1 summarises information provided by DoHA on the levels of Australian Government Indigenous Health Program expenditure administered through OATSIH for the period 1995/96 to 2005/06. The table shows varying annual percentage increases, generally in the 4%-18% range. Also included in the table are estimates of Medicare income received by ATSIHSs under the subsection 19(2) exemption for the years 2001-02, 2002-03 and 2003-04. The ﬁgures in Table 3.1 make it clear that ATSIHS income under subsection 19(2) is modest relative to total OATSIH expenditure on the Indigenous Health Program (representing of the order of 7% of OATSIH funding over the three years where comparisons can be made).

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 19 Table 3.1: Australian Government Indigenous Health Program Outlays administered through OATSIH, 1995/96 to 2004/05, and selected estimates of Medicare payments under S19(2)

Indigenous Health Estimates of Medicare beneﬁts rebates to ATSIHSs Program Outlays Annual under subsection19(2) administered percentage through OATSIH increase Community State/Territory controlled Total ($ million) services services 1995-96 114.8 1996-97 112.6 -1.9 1997-98 130.6 16.0 1998-99 155.3 18.9 1999-2000 162.0 4.3 2000-01 185.4 14.4 2001-02 201.7 8.8 $12,042,731 $1,870,647 (Qld only) $13,913,378 2002-03 209.5 3.9 $10,492,457 $1,878,114 (Qld & NT) $12,370,571 2003-04 243.7 16.3 $15,206,051 $2,276,067 (Qld & NT) $17,482,113 2004-05 287.1 17.8

Source: DOHA

Numbers of the people consulted during this study argued that OATSIH grants to health services had grown more slowly than increases in medical salaries and related expenses, and that as a result Medicare income is increasingly important in helping health services cover costs. A State/Territory OATSIH representative, for example, commented that while newly created ATSIHS positions may in general be adequately funded, established GP positions have been affected by salary increases over time, so that now there is a funding gap.

20 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 A recent study conducted by Dr Katie Panaretto on behalf of the Queensland Aboriginal and Islander Health Council (QAIHC) involved a review of Medicare billing activity in a sample of eight community controlled health services in Queensland. The study report argues that:

‘The costs associated with acquiring and maintaining up-to-date information technology, accreditation, indemnity insurance, costs associated with teaching and professional development for all staff, continue to escalate. In this context any funding derived from the Medicare system is vital to the viability of these services and any efforts to improve the quality of service delivery. Increasingly the income derived from general practitioner generated Medicare billings can provide a signiﬁcant source of income to ACCHS’.

(Panaretto 2005, p7)

As some of those consulted during the present study saw it, Medicare income has two obvious advantages for ATSIHSs: it is not capped and, not being earmarked for speciﬁc purposes, it can be used at the discretion of the service within the bounds of the subsection 19(2) exemption.

It should also be noted in this context that a number of ATSIHS representatives and other stakeholders argued that the most desirable approach to funding of Aboriginal and Torres Strait Islander services would be to provide a single grant which included a ‘cashing out’ of Medicare on the basis of an appropriate formula reﬂecting Indigenous population, remoteness and the like.

3.4 Claiming Medicare rebates

NACCHO representatives report that around 30% of community controlled health services receive no Medicare income. Among the ATSIHSs which took part in the survey of health services, just on 20% indicated that they received no income under subsection19(2). The most common reason given for this was ineligibility – eg having no GPs; other reasons included lack of administrative capacity and the difﬁculty of applying Medicare to the work of the service.

While many ATSIHSs are now claiming Medicare rebates, qualitative research (including consultation with stakeholders) indicated that current levels of Medicare claiming vary considerably among ATSIHSs, and that some are claiming beneﬁts well short of what they are entitled to. When the ATSIHS survey questionnaire asked respondents how conﬁdent they were that their service was claiming all the Medicare income to which it was entitled, the answers were as follows:

• Very confident 48% • Fairly confident 36% • Not very confident 10% • Not confident at all 6%

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 21 Among the services which responded to the ATSIHS survey, some 70% thought that they were generally well- informed about the Medicare system, but 30% believed that they needed additional information or training. Less than 20% of the ATSIHSs surveyed said that they had ‘many problems’ in making Medicare claims; among these, however, the problems most often referred to related to lack of Medicare knowledge/understanding and the need for further training10. In the course of the case study visits there were also occasional references to services trying to contain the number of long consultations claimed, lest they attract negative attention from Medicare Australia.

Some ATSIHSs have been using the HIC online system which enables them to lodge claims electronically. While MLOs in some locations expressed concern that erroneous claims (and thus rejection of claims) might increase with the introduction of electronic processing, those health services which were using HIC Online generally appeared to be well satisﬁed with the operation of the system.

Information provided by DoHA shows that levels of Medicare income received by ATSIHSs during the financial year 2003-04 varied widely, from $10,000 or less to over $500,000. While some of the differences shown in Table 3.2 doubtless reflect variations in patient numbers and numbers of GPs, it seems clear that such differences also reflect varying levels of skill and commitment in accessing Medicare funds. Consultation during the study also indicated that ATSIHSs generally have limited capacity to estimate the level of Medicare income that they can reasonably expect to claim – that is, no simple benchmarks are available to help them judge their performance in this regard.

Table 3.2: Level of Medicare Beneﬁts received by ATSIHSs in 2003-04 under the subsection 19(2) exemption

Income received Number of health services $10,000 or less 6 $10,000 - $50,000 10 $50,000 - $100,000 11 $100,000 - $200,000 29 $200,000 - $300,000 15 $300,000 - $400,000 5 $400,000 - $500,000 3 $500,000 or over 4 Tot al 83

Source: DoHA 2006

10 The great majority of services which took part in the ATSIH survey and were receiving S19(2) income said that it was either very easy (33%) or fairly easy (62%) for them to use the Medicare system. Most of those who said this was not the case referred to volume/complexity of paperwork or to internal systems that were inadequate or inappropriate for Medicare purposes.

22 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 The QAIHC research conducted by Dr Panaretto revealed that there were signiﬁcant differences in billing levels among the eight Queensland health services studied. In general, as would be expected, the level of Medicare billings was related to the number of FTE doctors (also to FTE medical staff overall) and to the number of consultations. However, average billings per consultation varied from around $31 to $62, with these differences apparently reﬂecting such things as variations in appointment length and in use of EPC items.

The QAIHC report notes (p14) that in mainstream general practice, GPs working full-time in 2001-02 generated median billing income of $209,000. In the Queensland ACCHS study, however, ‘annual billing per FTE doctor varied widely from $124,000 to over $183,00’ (2004-05 data). Average billings were thus below the levels that apply in mainstream practice – although the proportion of patient consultations billed as Standard (Medicare Item 23) was only 58% in Aboriginal community controlled health services as compared with 86% across all practices (p16).

Leaving aside size of practice, there appear to be a number of reasons why income received under the S19(2) provisions varies across health services. Most obviously, since the GP is the gateway to Medicare claims, health services which have little or no access to GPs can derive little if any income from this source. Beyond that, ATSIHSs vary in their capacity to capture Medicare entitlements; the present study suggests that relevant factors include:

• the level of GPs’ or MOs’ familiarity with the Medicare System and the effort they are prepared to put into making claims (for example, overseas-trained doctors may start out with little understanding of the system, and MOs based in hospitals are not usually accustomed to having to complete Medicare paperwork) • the level of understanding of the details of Medicare (including changes made from time to time) among medical and administrative staff11 • whether the GPs providing clinical services at a given ATSIHS have provider numbers for that health service • the nature of the relationship between medical staff and ATSIHS management • whether GPs have any direct contractual or ﬁnancial incentive to claim Medicare rebates12 • the extent to which ATSIHS administrative systems (including IT systems) facilitate claiming • whether the health service has an appropriately trained staff member responsible for co-ordinating Medicare claims13.

In Western Australia it was reported that some GPs working in ATSIHSs were reluctant to make Medicare claims because of the way this might affect the premiums payable for their professional indemnity insurance. In relation to services funded by the Queensland Government, there may be a lack of incentive for Medical Ofﬁcers to claim Medicare rebates because such funds do not in any direct way beneﬁt the particular health service.

11 For example, discussions with ATSIH staff members in the course of site visits suggested that there were some uncertainties or knowledge gaps around such issues as the availability of higher Medicare rebates for children and concession card holders, or the rebates available for allied health services relating to a care plan. It was also clear that Medicare knowledge was often fragmented among various staff members. 12 Some ATSIHSs have now included obligations relating to Medicare claims in their contracts of employment with GPs. There are also examples of GPs being entitled to a ﬁnancial bonus for reaching a certain level of claims, or receiving as an incentive some proportion of the Medicare income they generate. 13 Among health services which took part in the survey and which were making Medicare claims, just over 90% said that there was a person on staff who had particular responsibility for this.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 23 The QAIHC research report by Panaretto, referred to above, identiﬁed factors such as the following as having an impact both on level of ATSIHS Medicare billings – and also ‘the quality of chronic disease and preventative care delivered’ (p 21):

• reliance on overseas-trained doctors, who may not be Vocationally Registered in Australia and who are likely to need additional support and monitoring as they ‘struggle to get to grips with the care requirements of the Indigenous community, ACCHS and the Medicare system’ • apathy or lack of GP motivation to claim Medicare rebates – possibly reflecting unsatisfactory relationships with ATSIHS Boards or management; • absence of a link between GP salaries and income generated (eg ‘flat hourly rates irrespective of productivity’ – p23); • lack of a nominated Senior Medical Officer to provide GP leadership; • GPs not being adequately integrated into the overall structure and life of the health service; • inadequate patient records and IT systems, including limited capacity to monitor billings; • Medicare claims not being the responsibility of specific and appropriately trained staff-members; • the fact that Medicare initiatives and changes (eg EPC items) are sometimes complex and difficult to implement.

Some similar observations were made at a recent NACCHO workshop on Medicare barriers and enablers:

‘Overall there is still a lack of capacity inside ACCHS to keep up to date with changes to Medicare and PBS item numbers. In part this is due to staff turn-over as well as the competing priorities in services and the lack of dedicated Medicare staff in most ACCHSs.’ (NACCHO 2005, p3)

As a number of observers emphasised during the present study, establishing an effective system for making use of Medicare may involve substantial cultural and organisational change, and it obviously cannot be assumed that all ATSIHSs will make this transition without assistance.

On the evidence of this study, key factors that are likely to support or facilitate ATSIHS access to Medicare include:

• clear and effective relationships and communication between administrators and GPs • appropriate systems to encourage GPs to make optimal use of Medicare – for example provision of clear information and guidance, ﬁnancial incentives, contractual obligations, regular feedback on individual GPs’ claim levels • training and support of a particular ATSIHS staff member(s) to be responsible for handling Medicare claims • appropriate use of or improvements to IT systems • review of day-to-day procedures to provide ‘space’ for taking up EPC items and the like.

24 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 It was also clear that both doctors and management often struggled with the complexity of the information packages that they received on Medicare changes and innovations. One AMS doctor, for example, noted that ‘the eyes glaze over’ when you receive detailed packages on matters such as EPC items; she had taken it on herself to work in detail through some of the materials received from DoHA, and had produced much shorter and simpler material for use by her colleagues.

There are obvious opportunities here for ATSIHSs to assist each other through exchange of information, ideas and materials. Divisions of General Practice have speciﬁc responsibilities relating to Indigenous health, and the support services that Divisions offer to general practices need to be more systematically made available to ATSIHSs. The RACGP also has a contribution to make, and there are possible roles for the Practice Managers Association. It may be that Medical Receptionist training courses could be used to a greater extent to support frontline staff.

Another issue is that DoHA information about changes or additions to Medicare needs to communicate clearly and effectively with audiences including ATSIHS staff. Market testing of materials with relevant target groups can help ensure that this is achieved.

Recommendations:

9. Strategies to increase the use of Medicare by ATSIHSs need to address a range of factors such as communication and sharing of information, practical support to assist services in fully claiming Medicare entitlements, refinements in certain MBS items and the possible introduction of some new items. 10. Medicare Australia and OATSIH should work through the MLO network to identify health services which have particular needs for training and practical support in the effective use of Medicare, and should ensure that such needs are met promptly. 11. Medicare Australia and OATSIH should examine options for increasing exchange of information and ideas among health service staff responsible for Medicare administration – for example periodic conferencing by telephone, video or face-to-face, possibly on a regional basis. 12. Divisions of General Practice should specifically consider how they can best assist ATSIHSs in their area to make optimal use of the MBS. 13. Once review of the special Medicare claim arrangements that have been in operation at the Nganampa Health Service has been completed, Medicare Australia and OATSIH should consider options for making more flexible claiming arrangements available in other remote areas.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 25 3.5 Role of Medicare in Indigenous health services

Despite the greater or smaller financial benefits which ATSIHSs derive from Medicare rebates, it is well understood that Medicare cannot be more than a partial response to ATSIHS funding needs, and that OATSIH block grants will continue to be the key source of ATSIHS income. This is clearly reflected in the figures set out in Table 3.1 above. The key limitation of Medicare from an ATSIHS perspective is that it is squarely focussed on the GP, whereas GPs are involved in only about one-third of ATSIHS patient encounters14.

According to statistical analysis carried out by Professor Ian Anderson and Dr Margaret Kelaher, the estimated mean number of GPs per ATSIHS has gradually increased from 1.35 in 1998-99 to 1.93 in 2003-04. However, the proportion of health services with GP vacancies did not signiﬁcantly change over that period. Among the ATSIHSs which responded to the survey of health services, 66% had GPs on the payroll, 18% had only visiting GPs, and 21% had no GPs at all. (By contrast, only 8% of services reported having no nurse, and only 5% no AHW.) Among those which employed GPs, just on 60% had one or two GPs only.

While some ATSIHS representatives are keen supporters of the operation of subsection 19(2), others have reservations – arguing, for example, that there is a lack of fit between the type of practice which is most financially rewarding under subsection19(2) and that which best meets local circumstances and patient needs. In the Northern Territory, for instance, it was said that ‘Medicare is not designed around the primary health care teams which are the general model for delivery of Aboriginal health care’. Medicare’s focus on the GP was seen as particularly problematic in a situation where GPs, especially in less populated areas, are in very short supply. ‘Most (remote) Aboriginal communities have no GP’, with health care being provided by nurses and AHWs; there can be many weeks between GP or Medical Officer visits to remote communities. The fact that Medicare is a mainstream model not actively designed to meet the particular needs of Indigenous Australians or the circumstances of remote area health services was one reason why some stakeholders advocated alternative funding approaches such as that reflected in the Primary Health Care Access Program (PHCAP)15

In the context of the limited role played by GPs in the delivery of ATSIHS services, it was frequently suggested that Medicare should more adequately recognise the roles played by nurses and AHWs and of the health team approach that is central to much work in Indigenous health. It was noted that the Northern Territory, for example, has in place a system of ante-natal care which involves most of the work being done by a nurse or AHW. In the course of a normal pregnancy a woman will receive ongoing care but see a doctor on only two occasions. (In this context it should be noted that the Minister for Health, Tony Abbott, has recently announced the introduction of a new Medicare item covering ante-natal checks by nurses, midwives and registered AHWs in rural and remote areas, where such services are provided on behalf of a GP.)

14 see Section 4 of the separate data analysis report 15 PHCAP had its origins in the 1997 Keys Young report and subsequent expenditure reports conﬁrming that PBS and MBS expenditure were much lower for Indigenous than non-Indigenous Australians. PHCAP makes use of a multiplier of three times average MBS usage, in acknowledgement of higher morbidity among Indigenous Australians.

26 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 Other examples cited of standard Medicare provisions not adequately reﬂecting the realities of health services in remote areas included the following:

• the fact that a doctor caring for or monitoring a remote area patient awaiting transport to hospital may need to spend much longer than the maximum period provided for in the Medicare schedule; • the fact that the standard Medicare item for issuing a death certiﬁcate may bear no relation to the time and travel involved in doing this in remote areas; • the fact that specialists providing services for Indigenous patients in remote areas are likely to be faced with more complex and severe conditions than they might typically expect to deal with in the city.

Another aspect of Indigenous Australians’ limited access to GPs in isolated areas is the fact that it is common for diagnosis and treatment to occur in a situation where the patient sits with an ATSIHS nurse or AHW in the local community, while the doctor’s input is obtained by telephone from wherever he or she is at the time. It is estimated, for example, that approximately 50% of the consultations conducted by Medical Ofﬁcers in Northern Territory Government clinics are by telephone. The time that GPs spend in consultations of this nature cannot be claimed under Medicare. A number of stakeholders argued that it was time that a Medicare item to cover the ATSIHS situation described above was introduced. There were other people, however, who took the view that such a move would raise a number of problems relating to such matters as quality assurance, auditing and indemnity insurance.

Various suggestions were made by ATSIHS representatives and others in the ﬁeld as to ways in which aspects of the Medicare system could be made more responsive to the nature and needs of Indigenous health services. Reﬂecting the observations above, the more common suggestions included:

• reviewing and extending the ways in which ATSIHS nurses and/or AHWs can make Medicare claims in their own right, independent of a GP’s supervision; • allowing for at least some of the time spent by nurses and AHWs to be included in calculating the length of the GP consultation; • introducing a Medicare item for patient consultations conducted by telephone between a local nurse or AHW and a GP or MO located elsewhere; • providing a Medicare item suitable for the long periods of ‘attendance’ time that a doctor may need to spend with a sick or injured Indigenous person in a remote area; • considering new types of Medicare item which better reﬂect ATSIHSs’ health care team approach to various types of care – for example, the system of antenatal care operating in the Northern Territory.

There were also stakeholder suggestions that current provisions for claiming additional rebates in certain circumstances and locations should be revised to provide a higher level of rebates speciﬁcally in remote areas (RRMA 7).

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 27 3.6 Services provided by Practice Nurses and Aboriginal Health Workers

Since February 2004 it has been possible for health services to claim Medicare rebates for immunisations and for wound care provided by a practice nurse on behalf of a GP16. In January 2005 this entitlement was extended to Pap smears taken by a practice nurse on behalf of a GP in regional, rural and remote areas; as noted in section 3.5, a further item relating to ante-natal care is now to be introduced.

Where such services are provided by the practice nurse to a child under 16 or to a Commonwealth concession card holder, the GP can claim an additional incentive (currently $7.65 in regional, rural and remote areas, in Tasmania and in certain urban areas, and otherwise $5.10). Aboriginal or Islander health services which are eligible to claim Medicare beneﬁts are entitled to make use of these provisions.

In the Northern Territory, where there is a system of formal registration of Aboriginal Health Workers, approval has been given for extension of the immunisation and wound care practice nurse items to those services when provided by a registered Aboriginal Health Worker. There is considerable interest in other jurisdictions in similar arrangements being made for services provided by their Health Workers. However, stakeholders consulted during this study generally believed that an agreed system of Health Worker accreditation or registration system – comparable with the existing system in the Northern Territory – was still a long way off. There was considerable interest in DoHA’s taking steps in the meantime to give all Indigenous health services the opportunity to claim for at least wound care and immunisation provided by Health Workers. (It was noted that AHWs did not need to be registered in order to claim rebates for allied health services ancillary to EPC care plans - see section 3.7 below.)

3.7 Enhanced Primary Care items

Starting in 1999, the Australian Government has introduced a number of new Medicare items known as Enhanced Primary Care (EPC) items. There are currently around 30 such items, and they include some which are speciﬁcally designed to improve health care for Indigenous Australians. EPC items which are of particular relevance in the context of this report include the following:

• annual voluntary health assessments for any patients aged 75 or over and for Aboriginal and Torres Strait Islander people aged 55 or over; • Indigenous Adult Health checks – two-yearly health checks (introduced in 2004) for Aboriginal and Torres Strait Islander adults aged between 15 and 54, which are designed in particular to promote early detection and treatment of common, serious conditions such as diabetes and cardiovascular disease; • care planning and case conferencing for patients (of any age) who suffer from a chronic medical condition that involves complex needs requiring care from a multidisciplinary health team.

16 For the purposes of this provision a practice nurse is a registered or enrolled nurse employed or contracted by a general practice, and who is appropriately qualiﬁed to provide the relevant service.

28 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 Since July 2004, Medicare rebates have been available for up to ﬁve allied health services and in some cases up to three dental visits per year for patients who have an EPC multidisciplinary care plan. Services provided by Aboriginal Health Workers (along with services provided by physiotherapists, audiologists, podiatrists, dieticians and the like) are included in this provision; in this instance it is not required that the AHW be registered.

New Chronic Disease Management (CDM) items were introduced in July 2005, replacing EPC care plans. As a transitional measure, the original multidisciplinary care planning items ran in parallel with these from July until November 2005, when they were removed from the Medicare Beneﬁts Schedule. The new items are intended to be more ﬂexible and easier for GPs to use, and to provide greater scope for Practice Nurses and Aboriginal Health Workers to assist in care planning.

A Medicare item relating to health assessments for Aboriginal and Torres Strait Islander children aged under 15 was introduced on 1 May 2006, with the aim of helping to address high rates of Indigenous childhood illness and targeting risk factors for chronic disease, substance abuse and other health problems. Among other things this new item is intended to complement the Healthy for Life program that the Australian Government announced in the May 2005 Budget. Some stakeholders, however, expressed concern that the same limitations will apply in relation to this item as to the existing EPC items – eg too few doctors and other resources to carry out the checks.

EPC items are ‘premium priced Medicare items’; that is, they attract relatively high rebates in recognition of the amount of work and the range of clinical components that they involve.

The introduction of EPC items such as the 55+ health assessment, adult health check and care plans (now replaced by CDM items) has generally been welcomed by ATSIHSs; a number of services make the point that these fit well with their ‘holistic’ approach and with the sort of service they like to provide. Other observers say that such items reflect a welcome Medicare focus on preventive health rather than just on ‘treatment’. However, the specific requirements of the various EPC items are quite demanding, and at least some ATSIHSs have experienced difficulties in claiming them. For example, there may be a problem or delay in satisfying some particular aspect of the item, or in getting the required GP sign-off where the GP has only sporadic or part-time involvement with the service. Another problem is that the patient may not be clear whether he/she has had a relevant previous assessment, so that the service provider does not know whether a new assessment can be claimed or not.

More generally, providing EPC services requires GPs with the necessary time and commitment, responsive patients willing to make the time available, and good administrative/IT systems. Several service providers said that although they regarded EPC services as important, ‘we just don’t get to them’17. Having concluded that EPC services cannot readily be provided within current resources and arrangements, a number of ATSIHS indicated that they were taking a planned approach to introducing such services – for example reorganising systems and timetables to fit these sorts of items in, or appointing a dedicated person as EPC coordinator. It should also be noted that it is still ‘early days’ in the implementation of EPC services, and that for some ATSIHSs these represent a significant change in the necessarily reactive model of care traditionally provided. (Of course, the introduction of EPC items was specifically intended to help bring about clinically desirable changes in practice.)

17 Only one of the eight ATSIHSs included in Panaretto’s analysis ‘had come to grips with the EPC system’ (p17).

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 29 In light of this some suggested that, rather than simply allowing an ATSIHS to claim for EPC items once provided, consideration could be given to providing service providers with an upfront payment to enable the EPC services to be established.

The inclusion of allied health services as part of the EPC care plan (or CDM item) was generally welcomed, but the allowance of ﬁve such services was regarded as quite limited given that a person in cardiac rehabilitation (for example) may well require a number of sessions with a dietician, an occupational therapist, physiotherapist and so on. ATSIHSs which are beginning to implement group approaches to chronic disease management face the problem of not being able to claim the time of an allied health professional running a group session; more ﬂexibility in the use of the allied health provision would enable provision of more groups, which are reportedly producing better outcomes with Indigenous patients than one-to-one approaches.

As noted in section 3.4, it is important for DoHA to ensure that the information materials that it makes available to service providers – including information relating to EPC items – communicate as simply and effectively as possible. Another issue raised by a number of people was the continuing need for community information and education around the value of health checks in particular.

Among the services which participated in the ATSIHS survey and were receiving Medicare income under subsection 19(2), the percentage saying that they had made some use of various EPC items were as follows:

• Voluntary health assessments for people aged 55+ 75% • Adult health checks (ages 15-54) 76% • Allied health care by AHWs in Chronic Disease Management Plans62% • Wound care, immunisation or Pap smears by a nurse 73% • Wound care or immunisation by an AHW (NT services only) 92%

Most services (around 80%) reported no particular problems in claiming Medicare rebates for such EPC items. This result was somewhat surprising given the problems reported by a number of the ATSIHSs visited by members of the study team; the explanation may well be that the qualitative research offered more time and opportunity than the telephone survey for various staff members to reﬂect on their EPC experience. Problems that services participating in the survey did identify included the time or paperwork involved, complexity of the items, need for training/re-training (eg because of staff turnover), and nurses and AHWs being unable to claim independent of a GP. Virtually all the relevant ATSIHSs regarded Indigenous-specialist items of this kind as either very important (90%) or fairly important.

30 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 3.8 Practice Incentives Program

The Practice Incentives Program, or PIP, is one of a number of measures that have been introduced by the Australian Government over recent years to encourage what are seen as desirable improvements or innovations in general practice. PIP is an aspect of the ‘blended payment’ approach, which offers GPs the prospect of payments for certain types of activities or services, in addition to income earned direct from patient payments and Medicare rebates.

To be eligible for PIP, general practices must be accredited (or working towards accreditation18) under the Standard for General Practices endorsed by the Royal Australian College of General Practitioners. Aboriginal and Torres Strait Islander health services, including community controlled services, are eligible to participate in PIP if they are general practices and meet these accreditation criteria.

Medicare Australia is responsible for assessing all practice applications for participation in PIP and for the day-to-day administration of the program.

It has been estimated that around 80% of primary health care services are provided by practices which take part in PIP. As at May 2005 there were some 4,680 general practices across Australia participating in the program. The number of Aboriginal or Torres Strait Islander health services participating in PIP at the time that relevant data were provided to the study team in 2005 was 61. By March 2006 the number was 69 – most of them community controlled services. In broad terms, therefore, around half of community controlled health services currently participate in PIP. Statistical analysis conducted during the present study revealed no particular geographical bias, relative to services which make Medicare claims under subsection 19(2), among ATSIHSs which do and do not participate in PIP.

There are currently eleven separate components of PIP, and practices (including participating Aboriginal and Torres Strait Islander health services) may be eligible to claim any or all of these. These components are as follows:

• Information management – payments to practices for providing data to the Australian Government, using electronic software to generate scripts, and for having the capacity to send and receive data electronically • After-hours care – payments to practices for ensuring that patients have access to 24-hour care, including the provision of after-hours home visits where necessary and appropriate • Teaching – payments to practices for teaching medical students

18 Thus income that a practice receives under PIP can be used to help fund changes that may be required to achieve accreditation. Accreditation must be gained within a year of joining PIP.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 31 • Quality Prescribing Initiative – payments to practices that participate in the quality use of medicines program endorsed by the National Prescribing Service • Practice Nurses – payments to practices located in RRMAs 3-7, and also eligible urban areas of workforce shortage and Aboriginal Medical Services, to assist them to employ or retain the services of a practice nurse, Aboriginal health workers and/or allied health worker • Cervical Screening – payments to practices that achieve targets in cervical screening and payments to GPs who screen women aged 20 to 69 years who have not had a Pap smear for 4 years or more • Diabetes – payments to practices that achieve targets in providing care for their patients with diabetes, and payments to GPs for providing diabetes care according to best practice guidelines • Asthma – payments to practices for providing the Asthma +3 program and payments to GPs who complete an Asthma 3+ plan for patients with moderate to severe asthma • Mental Health – payments to GPs for using the 3 Step Mental Health Process with their patients • Procedural GP payment – payments to practices to support the provision of procedures such as surgery, anaesthetics and obstetrics in rural and remote areas • Rurality – a rural loading applied to the PIP payments of practices where the main location is situated outside a capital city or other major metropolitan area.

A number of health services indicated that participation in PIP was part of their commitment to providing high quality clinical services to their community, as well as a further source of income. In several areas the Division of General Practice was reported to have played a role in services achieving the accreditation that is required for participation in PIP; it is clearly desirable for Divisions to offer such assistance to any interested health services in their local area. The RACGP is another relevant source of support.

Qualitative research suggested that ATSIHSs most commonly claim PIP incentives for their teaching role, and statistical analysis conducted by Prof Ian Anderson and Dr Margaret Kelaher at the University of Melbourne during this study showed that this is an area where they are more likely to claim than mainstream service providers (see Table 3.3).

However, some of the PIP items require ongoing contact with the patient over a particular period, and service providers (including mainstream GPs) report that this is difﬁcult to achieve with many Indigenous patients. Statistical analysis by Prof Ian Anderson and Dr Margaret Kelaher showed that eligible ATSIHSs have been less likely than eligible mainstream practices to claim PIP items relating, for instance, to diabetes outcomes and cervical screening (see Table 3.3).

32 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 Table 3.3: ATSIHSs1 participating in PIP (August 2005)

Element (selected) ATSIHSs1 All PIP practices2 PIP elements3 After hours Tier 3 29% 29% Teaching Incentive 19% 12% Practice nurse/Allied health worker 68%4 64%4 Diabetes outcomes 17%4 45%4 Cervical screening outcomes 33%4 72%4 Asthma Service Incentive Payments5 4%6 26%6

1 Includes Aboriginal Community Controlled Health Services (as identified by OATSIH) as well as Queensland/Northern Territory Government funded community health centres whose clientele are predominantly Indigenous 2 Includes Aboriginal and Torres Strait Islander primary health care services. 3 Information on a selection of PIP elements was provided by DoHA by way of example. Those included were previously identified as of interest in relation to Indigenous health. 4 Percentage of eligible practices (ie practices who sign-on to receive PIP payments for a particular health outcome). 5 Service Incentive Payments (SIPs) differ from Practice Incentive Payments in that they are paid to the practitioner providing the service, rather than to the practice. 6 Percentages are mean figures calculated from quarterly claims for SIPs among ATSIHSs compared to all PIP practices.

A recent article by Dr Sophie Couzos and Scott Davis of NACCHO (Australian Family Physician, vol 34 No 10, pp 837-840) considers issues relating speciﬁcally to the Asthma 3+ Visit Plan in the context of community controlled health services. It notes that there is a high prevalence of asthma among Aboriginal and Torres Strait Islander adults – and also a high rate of hospital admissions for acute asthma episodes, indicating that preventive measures are inadequate among Indigenous Australians. Key risk factors for asthma (including smoking) are more common among Aboriginal and Torres Strait Islander people.

As part of a national evaluation of the Asthma 3+ Visit Plan in 2004, NACCHO undertook a quantitative and qualitative study of barriers to use of the Plan among community controlled health services. It was found that few ACCHSs had completed an Asthma 3+ Plan, and that even fewer had claimed the relevant Service Incentive Payment. Reasons why the 3+ Plan was difﬁcult even for accredited ACCHSs to apply included the following (p838):

• program inﬂexibility, complex implementation in a remote environment and ‘red tape’ • patients not returning for the third visit, and • lack of staff training and insufﬁcient resources to understand and implement the program.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 33 ACCHSs which took part in the NACCHO research indicated that there were also problems relating to access to asthma medication and to the spacer devices commonly used in asthma treatment.

Couzos and Davis note that Indigenous Australians visiting private GPs are also likely to have limited access to the beneﬁts of the Asthma 3+ Plan, since there is ‘a lower rate of asthma SIPs generated from general practice divisional regions with a higher Aboriginal and Torres Strait Islander population’ (p 839). They argue that the Medicare’s chronic disease management items offer a more suitable mechanism for ATSIHS care of people with asthma; for one thing these do not require the service to be accredited to RACGP standards.

The issue here is not about the clinical soundness of the Asthma 3+ Visit Plan, but about practical problems in Indigenous Australians gaining the beneﬁt of it.

Overall, the ﬁndings of the present study suggest that PIP is currently of fairly limited signiﬁcance in the work of Aboriginal and Torres Strait Islander health services, and that other initiatives such as Enhanced Primary Care items are seen as more obviously relevant and useful. Medicare Australia and OATSIH should aim to see that ATSIHSs do claim all of the PIP payments to which they are entitled, and it would also be desirable to conduct a campaign to increase ATSIHS awareness and use of PIP. As noted in section 3.4, providing information that is as clear and practical as possible is one key factor here.

There were some suggestions for further development of PIP items that speciﬁcally reﬂect Indigenous health needs – for example an incentive for general practices to employ Aboriginal or Torres Strait Islander staff, and possibly the addition of certain items relating to conditions that are particularly common or severe among Indigenous Australians (chronic lung disease was given as one example).

Survey responses

Of the services which participated in the ATSIHS survey, a quarter (26%) were neither accredited nor seeking accreditation, and thus not eligible to participate in PIP. Perceived problems in becoming accredited included ineligibility (eg no GPs), difficulties in finding out what is required and how to do it, finding the necessary staff time, and cost. The most useful type of accreditation support or assistance, it was said, would be someone visiting the health service to explain clearly what needs to be done (as suggested above, there is obviously a potential role here for Divisions of General Practice and other bodies such as the RACGP).

Among those services which were eligible to participate in PIP, 83% stated that they had received (or applied for) the Practice Nurse/Allied Health Worker incentive relating to employment of an AHW. Two-thirds nominated no other aspect of PIP as having been beneﬁcial for them and their patients. Elements of PIP which were mentioned in this context included incentives relating to immunisation (16% of those eligible for PIP), diabetes (8%) and after hours services (4%). (Note that Table 3.3 above sets out data on ATSIHSs use of PIP.)

Only a small number of the services participating in the survey made speciﬁc suggestions for changes or additions to PIP. These included funding for specialist services, funding for home visits, and funding for sexual health counselling/treatment.

34 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 Recommendations:

14. In introducing or amending Medicare items (including EPC and PIP items), DoHA should ensure that relevant information is provided to ATSIHSs in as clear, simple and effective a manner as possible. The same should apply to any other aspects of Medicare where uptake by ATSIHSs may be affected by communication barriers. Information packages should be ‘market tested’ with relevant target groups in advance. 15. Consideration should be given to further practical changes to Medicare which reflect the models of health care used within ATSIHSs and the circumstances in which they operate. Examples could include further recognition of the roles played by health professionals other than GPs, consideration of the role of GP services provided by telephone, increased rebates for services provided in remote locations, and increasing the number of allied health services provided for in Chronic Disease Management plans. 16. DoHA should promote awareness and education initiatives for Indigenous communities on the availability, purpose and value of periodic health assessments. 17. DoHA should implement a strategy designed to increase ATSIHS use of the Practice Incentives Program (PIP). In future consideration of the scope of the PIP, consideration should be given to the inclusion of items that reflect particular needs in Indigenous health – including possible incentives to mainstream practices to employ Indigenous staff. 18. All Divisions of General Practice should consult with ATSIHSs within their area on whether those services would value assistance with the accreditation required for participation in PIP. 19. DoHA and State and Territory Governments should provide appropriate registration systems for AHWs. Pending the introduction of such systems across Australia DoHA, in consultation with other relevant parties, should take steps to ensure that AHWs with appropriate skills can claim rebates for routine tasks such as wound care, immunisations and ante-natal checks. 20. DoHA should put in place a system for obtaining timely feedback from ATSIHSs on difficulties and limitations that they encounter in the use of Medicare, with a view to responding promptly to problems identified. 3.9 Immunisation

Under the General Practice Immunisation Incentives (GPII) Scheme, GPs receive ﬁnancial incentives for promoting, providing and monitoring appropriate immunisation services for children aged under seven years. GPs working with Aboriginal and Torres Strait Islander Health Services are eligible to participate.

There are three main elements to the GPII scheme, as follows:

• a Service Incentive Payment (SIP) for practitioners who notify the Australian Childhood Immunisation Register (ACIR) of the completion of a child’s vaccination schedule in line with the National Immunisation Program; • an outcome payment for practices which achieve an immunisation rate of 90% or above among their patients aged under seven; • Immunisation Infrastructure Funding for Divisions of General Practice and certain other bodies, designed to raise the percentage of children being immunised at national, State and local level.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 35 Many ATSIHSs are immunisation providers, and participate in providing data for the ACIR; many also access funds available through the GPII scheme. The qualitative research conducted during this study suggested that arrangements for claiming incentive payments relating to immunisations were in general working satisfactorily for ATSIHSs, and that some have been able to claim the additional outcome payments relating to achievement of 90% immunisation levels. Some services emphasised, however, that 90% was a difﬁcult target for them, for example because of high mobility and transience in the communities they serve.

Through analysis of ACIR data relating to rebates to service providers, Professor Ian Anderson and Dr Margaret Kelaher have concluded that rates of immunisation of Indigenous children have in recent years been increasing slightly faster than such rates among non-Indigenous children. Relative to other health service providers, there was a slight increase in beneﬁts paid to ATSIHSs providing immunisation over the period 2001-2005.

Most of the ATSIHSs consulted during the study reported immunisation rates around the 85-90% mark or above, and the use of proactive strategies by nurses and AHWs to maintain and improve these rates. Such strategies included:

• opportunistic approaches, eg taking advantage of any visit by a child to provide immunisation; • follow-up of children overdue for immunisation through use of the ACIR recall system; • outreach to families not bringing their children for immunisation, including transport by Aboriginal Health Workers to bring families into the ATSIHS; • direct approaches to families outside the clinic (particularly in non-urban areas) to remind parents to bring children for immunisation.

These were reported to be effective methods, and to be necessary in light of many parents’ lack of appreciation of the importance of immunisation to their children’s health. There was a common view that ‘grandmothers’ were often a positive inﬂuence in terms of promoting immunisation, but that there is a widespread lack of knowledge and a need for education about the risks of not immunising, both for each child and for the broader community.

Among Medicare staff who responded to the online survey, a number saw a need for more active education and information for Indigenous communities about the importance of immunisation. Some also suggested modest ﬁnancial incentives to encourage families to have children immunised, while some believed that relevant ﬁnancial incentives for health service providers ought to be increased.

Some stakeholders commented that the availability of infrastructure funding to Divisions of General Practice was not necessarily beneﬁcial for Aboriginal or Torres Strait Islander health services, since the closeness of health service relationships with Divisions was very variable across Australia. It was also noted, however, that Divisions commonly have Immunisation Ofﬁcers who could offer useful support to local ATSIHSs.

Recommendations:

36 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 3.10 Hearing services

Hearing disorders are common among Aboriginal and Torres Strait Islander people. For example, a high proportion of Aboriginal and Torres Strait Islander populations experience chronic suppurative otitis media (CSOM)19. Survey research has found that up to 80% of Indigenous students have an educationally signiﬁcant hearing disability (McRae et al 2000). Among other things, poor hearing can also represent a signiﬁcant barrier to training and employment.

The Australian Government provides hearing services to eligible Indigenous Australians through its Hearing Services Program (previously known as the Commonwealth Hearing Services Program). The voucher component of the Program provides access to free hearing services - including hearing assessments, and the ﬁtting of hearing devices and associated rehabilitation services - to eligible clients such as Pensioner Concession Cared holders. Other client groups, including children and young adults under the age of 21 years, are able to access the Program under Community Service Obligations which are delivered by Australian Hearing, the public provider of hearing services.

Indigenous Australians who meet the eligibility criteria are able to access hearing services under the Program. The majority access the services through Australian Hearing’s Specialist Assistance Program for Indigenous Australians (AHSPIA). Through AHSPIA, hearing services are provided through permanent hearing service sites, visiting centres, and other health services used by Indigenous clients, or schools with a high proportion of Indigenous students. Visits are made by a national team of specialist audiologists; the number of visits made each year varies and is subject to negotiation. For example, in 2004 audiologists visited Redfern for a day and a half each month, but visited the Ngaanyatjara Lands three times per year. Site locations, number of visits per year, activities undertaken on each visit, role deﬁnition, referral protocols, reporting and review processes are all subject to negotiation and form the basis of Service Level Agreements (SLAs) between Australian Hearing, the communities concerned and other involved health and education professionals. SLAs are generally negotiated for a two year period (Burton 2004, pp1-2).

A Report on the Delivery of Hearing Health Services to Aboriginal and Torres Strait Islander Peoples (2002) produced the following key ﬁndings relating to Indigenous access to the Australian Government Hearing Services Program):

• Access by Aboriginal and Torres Strait Islander adults to services under the CHSP is restricted by a range of factors. These are: • the eligibility criteria • the wide geographic spread and isolation of some Indigenous communities, which impacts on cost and therefore frequency of visits by audiologists, and the cost of transport for clients attending a service • lack of support in many communities for those ﬁtted with hearing aids • the relatively complicated nature of entry to the Hearing Services Voucher System.

19 The World Health Organisation has reported that a CSOM prevalence in greater than 4% of a population indicates an unacceptable public health problem. These rates are reported to be consistently exceeded in Aboriginal and Torres Strait Islander populations (Couzos et al 2001).

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 37 • There were signiﬁcant ongoing deﬁciencies in ear health and hearing services relating to: • lack of access to specialist services including Ear, Nose and Throat Specialists and audiologists • planning and coordination to support the continuity of ear and hearing care across the spectrum from primary to tertiary interventions • integration of ear health services within routine comprehensive primary health care services and effective detection and early intervention, particularly in the 0-3 age group • the clinical skills of the primary health workforce, which currently fall short of those required to produce real reductions in otitis-media related hearing loss.

(DoHA 2002, p6)

The Report indicated that in the year 2000, out of 130,000 adults who had accessed the Australian Government Hearing Services Program, only 100 were recorded as being Indigenous. In the same year, out of 40,000 children who received hearing services through the Program, 2,000 were reported to be Indigenous. NACCHO observed that ‘5% of services delivered were for Aboriginal children even though Aboriginal children have much higher rates of hearing loss’20 (NACCHO 2001, p2).

Since the release of the Report, measures to increase Indigenous access to hearing services have been introduced. These include streamlined referral procedures for Indigenous clients to facilitate and encourage their take-up of the hearing services provided by Australian Hearing. A reallocation of funding also meant that additional resources could be utilised to support and extend the AHSPIA program.

These measures have had a positive impact on the level of access to hearing services by Aboriginal and Torres Strait islander people, with 3,221 Indigenous Australians accessing hearing services through AHSPIA in 2004-05. This represented an increase of 31% from the previous year. Indigenous Australians receiving hearing services comprised 9% of all Special Needs clients in 2004-05 (DoHA 2005, p165).

Increased Aboriginal and Torres Strait Islander eligibility for access to the Australian Government Hearing Services Program was announced in the 2005-06 Budget. As of December 2005, Indigenous Australians aged 50 or over and those participating in the Community Development Employment Program (CDEP) are now eligible for hearing services assistance. The Government estimated that over the coming four years this measure will assist around 10,000 Aboriginal and Torres Strait Islander people suffering hearing loss.

Qualitative research indicated that ATSIHSs were generally not yet familiar with these new provisions. However, the level of knowledge should increase as a result of the ongoing media campaign and distribution of information about the new provisions. The work being undertaken by Australian Hearing to negotiate SLAs with individual ATSIHSs is also expected to increase awareness and take-up of the hearing services by eligible Indigenous Australians.

20 According to NACCHO, rates of hearing loss in Aboriginal children have been reported as 5 to 10 times high than for non-Aboriginal children, and that the prevalence of hearing loss in non-Aboriginal children has been reported to be around 5% or less (NACCHO 2001, p2)

38 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 Among ATSIHSs which did know about the new eligibility criteria, some were concerned that the age of eligibility remained inappropriate. The concerns expressed included the following:

• In some areas it was reported that the majority of people presenting for hearing assessment are in fact young people. For example, younger women (21-25) with hearing loss incurred as a result of traumatic head injury in the context of domestic violence would remain ineligible. (Those aged 15 to 20 can access hearing services under the existing Community Service Obligation arrangements.) • People in employment (particularly in low skilled jobs) who require hearing aids to stay in work remain ineligible unless they are participating in a CDEP project. • Children in isolated areas who require hearing aids also need regular access to health workers to maintain clean ears and have infections managed.

The Ofﬁce for Aboriginal and Torres Strait Islander Health (OATSIH) funds an ear and hearing health program that targets Aboriginal and Torres Strait Islander children up to ﬁve years old through screening and early intervention. This includes funding for 30 child health sites in 29 Aboriginal Community Controlled Health Services.

The OATSIH also provides funding for AHW hearing training delivered by Australian Hearing, the Northern Territory Government (Top End, NT) and Central Australian Aboriginal Congress (Central Australia, NT). This has a focus on developing skills and knowledge to manage screening and follow-up for the 0-5 year age group.

On 1 May 2006, the Australian Government introduced a new Aboriginal and Torres Strait Islander child health check item to the Medicare Beneﬁts Schedule (MBS). This new MBS item will encourage primary health care providers to take a more comprehensive and preventive approach to addressing the health care needs of Aboriginal and Torres Strait Islander children from birth to 14 years, including ear and hearing health.

Recommendation:

22. Consideration should be given to further extending beneﬁts under the Australian Government Hearing Services Program for people aged under 50.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 39 3.11 Point of care diabetes testing and the National Diabetes Services Scheme

3.11.1 Point of care testing for diabetes

Diabetes is a signiﬁcant cause of morbidity among Aboriginal and Torres Strait Islander people. The Medicare Beneﬁts Schedule provides a temporary item (73840) for doctors in community controlled health services to bill Medicare for HbA1c (glycosylated haemoglobin) testing of people with established diabetes, using the DCA2000 Analyser; this is known as point of care testing. The test provides immediate results and is valuable for the early treatment and management of diabetes. Importantly, it reduces the need for patients to revisit the health service for follow-up consultations.

Point of care diabetes testing has been trialled in 60 selected ATSIHSs as part of the Quality Assurance in Aboriginal Medical Services (QAAMS) project. Preliminary ﬁndings from an evaluation of the project suggest that the trial has been successful, and it appears that testing units will be distributed to a further 40 ATSIHSs in the near future.

Prof Ian Anderson and Dr Margaret Kelaher undertook data analysis regarding the uptake of item 73840; however this should be interpreted in light of the limited distribution of point of care testing units as part of the QAAMS project. Relevant ﬁgures are set out in Table 3.4.

Table 3.4: Uptake of Medicare item 73840 by State/Territory, Year

Use of item 73840 by year State/Territory* 2003/04 2004/05 n n

NSW 148 279 NT 25 0 QLD 232 390

SA 214 213

VIC 73 151 WA 291 471 Total 985 1509

*ACT and Tasmania are not reported because of low numbers

40 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 3.11.2 National Diabetes Services Scheme

The National Diabetes Services Scheme (NDSS) is funded by the Australian Government and administered by Diabetes Australia under a series of grant agreements. It provides access to products and services needed for the self-management of diabetes at prices subsidised by the Australian Government. These include syringes, insulin infusion pump consumables, and blood and glucose testing reagents. They are provided to NDSS registered people with diabetes, through Diabetes Australia ofﬁces, by mail order and by through accredited sub-agents such as pharmacies, hospital clinics and other outlets. Diabetes Australia also provides a range of educational and information services to assist in the best use of products and the effective self-management of diabetes.

Patient co-payments have not been increased since the inception of the scheme in 1987 and no indexation has applied. NDSS co-payments remain below PBS levels, and purchases on the NDSS do not count towards the PBS safety net. A number of products available through the NDSS are also available through the PBS.

Registration for the NDSS

To register for the NDSS, patients who have been diagnosed with diabetes are required to fill out a form, which must be certified by a GP or a Credentialled Diabetes Educator. This requirement has been identified as a potential barrier for those living in rural and remote areas, where a GP or accredited diabetes educator may not be available. In the Northern Territory there are arrangements in place allowing ATSIHS staff to fill out registration forms on behalf of patients, which are then sent in batches to a nearby GP to be signed.

Diabetes Australia has highlighted that low reporting of Indigenous status on the NDSS is of particular concern, given the prevalence of diabetes among Aboriginal and Torres Strait Islander people. While the NDSS registration form contains an Indigenous identifier question, identification is very low (around 5%), and non-response to the Indigenous identifier question is high. The NDSS database is not linked to the Medicare Australia database, so Indigenous status cannot be determined by cross-checking against this source.

Purchasing supplies through the NDSS

People purchasing products and services through the NDSS must supply either their Medicare number or their NDSS registration number each time. Diabetes Australia reports that this can be a particular problem for people in rural or remote areas who cannot always produce these numbers when required.

Costs

Patients need regularly to use testing strips and insulin pump consumables. Test strips must be used in conjunction with a glucometer; these can be relatively expensive to buy (between $30-$80), and are generally only available through pharmacies, although in some circumstances they can be purchased through ATSIHSs. The NDSS does not cover Glucometers costs.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 41 Discounts on co-payments for NDSS products (eg testing strips and insulin pump consumables) are available to those who are registered on the NDSS, and who also hold a Centrelink Health Care Card, a Commonwealth Seniors Health Card, a Department of Veterans’ Affairs Repatriation Health Card or a PBS Safety Net card. Those who cannot present both their NDSS card or number and the relevant concession card cannot receive discounts on NDSS products. Again, the fact that the NDSS database is not linked to the Centrelink, DVA, or PBS Safety Net databases prevents pharmacists and others from cross-checking patients’ eligibility to receive discounts. Diabetes Australia states that cost can be a barrier for those who are unable to produce the multiple cards required for eligibility for discounts. The introduction of a single ‘smart card’ has been suggested as a potential solution to this barrier.

An indication of the co-payments and discounts available for NDSS products is provided in Table 3.5.

Table 3.5: Co-payments and Discounts for Products Available Through the NDSS

General PBS Concessional Product Pack size General Pensioner Concessional Safety Net PBS Safety Net

Testing strip 50 $6.35 $0.50 $1.00 $0.50 Free Testing strip 100 $12.70 $1.00 $2.00 $1.00 Free Insulin pump 30 $15.00 $15.00 $15.00 $15.00 $15.00 Insulin pen needle 100 $8.00 $5.00 $5.00 $5.00 $5.00

Strategies to increase Indigenous Australians’ access to the NDSS

The Australian Government has identified Indigenous Australians as a priority group, as part of its Strategic Grant Program. In particular, Diabetes Australia and the Australian Government are exploring ways in which to increase Indigenous Australians’ access to the NDSS. These include development and distribution of Indigenous-specific educational materials and resources. Diabetes Australia has developed a series of educational materials specifically for Aboriginal and Torres Strait Islander people, which have been designed for use in ATSIHSs. Diabetes Australia is also employing a consultative process to develop an Indigenous-specific standard data pack for new registrants to the NDSS. Both of these resources have been developed using funds from DoHA.

Notwithstanding issues relating to the reporting of Indigenous status, NACCHO believes that participation in the NDSS by Indigenous Australians is low, and is keen to see progress made on a joint project with Diabetes Australia to review Indigenous access to the Scheme.

Recommendations:

42 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 3.12 Rural and Remote Health Initiatives

Over recent years the Australian Government has introduced a range of initiatives designed to support and strengthen health and medical services in rural and remote areas of the country. These include, for example, measures to support the training and employment of practice nurses in rural areas, recruitment and retention of general practitioners, provision of scholarships for rural-based medical training, higher Medicare rebates for services delivered by some ‘Other Medical Practitioners’ (OMPs) in rural and remote areas, a General Practice Registrars Rural Incentive Scheme, and the Medical Specialist Outreach Assistance Program (MSOAP).

In broad terms these initiatives can be expected to have some beneﬁts for remote-area Indigenous health services and their patients. For the most part, however, the ATSIHSs consulted in the course of this study were not particularly familiar with the various measures mentioned above, and had little comment to make about their value for Indigenous health in particular. Over 80% of the rural and remote health services which took part in the ATSIHS survey did, however, state that they knew that their medical practitioners were eligible for Australian Government training or ﬁnancial assistance relating to practice in rural/remote locations.

Since ATSIHSs tend to make considerable use of doctors trained overseas21, the liberalisation of some Medicare provisions relating to services provided by Overseas Medical Practitioners in rural and remote areas are desirable from an Indigenous health perspective. It was not clear from the conduct of the present study, however, that these provisions are well understood by ATSIHS staff.

The rural/remote initiative which attracted most comment from the stakeholders consulted during the study was the MSOAP. This is discussed in section 4.5 of the report. As previously noted, there were also suggestions from some stakeholders for higher Medicare rebates relating speciﬁcally to remote area services.

When respondents to the Medicare staff survey were invited to comment on any possible improvements to the Rural Retention Program, few felt able to comment in speciﬁc terms, although a number emphasised the importance of addressing workforce problems in rural areas.

Recommendation:

21 Data analysis by the CRCAH showed that approximately one GP in three employed by ATSIHSs during 2002-04 were overseas- trained. According to the Australian Medical Workforce Advisory Committee (AMWAC 2005,p6), the corresponding ﬁgure for all practitioners is one in four.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 43 3.13 Other Matters

Speciﬁc suggestions for further initiatives that were made by the services which participated in the ATSIHS survey included the following:

• Address workforce issues; need for more doctors/nurses/AHWs (11% of respondents) • Provide funding for transport services (7%) • Provision of/funding for dental services (7%) • More/better training in Medicare (6%) • Free medication/treatment for all Indigenous patients (5%) • S100 entitlement should apply in all locations (5%) • More outreach work by Medicare workers (4%) • Review remuneration of doctors and nurses (4%) • Medicare provider numbers for AHWs (4%) • Medicare information/education for Indigenous communities (3%)

Most of these issues are considered in other parts of this report. Workforce issues, including shortages of GPs, are widely recognised as a major problem in Indigenous health (most especially in remote areas), and initiatives designed to address workforce problems must clearly be part of broader strategies for improving services for Indigenous Australians. However, workforce matters were not directly within the scope of the present study.

Problems relating to the availability and cost of dental care were frequently mentioned in the course of the study and are referred to again in section 4 of the report.

3.14 Summary

At this stage health services appear to vary considerably in their capacity to capture all the Medicare income to which they are entitled. Reasons for under-claiming include varying GP or Medical Ofﬁcer familiarity with Medicare and varying degrees of motivation to claim; limited Medicare knowledge among other ATSIHS staff; the complexity of some aspects of Medicare; the limitations of administrative systems, patient record and IT systems; variations in the ways in which services are structured and in the relationships between management and GPs; and competing pressures that may reduce staff time available for investment in Medicare.

44 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 Ongoing information and training about Medicare for ATSIHS staff is clearly important, and some services need particular assistance in making changes necessary to the more effective use of Medicare. It is also important that DoHA communications about Medicare issues and changes be as clear and straightforward as possible.

Income from Medicare cannot in itself be an adequate source of income for ATSIHSs – particularly because Medicare is GP-centred, while GPs play only a limited role in the work of Aboriginal and Torres Strait Islander health services. Numbers of changes could be considered to improve the ‘ﬁt’ between Medicare and ATSIHS modes of operation – for example further Medicare recognition of the range of health services provided by nurses and AHWs.

The introduction of Enhanced Primary Care (EPC) items has generally been positive from the perspective of Indigenous health. However, ATSIHSs report that they sometimes find it difficult to provide specific EPC services and to claim for these. While maintaining high clinical standards, ongoing review of EPC items needs to take account of particular issues that arise in Indigenous-specific services. The new Chronic Disease Management items introduced by DoHA are intended to be simpler to use, and allow greater scope for AHW participation.

Further consumer or community education would be valuable in relation to health assessments in particular, to promote an understanding of the value and availability of these checks.

By no means all ATSIHSs are accredited and thus eligible to participate in the Practice Incentives Program; this is an area where Divisions of General Practice can appropriately offer support to interested ATSIHSs. Even accredited ATSIHSs face problems in using some elements of PIP (eg the Asthma 3+ program) because of difﬁculty in achieving the structured contact with patients over time that these require. Nevertheless it is important that efforts be made to increase ATSIHS understanding and use of PIP.

Medicare rebates for immunisation seem generally to present little problem for ATSIHSs. While some services achieve the 90% immunisation level required for receipt of additional outcome payments, this is a difﬁcult target to reach - for example because of mobility in the communities they serve.

Point of care diabetes testing, as introduced in some ATSIHSs on a trial basis, was seen as a valuable service.

Some ATSIHSs need further assistance in taking advantage of mainstream Australian Government programs relating to rural and remote area health.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 45 4 Access to Medicare through Mainstream Health Services

4.1 Use of mainstream services

In rural and remote areas there may well be no mainstream health services readily available to either Indigenous or non-Indigenous Australians. In cities and towns, however, many Indigenous Australians obviously make use of the services of private medical practices – sometimes in combination with the use of an ATSIHS. Apart from no Indigenous-speciﬁc service being available, other reasons that Indigenous Australians may choose to use mainstream GP services include the following:

• convenience – eg longer hours of opening, easier to get to or easier to get an appointment • maintaining a relationship with a doctor they know, continuity of patient records • greater privacy.

General practices aside, Indigenous Australians may also seek primary health care at hospital emergency or outpatient departments where these are available. Such services are normally provided without charge, and they are likely to be available in the evenings and at weekends when ATSIHSs are closed. In Perth, for example, the study team was told that, especially with limited bulk-billing available, the public hospitals see large numbers of Aboriginal outpatients22.

Some of those consulted during the study believed that the quality of care that Indigenous Australians receive from mainstream health services is very variable. For example, the former manager of a general practice who was interviewed in Perth perceived a tendency for mainstream providers just to deal with an Indigenous patient’s immediate problem, where they might be more likely to suggest pathology tests or other follow-up for a non- Indigenous patient. (It was pointed out by others that this would be consistent with Indigenous patients tending to be offered access to fewer hospital procedures.)

A number of stakeholders pointed to the difﬁculties that Indigenous Australians were likely to experience in small country towns in particular, where there is likely to be little choice in health services, and where mainstream service providers may lack skills and empathy in working with Indigenous patients, and in any event are unlikely to bulk-bill. Improvements in access to effective mainstream services are obviously especially important in the many locations where there is no ATSIHS available23.

22 The fact that there are Aboriginal people in Perth who have little if any contact either with the AMS Derbarl Yerrigan or with a GP lies behind a current initiative to link people discharged from Royal Perth Hospital into an ongoing GP relationship (see section 4.3 below). 23 Numbers of the stakeholders consulted emphasised that continuing and increased support for the community controlled sector was essential for improving Indigenous health. They believed that other providers – GPs, hospitals, State or Territory clinics or community health centres – could not provide the same kinds of services, the same level of acceptability to patients or the same outcomes across the spectrum of health needs.

46 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 General Practitioners

Past research shows that in general Aboriginal and Torres Strait Islander people tend to underuse GP services, indicating that there are various barriers that affect access in practice. The qualitative research undertaken during this study suggested that, where GPs are available, it is the cost of services which represents the greatest single barrier. It is widely accepted that, given their income levels, Indigenous patients will in general prefer a bulk-billing service; it was reported that in many areas it has become more difficult to find a bulk-billing practice. (This point was made strongly in Perth, for example.) The GP survey conducted during this study (see section 4.4) showed that GPs themselves recognised the cost of services as a significant barrier.

Other issues identiﬁed through qualitative and/or survey research included lack of Indigenous staff within private practices; language or communication barriers; lack of a choice between male and female practitioners; and location or transport problems. It is also recognised that, where they have a choice, Indigenous Australians may well prefer an ATSIHS where services can be expected to be culturally appropriate; for example, it is often said that the major role played by Health Workers is a major positive factor for many ATSIHS patients.

When the ATSIHS survey asked respondents about various factors that they believed might limit the numbers of Indigenous Australians using mainstream general practices, the responses emphasised factors relating both to cultural appropriateness and to cost.

According to the results of the GP survey, general practices are more likely to offer bulk-billing to their Indigenous patients than to patients in general. This point was also made in some qualitative interviews conducted with GPs who see a substantial number of Indigenous patients. A GP based in Far North Queensland, for example, stated that he and his colleagues bulk bill almost all their Aboriginal or Torres Strait Islander patients, because they know that these patients would not otherwise attend. Among other things this GP reported that his practice conducts ‘heaps’ of EPC health checks with Aboriginal patients, who are generally enthusiastic about them.

Other approaches that some GPs may use to encourage attendance by Indigenous patients include employment of Aboriginal or Torres Strait Islander staff, for example as receptionists or nurses. The GP survey showed that a small number of private practices also employ AHWs. The North Queensland GP referred to above reported that a few years ago an Opening Doors project was conducted in his area; this involved AHW trainees doing placement in a number of local general practices (‘It was excellent – needs to be done a lot more’). Funding was obtained jointly from the Department of Employment, Education and Training (DEET) and the Division of General Practice, but was not available in subsequent years.

It was also emphasised that if signiﬁcant numbers of Indigenous patients are to be attracted to a private practice, there needs to be established trust and rapport between the practice and the community. In this context it was interesting to observe that a number of GPs with substantial numbers of Indigenous patients had previously worked in an ATSIHS.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 47 4.2 Training of practitioners

Limited understanding of Indigenous Australians and their circumstances obviously restricts doctors’ capacity to deliver services that will be culturally and clinically appropriate. Over time there have been various initiatives, by NACCHO, the RACGP and others, designed to improve GP awareness and understanding of Indigenous Australians and their culture and way of life. In Western Australia, for example, the Aboriginal Health Council has recently had a grant from the RACGP to develop cultural awareness and cultural safety training programs for GPs. It was noted that, since 1996, all GP Registrars have been required to undertake training in cultural awareness.

The further point was made that ‘frontline’ staff working in general practices – including receptionists and nurses – also need to be aware of and sensitive to cultural and cultural safety issues.

Beyond cultural awareness lies the issue of GPs’ skill and experience in Indigenous health issues. Among the GPs surveyed during the present study, for example, only 20% said that they had had any training speciﬁc to Indigenous health. Over 40%, however, stated that their Division of General Practice offered some assistance, advice or training to doctors working with Indigenous patients.

The need for a more systematic approach to training in Indigenous health has been recognised in various ways. For example an Indigenous Health Project that began in 2001 involves a partnership between OATSIH and the Committee of Deans of Australian Medical Schools (CDAMS). The aim of the project is to develop a nationally agreed Framework for the inclusion of Aboriginal and Torres Strait Islander health in core medical curricula. The Framework was launched in September 2004. Phase II of the project is concerned with supporting medical schools in the implementation, monitoring and sustainability of the curriculum framework. The objectives of Phase II are:

• accreditation of each medical school’s curriculum framework; • development of a network of Indigenous and non-indigenous medical educators; • building medical schools’ capacity to address Indigenous health issues and create relevant partnerships with Indigenous communities; • Indigenous student recruitment, support and retention in medical schools; • ‘vertical integration’ with postgraduate training providers; and • evaluation and review of the curriculum framework to ensure best practice.

DoHA has provided some $340,000 (GST inclusive) for the project; to date it has been the only Australian Government agency to contribute. The current funding contract runs until 30 June 2007.

The RACGP has also been active in supporting a range of relevant initiatives relating to GP training.

48 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 4.3 Use of EPC items in General Practice

Mainstream take-up of Practice initiatives such as some of the EPC and PIP items has been slower than originally predicted; mainstream practices may themselves need additional encouragement and support to make the changes necessary to make effective use of such innovations. (As previously noted, DoHA has already made some changes such as the introduction of CDM items, that are designed to facilitate uptake of new approaches.)

It was reported that one speciﬁc barrier to use of EPC items by private practitioners with Indigenous patients was getting those patients to see other health providers in order to address all the EPC requirements. One private GP observed that in her experience patients would comply with requirements for tests and seeing other practitioners only if they clearly trusted the GP’s judgement and the GP could vouch for the other parties concerned. If a GP in these circumstances did not have relevant personal links to other providers, the EPC item could be difﬁcult to achieve.

The Canning Division of General Practice in Perth has initiated two pilot programs which involve AHWs working within private practices. One is a scheme to follow up Indigenous patients discharged from Royal Perth Hospital, with the aim of ensuring that they have a link with a GP. The other involves an AHW working in selected private practices to promote and support the use of EPC items with Indigenous patients. A pilot program similar to the second of these has just commenced in Port Augusta (SA) also.

Discussion with GPs and/or their practice managers indicated that private practices have in the past often lacked reliable information about which of their patients identified as Aboriginal or Torres Strait Islander. Among other things, it was said, this made it difficult for them to identify the range of patients eligible for Indigenous item specific EPC services such as the adult health check. One of the occasions on which practices were most likely to ask about Indigenous status was in relation to vaccinations that are recommended specifically for Indigenous children. It was noted that the RACGP has set practice standards relating to the identification of patients of Aboriginal and Torres Strait Islander background.

Survey information relating to the use of EPCs in private practice is set out in section 4.4 below.

4.4 Survey of GPs

As explained in section 1.3, the study included a telephone survey of a sample of GPs in each State and Territory, drawn in each case from postcode areas with relatively high numbers of Indigenous residents. It is important to emphasise that this was therefore not a random sample survey of practitioners across Australia, but a survey covering a range of practitioners in the various States and Territories who might reasonably be expected to have some knowledge and experience in Indigenous health.

The total number of GPs interviewed was 407; approximately half of these were based in metropolitan areas. In some cases the GP answered all questions; in other cases a number of questions (those of a more factual nature about the practice) were answered on the GP’s behalf by the practice manager.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 49 4.4.1 Characteristics of the practice

Size of practice ranged from one GP (23% of responses) up to seven or more GPs (17%). Thirty of the practices (7%) reported having an Aboriginal Health Worker on staff. A number of practices had Indigenous Australians working in other roles, eg:

• Reception or administration 15 instances • Practice nurse 9 instances • GP 8 instances • Allied health workers 8 instances • Practice manager 2 instances

4.4.2 Numbers of Indigenous patients

In terms of numbers of Indigenous patients, respondents described their practices as having:

• Quite a lot of Indigenous patients 5% • Some Indigenous patients 19% • Just a few Indigenous patients 50% • No Indigenous patients as far as respondent knows 25%

Thus only about one in four of these practices worked with anything more than ‘just a few’ Aboriginal or Torres Strait Islander patients.

Respondents were also asked for their opinion on factors which might limit the number of Indigenous Australians using a general practice. Answers included the following:

• Availability of an ATSIHS nearby 37% • Availability of another local practice or a hospital that most Indigenous Australians use 32% • Indigenous Australians may not feel comfortable coming to a mainstream practice 27% • Cost – may be unable to afford the charges 26% • Location/transport difﬁculties 18% • No Indigenous Australians on staff 16% • Language barriers 13% • Practice does not bulk bill 12%

Other barriers mentioned by various respondents were the practice lacking skills or experience in Indigenous health, and differing attitudes to health and related personal matters as between Indigenous and non-Indigenous Australians.

50 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 4.4.3 Recording of information

Ninety-two per cent of respondents said their practice usually kept a record of patients’ Medicare numbers, while 83% said they usually kept a record of patients’ concession card numbers.

When respondents were asked if the practice kept a record of whether patients are Aboriginal or Torres Strait Islander, they replied as follows:

• As a matter of routine 44% • In certain circumstances 22% • Not at all 35%24

Where this information was collected, it was mostly sought by the receptionist or another administrative worker (66%); 28% of practices reported that it was the GP who would ask this question.

4.4.4 Charging for services

When respondents were asked how the practice usually charged patients for its services, answers were as follows:

• Bulk bill all patients 19% • Charge all patients 16% • Bulk bill some patients (eg pensioners), charge others 66%

Charging practice in relation to Indigenous patients reportedly involved greater use of bulk billing, as follows:

• Bulk bill all Indigenous patients 40% • Charge all Indigenous patients 12% • Bulk bill some, charge others 49%

4.4.5 Medicare

When respondents were asked how often it happens that Indigenous and non-Indigenous patients are unable to produce a Medicare card when going to the doctor, answers were as follows:

Indigenous patients Non-Indigenous patients • Very often or quite often 17% 8% • Sometimes 16% 12% • Occasionally/rarely/never 67% 80%

Thus this issue arose more often with Indigenous than with non-Indigenous patients, but was not particularly common.

24 It should be remembered that these are responses from doctors practising in areas with relatively high numbers of Indigenous residents.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 51 Similar questions were asked about the frequency of Indigenous patients being unable to produce a health care card, and the responses were very much the same as for the Medicare card:

Indigenous patients • Very often or quite often 16% • Sometimes 17% • Occasionally/rarely/never 67%

Respondents who had experience of Indigenous Australians being unable to provide a Medicare card were asked what they usually did in this situation (more than one response was possible). About one respondent in three indicated that they would refuse treatment or tell the patient to come back when they had found or obtained a card; obviously this result is of concern in terms of denial or limitation of access. On the other hand, 8% of respondents said they would provide treatment regardless of the appropriate and being produced.

Twenty-two per cent of the those surveyed indicated said they would contact a Medicare Liaison Ofﬁcer for Indigenous Access or call the special 1800-number access line for Indigenous enquiries; but a much larger number (53%) said they would ‘contact Medicare’ – without making any mention of Indigenous-speciﬁc services. Among those who said they would seek information from Medicare, the great majority (87%) said they found it either easy or very easy to obtain a Medicare number in this way.

Only 6% of respondents said that they had had any particular problems in making Medicare claims relating to Indigenous patients. When such problems did arise they involved issues such as wrong or inconsistent information being recorded, the Medicare card having expired, more than one person using the same card, or newborn babies not being registered.

Respondents whose practices had at least a few Indigenous patients were asked if they were aware of there being Medicare Liaison Ofﬁcers for Indigenous Access. Forty-six per cent said that they were aware of the existence of the MLOs, while 37% said they knew about the Indigenous-speciﬁc information line.

4.4.6 EPC items

Respondents with Indigenous patients were asked whether or not they had made any use of certain EPC items.

• 38% said they had made some use of voluntary health assessments for Indigenous Australians aged 55+. • 36% said they had used Indigenous health checks for adults aged under 5525. • Among those whose practices employed an AHW, more than half reported using the provision for allied health care by an AHW in Chronic Disease Management items.

25 These are lower rates of utilisation of Indigenous-speciﬁc EPC items than reported in the ATSIHS survey (see section 3.7).

52 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 4.4.7 Practice Incentives Program

Forty-three per cent of the respondents reported that their practice received some funds under the Practice Incentives Program26.

Of twelve respondents whose practices participated in PIP and had an Aboriginal Health Worker on staff, only eight said that they received the relevant PIP incentive.

When respondents were invited to say what other aspects of PIP had been beneﬁcial for Indigenous patients or what changes might be helpful, a number of the answers showed confusion about the nature and scope of PIP.

4.4.8 Length of appointments

Among respondents with Indigenous patients 24% said that, for a given illness or problem, consultations with Indigenous patients generally took longer than those with non-Indigenous patients (74% thought there was little difference, and 2% said that consultations with Indigenous patients were generally shorter).

Of the 72 respondents who said that Indigenous consultations generally took longer, two-thirds estimated the average difference in length of consultation at somewhere between 3 and 20 minutes. Others indicated that the appointment might take two or three times as long – up to an hour per consultation. The reasons given for these consultations taking longer centred on Indigenous Australians presenting with multiple health problems or complex social and medical issues; on the value of a thorough consultation when people did go to the doctor; and on communication issues such as the need to allow time to overcome patient reserve and to establish trust, and to ask more questions to elicit relevant information.

The qualitative research indicated that consultations with Indigenous patients often took longer than average – possibly because such patients are less likely to go to the GP regularly, and thus are likely to have more/more serious problems by the time they present27. There may also be other issues such as language or cultural barriers.

26 A ﬁgure that is low by national standards. Again it should be remembered that this was not a national random sample of GPs. 27 It was said that the fact the normal consultations were quite long was one factor that led to ATSIHSs frequently claiming short consultations.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 53 4.4.9 Specialist referrals

Respondents with Indigenous patients were asked about any barriers or problems that arose in referring Indigenous Australians to medical specialist or for X-rays, ultrasounds or pathology tests. Half of them identiﬁed problems in this regard, including the following:

• Patient discomfort/lack of culturally appropriate services 25% • Cost – eg services not bulk-billed 23% • Access problems or unavailability of services 18% • Some services and tests not covered by Medicare 17% • Problems relating to Medicare cards or numbers 11% • Medicare-related problems with referrals 11%

It was said that referrals of Indigenous patients to specialists tend to be time-consuming for GPs because patients may have limited recall or understanding of their previous medical history.

4.4.10 Medications

Barriers to Indigenous Australians accessing the PBS were identiﬁed by a majority of the respondents. The most common of these were:

• Cost/co-payments (49% of respondents) • Cultural barriers, reluctance to use mainstream pharmacies (33%) • Transport problems (16%) • Lack of a community pharmacy nearby (11%)

Strategies that respondents reported having used to assist patients to access medications included providing medicines free from stock or samples, and using emergency or Doctor’s Bag supplies. Several respondents stated that they were authorised to dispense medicines under S100.

Just on 40% of the respondents thought that Indigenous patients had more problems than non-Indigenous patients with correct storage and use of medicines (10% thought Indigenous patients had fewer problems, and 51% saw little difference between the two groups).

4.4.11 Rural Health Strategy

Respondents in practices in rural and remote locations were asked whether they had received any ﬁnancial or training assistance from Australian Government programs designed to assist such practices. Forty-ﬁve per cent said Ye s , 55% said No. Of those who reported receiving such assistance, virtually all said that was either important or very important for the medical services they provided to Indigenous Australians.

54 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 4.4.12 Training or experience in Indigenous health

• Only 21% of the respondents said they had had any speciﬁc training relating to Indigenous health. • 42% said that, aside from their current practice, they had some other current or previous experience with Indigenous patients. • 44% said that their Division of General Practice provided some assistance, advice or training to GPs in working with Indigenous patients or families.

4.4.13 Possible innovations or changes

About one respondent in four made a suggestion for changes or additions to Medicare that could be beneﬁcial for Indigenous health. The suggestions that were made included increased community education (eg for pregnant women and new mothers), extension of bulk-billing, and increased funding for ATSIHSs.

About one respondent in three made other suggestions as to things that the Government or Medicare Australia could do to assist their practice in meeting Indigenous patients’ health needs. The most frequent suggestions included:

• Education to change Indigenous Australians’ attitudes or approach to treatment • Additional funding speciﬁc to Indigenous health, subsidisation of medicines, increased bulk billing • Training/recruitment of Indigenous doctors and nurses • Subsidies for outreach/mobile services.

Recommendations:

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 55 4.5 Specialist medical services

ATSIHS patients enjoy varying levels of access to the services of medical specialists. In some places – especially rural and remote locations, such as East Arnhem Land – both the number and the range of specialists available may be very limited, and seeing a specialist can involve the patient’s travelling long distances to an urban centre. Some ATSIHSs, on the other hand, are reasonably well satisﬁed with their patients’ access to specialist services – usually provided on the basis of a partnership with the relevant State Health Department.

The current exemptions issued under subsection 19(2) of the Health Insurance Act 1973 relate to non-referred attendances. Specialists have no particular ﬁnancial incentive to provide services as employees of ATSIHSs, since in that situation they cannot claim for Specialist services provided on referral.

Data analysis conducted during this study showed that the provision of client contacts by specialists at community controlled health services remains relatively uncommon, with less than half of these services reporting any client contact by specialists in any year. The analysis showed that between 1997-98 and 2003-04, specialist contacts with ACCHS clients actually decreased within services located in highly accessible/accessible/ moderately accessible areas, though they increased in services in remote/very remote locations.

Several stakeholders placed strong emphasis on workforce problems as a major barrier to health care access in the Northern Territory and in other remote areas. There was, for example, ‘no real sustainable GP workforce’ in Aboriginal communities in the Territory, and, for this and other reasons, access to specialists was a completely different story from the situation that applied on the eastern seaboard (‘a huge divide’).

Other issues that were raised in the course of the study included the following:

• Specialists working (or wanting to work) in rural and remote areas cannot charge at the usual level for their services if they cannot get a GP referral – something which is often very difﬁcult. Possible solutions, short- term or long-term, included GPs being authorised to sign referral forms after the event, or nurses (or AHWs) being entitled to make referrals. • Specialists working in remote settings frequently have to deal with complex and severe conditions. For this among other reasons, it was argued that increased rebates should be considered for specialist services provided in such locations, and/or that certain remote-speciﬁc Medicare items could be introduced. • More adequate access to dental services was seen by numbers of health care providers as very important, especially in light of the ongoing poor dental health in Aboriginal people.

The Medical Specialist Outreach Assistance Program (MSOAP) was introduced in the 1999 Budget and is currently expected to remain in operation until June 2008. The MSOAP aims to promote increased specialist visits to country areas by covering some of the costs (eg travel, accommodation and hire of premises) associated with outreach work of this kind. The program also pays specialists for providing support and training to local GPs and other health care professionals, including allied health workers. It is a general purpose program, not Indigenous-speciﬁc.

Stakeholder feedback on the MSOAP was to the effect that ‘It’s OK so far as it goes’, but is quite limited in scope. In particular, MSOAP applies to new services and not to those which were already in operation. ‘These various grants’ for outreach were described in the Northern Territory as an example of ‘bickering’ between the Territory and the Commonwealth; what was needed was ‘an over-arching, patient-centred approach’. A speciﬁc issue raised in relation to MSOAP was the absence of clear reporting or accountability requirements in relation to State and Territory fundholders.

56 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 As indicated above, it was suggested that one way of improving access to specialist services, was for nurses and possibly AHWs working in small towns and communities to be authorised to make referrals; requiring a GP to act as gatekeeper was inconsistent with the realities of health services in these areas. Numbers of different stakeholders made this suggestion. (There were said to be precedents in other areas of the health system – for example optometrists referring to ophthalmologists, physiotherapists referring to radiologists, and so on.)

Further, it was argued, the level of remuneration for specialists visiting remote areas needs to be increased to provide a realistic incentive for such work. ‘Increasing costs and increasing workloads’ make it increasingly difﬁcult for specialist to offer services in remote or isolated locations. MSOAP represented one effort to address some of the relevant issues but, as indicated above, was seen by some as limited and inadequate.

The health services which participated in the ATSIHS survey were asked whether particular problems or barriers arose when they wished to refer patients to medical specialists, or for X-rays, ultrasounds and the like. Almost half identiﬁed no particular problems, but others referred to cost (37% of respondents); lack of accessible services (27%) or infrequency of specialist visits (15%); problems with Medicare cards or numbers (15%) or with Medicare- related referral issues (13%); and services not being culturally appropriate (15%).

Similar questions were asked in relation to ATSIHS patients needing pathology services, In this instance just over half the respondents mentioned no particular problems or difﬁculties. Those who did identify problems referred to such matters as cost (33% of respondents); distance/transport issues (25%); difﬁculties relating to Medicare entitlements (16%); delays (14%); and the fact that some of the tests that patients require are not covered by Medicare.

Most of the services which took part in the ATSIHS survey readily identiﬁed problems relating to provision of dental services. Chief among these were cost and unavailability/infrequency of services.

Recommendation:

30. Given limited Indigenous access to specialist medical care, especially in remote areas, DoHA should explore options for: (i) overcoming the problem that shortages of GPs, especially in remote areas, create a barrier to specialist referrals for Indigenous patients; (ii) modifying the current exemption under subsection 19(2) to allow Medicare claims in relation to referred attendances as well as non-referred; and (iii) providing further ﬁnancial assistance and incentives for specialists to provide outreach services to Indigenous patients in isolated areas.

DoHA should also review the operation of the Medical Specialist Outreach Assistance Program (MSOAP) with a view to extending its scope.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 57 4.6 Summary

There are some Indigenous Australians who are in a position to choose between use of private GPs and ATSIHSs, or to use one or other as they prefer. Advantages typically attributed to ATSIHSs include provision of services free of charge, culturally appropriate services, supportive staff, sensitivity to gender issues (eg separate male and female clinics), availability in some cases of free medications, and ‘fringe beneﬁts’ such as assistance with transport. GPs may be chosen, on the other hand, on the basis of greater privacy or anonymity, maintaining long term doctor-patient relationships, or simply convenience.

A number of stakeholders believed that the quality of service that Indigenous Australians received from mainstream service was quite uneven. Particularly in some country towns, there may be no access to Indigenous-speciﬁc services and patients have to use whatever mainstream services are available, regardless of levels of empathy and expertise.

The limited availability and the cost of dental services is seen as a signiﬁcant health problem for Indigenous Australians.

There have been past initiatives in providing GPs (and other mainstream health professionals) with some form of cultural awareness training. Such work clearly needs to continue, with NACCHO, the RACGP and Divisions of General Practice being among the relevant players. Similarly Indigenous health content in formal education and training of doctors, nurses and other health professionals has been increasing, and again this needs to continue.

A small number of general practices employ AHWs, and there have been some short-term or pilot schemes encouraging broader AHW involvement in working with GPs – for example on delivering EPC services. Some GPs say that they would like to be able to access the services of an AHW from a nearby ATSIHS in appropriate circumstances.

The availability of bulk-billing is a key factor in Indigenous access to mainstream services, and any decline in the number of bulk-billing practices will have implications for Indigenous Australians. The survey of GPs that was conducted during the study showed that GPs were somewhat more likely to offer bulk-billing to Indigenous than to non-Indigenous patients.

Indigenous access to medical specialists varies considerably from place to place; where specialists are available this is often through State and Territory Health departments. In general, however, the level of use of specialist services by Indigenous patients is low. A number of problems or barriers affecting access to specialists were identiﬁed, including:

• the restriction of subsection 19(2) exemptions to non-referred services • the difﬁculty of obtaining GP referrals in remote or sparsely populated areas.

The Medical Specialist Outreach Assistance Program (MSOAP) was not seen as offering adequate incentives to encourage specialists to provide services in remote areas.

58 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 5 Access to Medications under the Pharmaceutical Beneﬁts Scheme (PBS)

5.1 Introduction

In a report issued in 2003 the Australian Institute of Health and Welfare noted that, despite the health of Indigenous Australians being much poorer than that of other Australians overall, expenditure on Aboriginal and Torres Strait Islander health through the Pharmaceutical Beneﬁts Scheme was low. In 1998-99, according to the Institute, PBS expenditure per Indigenous Australian was only about one-third of the PBS expenditure for other Australians (AIHW 2003).

This section of the report covers issues relating to Indigenous access to the PBS that emerged during the present study. It starts with a discussion of the arrangements under Section 100 of the National Health Act 1953 which make special provision for supply of medications to clients of eligible approved ATSIHSs in remote areas.

5.2 Section 100 of the National Health Act 1953 and the 2003 review

Under Section 100 of the National Health Act 1953, clients of eligible approved Aboriginal and Torres Strait Islander health services located in remote areas are able to receive PBS medications, at no cost at the time of consultation. Both community controlled health services and services operated by State or Territory Governments can be approved to participate in the S100 arrangements. These provisions contrast with the S85 arrangements that govern the standard dispensing of individual medication in accordance with a doctor’s prescription.

Section 100 medications are ordered through a community pharmacy, but no co-payment is charged. Since the medications are supplied in bulk and the pharmacist has no direct dealings with the client, the pharmacist is paid by the Australian Government at a rate lower than the standard (S85) dispensing fee. ATSIHS staff are responsible for distributing S100 medications to their patients as needed28.

A review of the S100 arrangements was commissioned by DoHA and reported in 2003. The review was undertaken by the Cooperative Research Centre for Aboriginal Health and the Program Evaluation Unit of the University of Melbourne. The evaluation team was led by Dr Margaret Kelaher.

In the words of Kelaher et al (2003, p1):

The removal of the co-payment has resulted in removal of the ﬁnancial barriers to access to mediation for clients, and the burden of meeting these costs where co-payments were made by ATSIHSs. Increased use of the PBS system to fund medicine has reduced disparities in PBS expenditure and enabled funds previously spent on medicine to be redistributed to other areas of Aboriginal and Torres Strait Islander health.

28 On Thursday Island, in the Torres Strait, the S100 arrangements have been implemented in a somewhat different way. There the patient takes a prescription from the health service to a community pharmacy, where it is dispensed free of charge. Apart from providing direct contact between the patient and the pharmacist, this arrangement avoids the situation where the health service may have to refuse to provide medication to a non-Indigenous patient (or indeed the situation where the service feels obliged to make free medication available). A Queensland stakeholder commented that a similar system could be used to extend the S100 arrangements to certain areas where a community pharmacist is available.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 59 The S100 arrangements have thus had at least two major beneﬁts – increasing access to medications in remote areas, and reducing the costs that many health services previously incurred in purchasing medicines for patients. According to the 2003 report by Kelaher et al, other positive impacts of the S100 arrangements have been ‘the development of stronger relationships between pharmacists and ATSIHSs’, and improvement in levels of ATSIHS compliance with State and Territory laws relating to pharmaceuticals (p 21). Kelaher et al found that at the time of their report in 2003, the S100 arrangements were beneﬁting around 36% of the total Aboriginal and Torres Strait Islander population.

For the purposes of the present research, Dr Kelaher undertook further analysis of PBS data that have become available since the 2003 report was prepared. That further analysis confirmed the findings of the original report in relation to the positive impact of the S100 arrangements on access to a range of significant medication types. Where the earlier research had indicated a possible ‘plateauing’ in the distribution of medications, the current analysis showed renewed growth. Dr Kelaher surmises that the continued increase in the supply of medications under S100 may indicate improved detection and treatment of chronic disease.

Table 5.1 below summarises expenditure on the S100 arrangements from 1999-2000 to 2004-05, and also shows the number of health services involved in the scheme year by year. It shows that expenditure increased from just under $4 million in 1999-2000 – when there were 38 health services approved – to over $24 million in 2004-05, when the total number of services approved had risen to 174. As the table shows, the number of community controlled services covered by the S100 arrangements has increased only moderately over this 5-year period; the main growth has been through extension of these arrangements to Aboriginal and Islander health services operated by State and Territory Governments.

Table 5.1: Expenditure under the special S100 arrangements, 1999-2000 to 2004-05

1999-2000 2000-2001 2001-2002 2002-2003 2003-2004 2004-2005 ($’000) ($’000) ($’000) ($’000) ($’000) ($’000)

Total expenditure $3,880 $6,576 $13,333 $16,639 $19,626 $24,167 ACCHSs approved 38 39 44 45 45 47

Total services approved 38 104 150 152 153 174

Source: DoHA 2006

Kelaher et al (2003, p1) note that health services in the Northern Territory account for a substantial proportion of the expenditure on S100 arrangements. DoHA ﬁgures show that, as at 30 June 2005, 19 of the 47 community controlled services then participating in the S100 arrangements, and 59 of the 127 State/Territory operated services, were located in the Northern Territory.

The S100 arrangements are backed up by a pharmacy support allowance which aims to assist community pharmacists in providing advice, training and other assistance to ATSIHSs covered by S100. Relevant services by the community pharmacist include medication management, training of AHWs, and oversight of medications (eg identiﬁcation of out-of-date stock). The amount of this allowance is between $2,000 and $4,500 per year (plus a GST component).

60 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 The S100 arrangements have in general been warmly welcomed by people working in Indigenous health, and they have been assessed (eg by Kelaher et al) as substantially improving access to medications in the remote areas where they operate. A joint paper prepared by NACCHO, the Pharmacy Guild and the AMA in May 2004 (Position Paper on improving access to PBS medications for Aboriginal peoples and Torres Strait Islanders) stated that:

The implementation of Section 100 … medications for remote area Aboriginal Health Services … has completely revolutionised access to medications on the Pharmaceutical Beneﬁts Scheme …. It represents one of the most substantial positive developments in remote Aboriginal health service delivery for many years.

The main reservation that is expressed about the S100 arrangements is that, while they have had important beneﬁts in terms of increasing access to medications, they have meant little improvement in relation to quality use of medicines, or QUM. Some observers go further and claim that, notwithstanding its success in improving access to medicines in remote areas, S100 arrangements are clearly second best relative to the S85 dispensing arrangements which apply in the mainstream. People interviewed in several locations described the S100 arrangements as creating a ‘two-tier’ system in terms of quality of dispensing: it was argued that the Commonwealth had achieved a cost- neutral solution by eliminating the standard pharmacist role in prescription review and the offer of information and counselling – that is, by reducing expert pharmacy input.

Some difﬁcult issues can arise in relation to geographical eligibility for the S100 arrangements; for example the Yarrabah community in North Queensland is ineligible because of its proximity to Cairns, yet the two are far apart by road and no public transport is available. Two other issues sometimes raised are that the S100 arrangements can have a ‘perverse’ effect in encouraging the use of relatively costly PBS medicines over simpler and cheaper non- PBS products29; and that they impose additional, unfunded, tasks and responsibilities on the AHWs and nurses in remote area health services who become responsible for ‘dispensing’ medications to patients.

Despite such reservations, response to the S100 arrangements in remote areas has been strongly positive, and the issue most commonly raised in debate is whether they should be extended to ATSIHSs in non-remote locations. (The 1997 Keys Young report included a recommendation that the possibility of extending S100 to urban health services be considered.) This issue is taken up in section 5.9 below.

In their 2003 report Kelaher et al made a series of recommendations for reﬁnement and improvement to the S100 arrangements. Some of their key recommendations included the following:

• review of the local impact of geographical restrictions on eligibility for S100 – including issues arising in centres such as Darwin which experience ‘large seasonal migration’ (recommendation 5); • maintenance or increase of funding for doctors at ATSIHSs participating in the S100 arrangements (recommendation 8); • development of a central resource to enable sharing of information and learnings relating to S100 (recommendation 13); • increased support to respond to greater ATSIHS workloads relating to the S100 arrangements (recommendation 19);

29 This can be seen as one example of a broader tendency of the PBS to encourage increased use of those medications that are covered by the Schedule.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 61 • increased pharmacist remuneration, including an additional freight component (recommendation 20); • review of the requirements and provisions of the support allowance that is designed to facilitate pharmacist visits to ATSIHSs to offer training and advice (recommendation 21); • a range of initiatives designed to promote quality use of medicines in the context of S100, including: • a generic set of procedures and protocols that can be adapted for local use (recommendation 16.4) • enhanced training for ATSIHS staff (recommendations 16.6, 22, 23, 24, 25) • appropriate IT funding and support (recommendation 16.1) • introduction of processes for review of errors (recommendation 16.7) • funding for information sheets on common and new medicines (recommendation 29) • DoHA funding for dose administration aids (recommendation 28). 5.3 Role of community pharmacies

5.3.1 Community pharmacist perspectives

In the course of their visits to the twelve case study locations, members of the study team spoke with a number of community pharmacists in metropolitan, regional and remote locations. Some of these had active links with ATSIHSs through the S100 arrangements, through their role as suppliers to ATSIHSs of non-PBS medications, and/or through arrangements whereby ATSIHSs make co-payments for their patients’ prescriptions. Others simply had some Indigenous customers.

Levels of awareness and understanding of Indigenous health issues appeared to be quite varied. While some pharmacists were clearly knowledgeable about and actively interested in their work with Indigenous customers and Indigenous health services, there were some, at the other end of the spectrum, who showed no obvious interest in the needs of Aboriginal or Torres Strait Islander customers.

A number of themes that emerged in these various interviews are summarised below.

Medicare information

While some Indigenous customers might present at the community pharmacy without a Medicare card, or some ATSIHS scripts arrive without all the information required (eg lacking the Medicare expiry date), pharmacists indicated that it was generally not difﬁcult for them to obtain the missing information. (A number of them, however, were unaware of the special Indigenous access line and had continued to call the general Medicare enquiry service.) These days the process was generally ‘very straightforward’, said a Brisbane pharmacist.

62 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 PBS Safety Net

Several of the pharmacies visited by the study team had arrangements with a local ATSIHS whereby:

• a large proportion of the prescriptions written by doctors at the health service came to the particular pharmacy to be dispensed (for example because it was located conveniently to the health service and/or because the service’s drivers routinely took prescriptions there); • the health service took responsibility for making the co-payments on such prescriptions, for some or all of its patients.

Arrangements of this kind were in place in Port Augusta, in Perth and in Darwin, for example. In the great majority of cases the prescriptions were dispensed at the concessional rate.

In this situation, with most of a patient’s prescriptions going to the one pharmacy, that pharmacy was able to keep a good record of co-payments made and therefore of Safety Net eligibility; it was thus in a position to ensure that, once the Safety Net ﬁgure was reached, the health service was no longer charged the (concessional) co-payment. With the exception of this particular situation, the impression gained was that there were relatively few Indigenous Australians who beneﬁted from the Safety Net provisions. Discussion groups with community members similarly indicated that few were aware of or accurately understood the Safety Net arrangements and that, even if aware of these, most people were unlikely to maintain the records required to show Safety Net eligibility.

The 20-day rule

It was noted that, as part of a ‘tightening up’ of Safety Net arrangements since the beginning of 2006, prescriptions for certain PBS medications now cannot normally be dispensed twice within 20 days while still contributing to a customer’s Safety Net entitlement. Pharmacists pointed out that a number of drugs commonly used for treating chronic (eg cardio-vascular) conditions may need to be dispensed more often than this for a given patient. Therefore, unless speciﬁc arrangements are made to the contrary, extra co-payment expense will be incurred by the patient or by the health service on the patient’s behalf.

Over-the-counter medications

In general pharmacists indicated that Indigenous Australians were less likely than non-Indigenous customers to use the community pharmacy as a source of health information and advice or to purchase over-the-counter medications. The cost of over-the-counter products was seen as one signiﬁcant barrier.

Section 100 arrangements and the pharmacy support allowance

The point most often raised in connection with S100 arrangements and the related support allowance was that one or two visits a year by a pharmacist to an ATSIHS represented a very limited contribution to the effectiveness of medication arrangements at the health service. Several of the pharmacists who were involved in S100 arrangements indicated that they tried to visit the relevant health service more often than this. A Darwin pharmacist emphasised the contrast between the standard S85 dispensing arrangements and what he saw as the much more ad hoc and less satisfactory arrangements involved in distribution of medications to patients under S100.

The Pharmacy Guild of Australia wishes to see an increase in the level of pharmacy support allowances, and also in the fee paid to the community pharmacy for each medication dispensed under the S100 arrangements.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 63 Customers without health care cards

A number of pharmacists referred to the difﬁculty that Indigenous (and of course other) customers sometimes faced in paying the general co-payment for PBS medications. Having to ﬁnd the money for the general co-payments on several medications at once – common in the case of families (including sole parents) with young children, or people with chronic disease – could obviously be a major problem. Some people commented that in this situation an Aboriginal parent or grandparent may choose to spend the available money on medicines needed by children, leaving aside their own medication needs. Some pharmacists were prepared to offer short-term credit to regular customers in such situations, but nevertheless cost was described as a major barrier for those without concession cards.

5.3.2 Survey of community pharmacies

As explained in section 1, telephone survey interviews were conducted in February 2006 with a sample of 244 community pharmacies, drawn in approximately equal numbers from the various States and Territories30 and, within each jurisdiction, from postcode areas with relatively high numbers of residents identified as Indigenous. Just under 75% of respondents were from pharmacies classified as highly accessible within the PhARIA classification of accessibility and remoteness; just over 10% were in locations classified as remote or very remote. Seventy- seven per cent of the respondents stated that there was an Aboriginal or Torres Strait Islander health service in the surrounding area.

As with the GP survey, it needs to be remembered that this was not a random sample survey of all community pharmacies, but was weighted towards those which might reasonably be expected to have some contact with Aboriginal or Torres Strait Islander people and services.

Indigenous Australians’ use of community pharmacies

When asked about their approximate numbers of Indigenous customers:

• 18% of the pharmacies surveyed reported having quite a lot of Indigenous customers • 22% reported some Indigenous customers • 45% said they had just a few Indigenous customers • 15% said they had no Indigenous customers that they knew of.

Respondents were asked whether they felt that Indigenous Australians’ use of their pharmacy was limited by various factors, such as location of the pharmacy or an absence of Indigenous staff. Responses to the eight possible barriers listed in the questionnaire were as follows:

30 The highest number of respondents was 41 for NSW/ACT, and the lowest 27 for the Northern Territory.

64 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 Pharmacies with All pharmacies ‘quite a lot’ of Indigenous customers

•Cannot afford the co-payment 33% 50% •Not conveniently located 31% 7% • Some Indigenous Australians get medicines free or 29% 48% cheaply elsewhere • Indigenous Australians hesitant or nervous about coming 22% 30% to the pharmacy •Local doctors or clinics have few Indigenous patients 20% •19%Pharmacy has no Indigenous staff •14%Most Indigenous Australians use a different pharmacy • Pharmacy lacks skills or experience to assist Indigenous 10% customers

As indicated above, among the respondents whose pharmacies had most experience in dealing with Indigenous Australians – that is, those with quite a lot of Indigenous customers, the percentage identifying the cost of the co-payment as a barrier to access rose to 50%. At the other extreme, among those who knew of no Indigenous customers, only 5% identiﬁed co-payment cost as a barrier.

When asked to suggest things that might make Indigenous Australians feel more comfortable about using the pharmacy, respondents made suggestions such as the following:

• employ Indigenous staff (11% of respondents) • provide more education/information for Indigenous Australians (7%) • train existing staff to avoid prejudice or discrimination (6%) • reduce the cost of medication (5%).

Awareness of MLOs and the special Indigenous access line

• 27% of the respondents said they were aware of the existence of Medicare Liaison Ofﬁcers for Indigenous Access within Medicare Australia, and 23% said they were aware of the special 1800 information line

Medicare cards and health care cards

Pharmacies which reported having at least a few Indigenous customers were asked how common it was for their customers to be unable to produce a Medicare card when requested.

• Some 25% of respondents said that Indigenous customers were either very often or quite often unable to produce a Medicare card; the corresponding percentage for non-Indigenous customers was 10%.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 65 • When this situation arose with an Indigenous customer, 37% of the pharmacists indicated they would usually call the general Medicare (IME) enquiry line; 26% that they would contact an MLO or call the special Indigenous enquiry line; and 22% that they would contact Medicare Australia generally (no further details provided). However, over one-third of respondents (36%) said that they would tell the customer that s/he would either have to provide a Medicare card or pay the full price of the medication. (Percentages add to over 100% because of multiple responses.)31 • Among those who said they would contact Medicare Australia for information, three-quarters (77%) said that it was either very easy or fairly easy to obtain a Medicare number in this way.

Respondents with at least a few Indigenous customers were similarly asked about production of health care concession cards:

• Twenty-seven per cent said that their Indigenous customers were unable to produce a concession card either very often or fairly often; the corresponding percentage in relation to non-Indigenous customers was 12%. • When this situation arose with an Indigenous customer, 30% of the pharmacists said they would contact Centrelink; 28% that they would contact Medicare Australia generally, and 15% the MLO or the 1800 information line; 17% said that they would contact someone else such as an ATSIHS; and 12% that they would seek information online. Ten per cent said they would use an emergency Medicare number to dispense the medication requested. However, 34% said they would tell the customer to come back when s/he had found the card, and 20% that the customer would have to pay the non-concession price for medication. • Among respondents who said they would seek information from Centrelink or on line, 58% said that it was either very easy or fairly easy to obtain a concession card number in this fashion.

Compliance

• 45% of these pharmacists believed that Indigenous customers experienced more compliance problems than non-Indigenous customers, while 50% thought the incidence of compliance problems was about the same for both groups. Among pharmacies with quite a lot of Indigenous customers, the percentage identifying Indigenous Australians as having more compliance problems rose to 66%.

Access issues

• When asked whether, over recent years, Aboriginal or Torres Strait Islander people’s access to the PBS in the local area had improved, declined or stayed about the same, 80% of respondents saw little change, 14% said that the situation had improved, and 6% that things had got worse. • It was pharmacists with quite a lot of Indigenous customers who were most likely to perceive an improvement in access – 45% of these respondents. Factors identiﬁed as contributing to improved access included the S100 arrangements, increased funding, and increased community awareness and understanding.

31 Subsequent to the 1997 Keys Young report a requirement was introduced that people need to produce a valid Medicare card in order to obtain a prescription under the PBS [the IME system]. At the time NACCHO expressed concern that this system could further limit Indigenous Australians’ access to the PBS. The survey results suggest that the IME requirements do pose practical problems in some cases, and that further promotion of the availability of the special Medicare numbers is desirable.

66 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 • Factors which some pharmacists saw as having contributed to a decline in access included increased co- payments and removal of some items from the PBS. • When asked whether Indigenous customers experienced particular problems in accessing over-the-counter (non PBS) medications, 40% identiﬁed relevant problems. The cost of medications was the barrier most often speciﬁed (by around 3 out of 4 relevant respondents). Other factors included cultural and communication issues and lack of understanding of medications.

PBS claims

• Only 8% of the pharmacists with Indigenous customers reported any particular problems in making PBS claims relating to such customers. The problems that were mentioned included incorrect Medicare numbers or incorrect patient contact information.

ATSIHSs meeting co-payment costs

• Among the pharmacies which had at least a few Indigenous customers, 40% said that they had arrangements with an ATSIHS to cover the cost of co-payments on behalf of the service’s Indigenous patients.

Supply arrangements outside S100

• 26% of respondents said that, aside from any S100 arrangements, their pharmacy had a contract or arrangement for regular supply of medicines to an ATSIHS.

Safety Net

• Interestingly, given the ﬁndings of the qualitative research (see section 5.3.1) and the statistical information provided by DoHA (see section 5.4 below), only 19% of the pharmacists surveyed thought that the PBS Safety Net did not work well for Indigenous customers. Among those with quite a lot of Indigenous customers, this percentage rose to 35%.

Pharmacy Support Allowance

• Among six pharmacies which were located in a remote area but were not receiving the Pharmacy Support Allowance, four respondents said they were aware of the allowance, and two that they were not. • Suggestions for change • Over 40% of the respondents made suggestions for further changes or improvements to assist Indigenous Australians access to PBS services and medicines. Suggestions made included the following: • more information and education (12% of all respondents) • improved services and more affordable medicines in areas of high Indigenous population (7%) • more ﬂexibility in the 20-day rule (3%) • extension of the S100 arrangements (3%).

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 67 5.4 The PBS Safety Net

Several references have already been made to the PBS Safety Net provisions. These are designed to cap the amount that a given individual or family needs to pay for prescription medicines in any calendar year.

• For holders of Australian Government health care concession cards, who currently pay $4.70 for a standard prescription, the Safety Net threshold in 2006 is $253.80. Once the individual or family has spent this amount on prescribed PBS medicines, future prescriptions for the remainder of the calendar year are dispensed at no charge to the patient. • For other people (non concession card holders), who currently pay some $29.50 for a standard prescription, the Safety Net threshold in 2006 is $960. Once the individual or family has spent this amount on PBS medicines, subsequent prescriptions for the rest of the calendar year are charged at the concession rate of $4.70.

Data provided to the study team by DoHA show that:

• Among patients identiﬁed as Indigenous (through the VII) and who obtained PBS medicines in 2005, 92% obtained medicines at concessional rates. This compared with 69% of all patients who obtained PBS medicines in that year. • Among patients identiﬁed as Indigenous (VII) and who obtained PBS medicines in 2005, only 5% did so using the PBS Safety Net. This compared with 20% of all patients who obtained PBS medicines in that year.

In other words, access to the PBS Safety Net among Indigenous patients, as identiﬁed through the VII, is markedly lower than among Australians in general. This is consistent with the qualitative research conducted during the present study, which suggested that awareness and use of the Safety Net among Indigenous Australians is low, and therefore that the Safety Net has very limited impact in terms of facilitating Indigenous access to the PBS.

During the study the question was asked why Medicare records could not be used to keep track of Safety Net eligibility, as is the case in relation to the MBS Safety Net. DoHA representatives advised that there were currently some speciﬁc problems regarding the capture of payment for items under the co-payment amount, but that changes to the system were in train.

Recommendation:

31. DoHA should pursue the possibility of PBS Safety Net entitlements being triggered automatically from Medicare records, as with the MBS Safety Net.

68 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 5.5 Medications on discharge from hospital

Provision of medication to patients on discharge from hospital is generally a State/Territory responsibility. Hospitals typically discharge patients with only a few days’ supply of the medications that they now need to take. These are often different (or may look different) from the medication the patient was previously using before admission to hospital.

People consulted over the course of the study identiﬁed this limited dispensing by hospitals as likely to create problems for Indigenous patients from remote areas in particular, because they may not immediately return to their home community and their usual health service provider. Particularly given the cost of purchasing medications, there is a high probability in this situation that the patient will not receive the medications he or she requires32.

DoHA representatives advised that this issue will be addressed as one aspect of negotiations relating to pharmaceutical reforms under the Australian Health Care Agreements.

Recommendation:

32. In the context of current negotiations relating to the Australian Health Care Agreements, DoHA should address the issue of Aboriginal and Torres Strait Islander patients needing larger quantities of medication on discharge from hospital. 5.6 Quality Use of Medicines

5.6.1 General

At every ATSIHS that was visited during this study, the point was made that inadequate or incorrect use of medications among Indigenous Australians represents a major problem.

Poor compliance may mean, in the first instance, failure to get a prescription filled, either promptly or at all. The PBS co-payment was identified as a barrier by 52% of ATSIHSs surveyed, in particular for people who do not qualify for a health care card. Other possible problems or barriers included transport/distance to a pharmacy, and lack of conviction that the prescribed medication was necessary or would help.

Once the patient has the medication, it was reported, he or she may possibly lose it or fail to use it at all, may not complete the full course of treatment, or may use the drugs in a sporadic or inconsistent fashion. Relevant factors here may include mobility, impoverished living conditions or a lack of a regular daily routine, substance abuse or mental health problems, failure to understand the spoken or written instructions, seeing no need to continue with medication once you are feeling better, or alternatively seeing no value in continuing if you do not notice a quick improvement.

32 Some made the point that good discharge planning with Indigenous patients needs to address their means of getting home, physical and ﬁnancial capacity to access medication, care arrangements, follow up directions, and advice regarding unexpected complications or relapse. The view taken by some hospital staff is that the comparative cost of ensuring that a person has access to the prescribed medication (eg the time taken to ask and the cost of a co payment) is signiﬁcantly less than a re-admission into hospital.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 69 Health service providers have responded to such issues in a number of ways, including use of injectable or long-lasting medications where available, use of dose administration aids (eg Webster packs or dosette boxes), encouraging patients to take medications under supervision (eg at the health service), and providing only small quantities of a drug at one time if it is possible for the patient to return frequently to the service.

As noted elsewhere, the S100 arrangements have greatly improved the availability of PBS medicines in remote areas, but they have entailed increased responsibilities for the health workers (nurses or AHWs) on the spot, and some of these workers may lack the expertise or conﬁdence necessary to promote quality use of medicines among their patients.

Conduct of the study indicated that remote area health services vary in the way they are able to approach their role in distributing S100 medications. At the Yirrkala health service in the NT, for example, all medications are checked by two people, while the Katherine West Health Board has employed a Quality Manager to oversee the system and to improve risk management processes. It appeared that various practical problems made arrangements of this type more difﬁcult at other services.

Health services which took part in the ATSIHS survey and which were not covered by the S100 arrangements were asked to indicate any speciﬁc reasons why they believed they should be covered. Around half simply conﬁrmed that they were not located in a remote area and thus not eligible. The remainder gave reasons including the incapacity of Indigenous patients to afford medications and the severity of health problems suffered by Indigenous Australians.

Most of the services surveyed nominated problems or barriers affecting Indigenous Australians’ access to PBS medicines through community pharmacies. These included:

• cost/co-payments (52% of respondents) • issues of comfort/cultural appropriateness (23%) • transport issues (22%) • no pharmacies nearby (19%)

The strategies that health services reported using to help patients get the required medications included:

• providing medicines directly (62%) • meeting the cost of co-payments (48%) • providing transport, going to the pharmacy with or on behalf of the patient, etc (28%)

In relation to over-the-counter (non PBS) medicines, around two-thirds of the services nominated problems faced by Aboriginal or Torres Strait Islander patients. Almost 90% of these referred to cost. Other issues raised were access/distance/transport and lack of culturally appropriate services.

Nearly 80% of the ATSIHSs surveyed said that (Indigenous) patient problems relating to correct use or storage of medicines were either very common (47%) or quite common (32%). Strategies to address such issues included use of dose administration aids, encouraging patients to take medicines under supervision eg at the health service, and outreach or home visits.

70 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 Progress in relation to quality use of medicines by Aboriginal and Torres Strait Islander people emerged as a major priority for many of the individuals and organisations consulted in the course of the study. In particular this was seen as requiring appropriate medication information and training for Aboriginal and Islander Health Workers, who play a key role in ATSIHS patient relationships and communication, whether or not the S100 arrangements apply. As previously noted, the Australian Government’s 2003 review of S100, conducted by Kelaher et al, also focused attention on issues relating to dose administration aids, and it recommended that DoHA should fund the use of dose administration aids in ATSIHSs in the context of S100. Other QUM-related recommendations made as a result of that review included a generic set of procedures and protocols suitable for adaptation to local circumstances; appropriate IT support; funding for information sheets on new and commonly used medications; and introduction of processes for review of errors in the distribution of medications.

It appears that funding earmarked in the new Community Pharmacy Agreement for the training of Indigenous pharmacy assistants could contribute, at least in part, to the provision of training for AHWs.

In the context of the S100 arrangements it is interesting to note that some ATSIHSs have found it possible to negotiate with community pharmacies a level of pharmacy service and support that goes beyond the ‘base’ situation of bulk supply coupled with one or two pharmacist visits a year to the health service. In some instances this reﬂects the willingness of the community pharmacist to engage more closely with the relevant health service; for example, community pharmacists interviewed in Darwin and in Nhulunbuy indicated their interest in establishing closer and more regular contact with relevant health services. Katherine West Health Board has been able to negotiate with its S100 supplier for a fully prescription-based service – that is, for a level of pharmacy service that approximates the standard expected under S85. Similarly, the DHCS in the Northern Territory has evidently had no difﬁculty in retaining community pharmacy interest in its S100 contracts, even though it continues to use a prescription-based system and has increased the level of support services that pharmacies are required to provide.

5.6.2 Home Medicines Review

The Home Medicines Review (HMR) is a mainstream initiative designed to maximise medication beneﬁts to people living in the community. It involves the consumer and his or her GP and community pharmacy working together to ensure that medicines are being stored and used correctly. The HMR involves a visit to the consumer’s home by an appropriately accredited pharmacist (who may or not be associated with the community pharmacy).

While take-up of the HMR in the general community has not been rapid, it is widely regarded as a valuable QUM intervention. However, numbers of those consulted during the present study argued that the HMR was likely to be of limited beneﬁt to Aboriginal and Torres Strait Islander people – especially in remote or isolated areas where there is unlikely to be a local community pharmacist and/or GP available. Even in more populated areas it was argued that Indigenous Australians would not necessarily feel comfortable having a non-Indigenous stranger (the accredited pharmacist) come into their home to discuss possibly sensitive matters.

There were suggestions made for development of a more ‘Indigenous-friendly’ HMR model. For example, pharmacist visits to a group of people in a given community could possibly be undertaken, by analogy with the arrangements that currently apply to medication reviews in a residential care facility (the RMMR). The Pharmacy Guild of Australian has suggested that referrals for HMRs could be made by ATSIHS nurses or Health Workers, and that some reviews could be conducted at the health service with an AHW present; in some circumstances (eg in very isolated locations) an AHW could conduct the patient interview component of the HMR. The Guild also suggests that ATSIHSs should be entitled to use the HMR item regardless of their eligibility to access Medicare items.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 71 Recommendation:

33. DoHA should consider options for providing medication review services better suited to the needs of Aboriginal and Torres Strait Islander people in varying locations. 5.7 Access to a wider range of pharmacy support

Particularly in rural or remote areas, the study team was told that it was unnecessarily restrictive for ATSIHSs to have to rely on community pharmacy assistance provided through the S100 arrangements and the related pharmacy support allowance. It was argued that local hospital pharmacists, for example, might be in at least as good a position as a community pharmacy to provide staff training and other forms of support. While the current support allowance is funded through the Fourth Community Pharmacy Agreement, it was argued that the Australian Government should provide some support for health services which believe they can obtain more appropriate or convenient assistance from elsewhere in the pharmacy sector.

Other stakeholder perspectives on this issue included the view that increased roles for hospital pharmacists should be funded from State/Territory sources. The Pharmacy Guild of Australia emphasised that any appropriately qualiﬁed pharmacist could contract with a community pharmacy to provide ATSIHS support services under the S100 arrangements.

5.8 Medications covered by the PBS

A number of those consulted during the study expressed concern that issues speciﬁc to Indigenous health were not adequately taken into account in the process of adding medications to, or removing them from, the PBS. DoHA, however, advised the study team that steps have already been taken to address this issue, through establishment of a specialist panel to advise on the impact of changes to the scope of the PBS in relation to Indigenous Australians. The Advisory Panel provides expert advice, as required, to DoHA and to the Pharmaceutical Beneﬁts Advisory Committee.

5.9 Possible initiatives to improve access to the PBS

Conduct of this study identiﬁed a number of different proposals or suggestions for improving Aboriginal and Torres Strait Islander access to the PBS. Some of these related to reﬁnement of the S100 arrangements that currently apply to ATSIHSs in remote areas, and others related to improving access for Indigenous Australians elsewhere. It was noted that the Fourth Community Pharmacy Agreement (between the Australian Government and the Pharmacy Guild of Australia) earmarks substantial funds for initiatives relating to Indigenous access. The Agreement provides some $27 million, indicatively allocated, for four main types of initiative relating to Indigenous health, as follows:

• greatly increased funding (from $2 million to over $13 million) for the Pharmacy Support Allowance • some $10 million to improve access to community pharmacy services in non-remote areas • $3 million for funding of undergraduate pharmacy scholarships • $0.6 million for an Indigenous pharmacy assistant scheme.

To assist the Minister for Health and Ageing in making decisions about the use of these funds, a Professional Programs and Services Advisory Committee has been set up, with ﬁve members appointed by the Guild and ﬁve by the Minister.

72 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 As noted in section 5.2 of the report, introduction of the S100 scheme has been widely welcomed in the Indigenous health sector. It increases remote area access to medications and also relieves some ﬁnancial pressures on health services which previously paid for medications; research has conﬁrmed its value in improving access to medicines in remote locations. However, in itself S100 does little to advance quality use of medicines, which remains an area of major concern in Indigenous health. Section 100 also imposes additional roles and responsibilities on nurses and AHWs working in remote-area health services.

Many of those consulted during this study wished to see the S100 scheme expanded in various ways – in particular, extended to ATSIHSs in regional and metropolitan areas. In these settings the aim would be to address cost barriers rather than just physical access. (As noted in section 5.3.2, 50% of pharmacists with higher numbers of Indigenous customers who took part in the pharmacy survey identiﬁed cost as a major barrier.) There were also some observers, however, who argued that the aim in urban areas should be to achieve substantially improved access without importing the limitations of the S100 arrangements as earlier described.

Thus there were two key issues that emerged in relation to PBS access: ﬁrst the need to improve the S100 arrangements in remote areas, especially from a QUM perspective; and second the need to address barriers (especially cost) in non-remote areas, whether through use of S100 or otherwise.

Proposals which were raised in the course of the study included the following:

• improvement of the S100 arrangements in remote areas by ensuring more substantial QUM input from community pharmacists or others • a NACCHO/AMA/Pharmacy Guild proposal (2004) for extension of S100 arrangements to ATSIHSs in all areas, plus capacity for health services to write prescriptions that can be ﬁlled at a community pharmacy without any co-payment, payment to community pharmacists of the full dispensing fee per item, and appropriate funding to address QUM needs • extension of S100 provisions to non-remote areas but with certain modiﬁcations (eg clearly limited to Indigenous ATSIHS patients) • provision of funding to ATSIHSs to cover the cost of the co-payments that they currently meet on behalf of patients • introduction of a general scheme to cover co-payments for ATSIHS patients, or for those with a health care card, etc • coverage of urban ATSIHSs’ costs of making co-payments on behalf of patients visiting from rural or remote areas • introduction of a system for subsidising the purchase by ATSIHSs of non PBS (over the counter) items • funding for the use of dose administration aids in association with the S100 scheme • introduction of other QUM initiatives, such as systematic arrangements to provide medication management training for AHWs and nurses • development of a model of medication review that is appropriate for Indigenous communities – possibly by analogy with the RMMR

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 73 • providing ATSIHSs with ﬂexible funding for pharmaceutical purposes, to be used as seems most appropriate in various situations – eg to purchase additional training, professional support and the like, or possibly to employ a pharmacist33 • support for wider take-up of the possibility of providing on-site pharmacy services at ATSIHSs – eg along the lines of the current service at Congress in Alice Springs (which makes use of the S100 arrangements).

The study team believes that in remote areas the S100 arrangements should clearly be retained, but substantially strengthened from a QUM viewpoint – eg through provision of systematic medication training for AHWs and nurses, and through an expanded professional support role for the community pharmacist. (The funding earmarked in the Fourth Community Pharmacy Agreement appears to offer a means of providing the latter.)

The cost of medications was clearly identified as a significant barrier to PBS access in non-remote areas and, as indicated above, there are various ways in which this could be tackled. Other identified barriers include cultural or communication issues (such as some Aboriginal or Torres Strait Islander people not feeling comfortable or confident in using community pharmacies) and problems relating to distance to a pharmacy and lack of transport. Following on from the achievements of the S100 arrangements in remote areas, it is important for the Australian Government to implement strategies to greatly improve Indigenous access to and quality use of medications in other locations. These strategies will need to address the range of problems that currently restrict effective access – including the cost of the co-payment for people who are not entitled to a health care card.

Independent of options relating directly to the PBS, there would clearly be beneﬁt in assisting ATSIHSs with funding towards the cost of purchasing non-PBS/over-the-counter drugs and, as recommended in the 2003 report prepared by Kelaher et al, for the cost of dose administration aids.

As previously noted, other desirable initiatives would include the development of a scheme designed to achieve objectives similar to those of the Home Medicines Review, but in a way better calculated to meet the needs of Aboriginal and Torres Strait Islander people.

Recommendations:

34. The S100 arrangements operating in remote areas should be retained, but strengthened from a QUM perspective by measures designed to ensure substantially increased professional support from community pharmacies and by delivery of appropriate training for AHWs and nurses. Funds available under the Fourth Community Pharmacy Agreement could be used to support such improvements. 35. DoHA should review progress relating to other recommendations that were made in the Australian Government’s evaluation of the S100 arrangements in 2003, and should report on this by the end of 2006. 36. In consultation with relevant stakeholders, DoHA should develop speciﬁc strategies to substantially improve Indigenous Australians’ access to the PBS in areas which do not beneﬁt from the current S100 arrangements. These strategies need to address cost barriers for both holders and non-holders of health care cards, and also cultural and physical/transport barriers. 37. DoHA should develop community education and other strategies (such as funding towards the cost of dose administration aids) to address the problems of suboptimal use of medication among Indigenous Australians.

33 Ideally, some rural/remote health services would employ their own pharmacist rather than simply relying on occasional services provided by their S100 contractor.

74 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 5.10 Summary

Arrangements under S100 of the National Health Act 1953 have greatly improved access to PBS medications for Aboriginal and Torres Strait Islander people living in remote areas, and this scheme represents one of the major advances of recent years. It is apparent, however, that access to PBS medications remains a major concern in areas not covered by the S100 arrangements, and that here the cost of medications is the greatest single barrier. In particular, the study team was consistently told that the cost of PBS medicines was a major problem for many Indigenous families and individuals who do not qualify for a health care concession card.

Two key issues emerged from the study in relation to access to the PBS – ﬁrst, the need to strengthen the existing S100 arrangements in remote areas by appropriate initiatives to improve Quality Use of Medicines; and, second, to address cost and other barriers in non-remote areas. Key QUM measures in remote areas are likely to involve medication training for AHWs and nurses, and increased advice and support to ATSIHSs from community pharmacists supplying medications under S100.

Both qualitative research and data provided by OATSIH show that few Indigenous Australians obtain the beneﬁt of the PBS Safety Net arrangements.

Correct storage and use of medications is a signiﬁcant and ongoing problem, and there is a need to address this through community education and other measures. It would be desirable, for example, to develop an alternative to the Home Medicines Review that would better meet the needs of Indigenous Australians.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 75 Key References

Australian Institute of Health and Welfare (AIHW) (2001). Expenditures on health services for Aboriginal and Torres Strait Islander peoples 1998–99, AIHW cat. no. IHW 7. Canberra: AIHW and Commonwealth Department of Health and Aged Care.

Australian Institute of Health and Welfare (AIHW) (2003) Health Expenditure in Australia 2001-02, Health Expenditure Series No 17, AIHW Cat No HWE 24, AIHW, Canberra

Australian of Health and Welfare (AIHW). (2005) Health Expenditure in Australia 2003–04. Canberra:. (Health and Welfare Expenditure Series No. 25), AIHW Cat. No. HWE 32, AIHW, Canberra

Australian Medical Workforce Advisory Committee (AMWAC) (2005) The General Practice Workforce in Australia: Supply and Requirements to 2013, AMWAC Report 2005.2, Sydney

C Burton (2004) Working in Partnership – ‘Shaping’ Indigenous Hearing Services to Meet Community Needs’, conference paper presented at the National Services for Australian Rural and Remote Allied Health (SARRAH) Conference, 26-28 August 2004, Alice Springs

M Clarke (2004) Report of Findings from a National Consultation Process: Indigenous Access to Medicare, Australian Government, Canberra

S Couzos & S Davis (2005) ‘Inequities in Aboriginal Health: Access to the Asthma 3+ Visit Plan’, Australian Family Physician, vol 34, no 10, pp837-840

Cultural Partners Australia (2004) Aboriginal and Torres Strait Islander Information Campaign Evaluation and Materials Review, draft report prepared on behalf of the Health Insurance Commission, Canberra

DoHA (2002) Report on Commonwealth Funded Hearing Services to Aboriginal and Torres Strait Islander Peoples: Strategies for Future Action, Australian Government, Canberra

DoHA (2005) 2004-05 Annual Report from the Department of Health and Ageing, DoHA, Canberra

M Kelaher, D Dunt, D Thomas & I Anderson (2005) ‘Comparison of the Uptake of Health Assessment Items for Aboriginal and Torres Strait Islander People and Other Australians’, Australia and New Zealand Health Policy, Vol 2, Issue 21

M Kelaher, D Taylor-Thomson, N Harrison, L O’Donoghue, D Dunt, T Barnes & I Anderson (2003) Evaluation of PBS Medicines Supply Arrangements for Remote Area Aboriginal Health Services under S100 of the National Health Act, Cooperative Research Centre for Aboriginal Health, University of Melbourne

NACCHO (2001) Response from NACCHO: Report on the Delivery of Hearing Health Services to Aboriginal and Torres Strait Islander Peoples, NACCHO Advisory Group Aboriginal and Islander Hearing Health Project, , NACCHO, Canberra

NACCHO, Pharmacy Guild of Australia & Australian Medical Association (2004) Position Paper on Improving Access to PBS Medications for Aboriginal Peoples and Torres Strait Islanders, NACCHO, Canberra

76 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 NACCHO & Medicare Australia (2005) Barriers and Enablers to Improving Access for ACCHS’ to Medicare Australia Programs, Draft Brief Report of Medicare Australia – Indigenous Access Program and NACCHO Members, Canberra

K Panaretto (2005) Medicare Modelling Project, research report on behalf of the Queensland Aboriginal and Islander Health Council, Brisbane

Wendy Bloom & Associates (2001) Market Research to Inform a Communication Campaign for the Improved Monitoring of Entitlements (IME) Measure for Indigenous Australians, report prepared for the Commonwealth Department of Health and Aged Care, Public Affairs Branch, Canberra

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 77 Case Studies

1. Darwin

2. Nhulunbuy

3. Port Augusta

4. Halls Creek

5. Perth

6. Echuca

7. Sydney

8. Wagga Wagga

9. Moree

10. Townsville

11. Torres Strait and Peninsula

12. Brisbane

78 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 Darwin, Northern Territory - Urban

1 Background

Darwin, capital city of the Northern Territory, had a population of 109,498 people at the time of the 2001 census. Some 9% of these (9,497 people) were identiﬁed as Indigenous – proportionately the largest Indigenous population of any Australian city. There is signiﬁcant movement of Aboriginal people between Darwin and surrounding rural and remote areas.

Darwin is an important port, for example for export of minerals and live sheep and cattle. It also has a signiﬁcant tourism industry and is the site of a large army base. The city’s health services include Royal Darwin Hospital (located some distance from the city centre) and the Darwin Private Hospital. There are two Aboriginal health services, Danila Dilba and the smaller Bagot Community Health Centre.

For Medicare and PBS-related purposes Darwin is generally categorised, like other capital cities, as a highly accessible location. In practice, as a number of stakeholders saw it, Darwin is more like a large regional town (something like Cairns, for example). They felt that Darwin’s RRMA 1 classiﬁcation – the same as Sydney and Melbourne, for example – has had some ‘unfortunate’ results in terms of various entitlements and concessions. However, the study team heard that Darwin has now received ‘area of consideration’ status which provides improved access to some GP programs and higher Medicare rebates.

2. Medicare Enrolment and Claims (Medicare Regional Ofﬁce)

There is a total team of 12 people in the Northern Territory Regional Ofﬁce of Medicare, including the MLO; three members of staff are Indigenous. Indigenous health is a major focus of this Ofﬁce, and all 12 staff-members are appropriately trained and experienced in dealing with issues relating to Indigenous clients. For example, all are equipped to staff the special Indigenous 1800 enquiry line.

Most calls to the Regional Ofﬁce are from health services; ‘only a handful’ come from individual consumers.

Enrolment

Staff at the MLO ofﬁce in Darwin were conﬁdent that ‘98% or more’ of the Territory’s Indigenous population is now enrolled in Medicare. Medicare Australia and the NT Department of Health and Community Services (DHCS) have worked in close co-operation to achieve this level of enrolment. Together with relevant DHCS staff, the MLO plays an active role in helping keep population and enrolment lists up to date for all ATSIHSs in the Territory. Attention to the accuracy and completeness of these records ensures ‘continuity in eligibility’. Simpler means of proving identity has been one factor in achieving greatly increased enrolment levels.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 79 In the Northern Territory Medicare has set up a system designed to deal with the fact that a baby may not be named for up to a year or so after birth. Each ‘newborn’ therefore gets a Medicare number, and his or her card is sent to the relevant health service so that there need be no delay in submitting relevant Medicare claims. MLO staff visit Royal Darwin Hospital twice a week to collect all the necessary information. Once the baby is named, the name can be entered on the enrolment form and the details sent by the health service to the MLO ofﬁce. This system was said to be culturally appropriate in traditional settings, and to work smoothly34.

In remote areas, new or replacement Medicare cards are often sent to the relevant health service, since the individual may not have a clear address etc. In some cases the clinic will then continue to hold the card on the person’s behalf.

It was said that in the Northern Territory the DHCS generally has a preference for individual rather than family Medicare cards.

Claims

The MLO indicated that over time she and her support staff have gradually worked to build closer relationships with Aboriginal health services (both Territory-run and community controlled), and one result has been a significant improvement in the efficiency and accuracy of Medicare claims. However, under-claiming by ATSIHSs still remains a problem, in the Territory as elsewhere. Interviews at the MLO office in Darwin highlighted the need for additional outreach work with health service providers.

Likewise some other stakeholders, while saying that Medicare Australia has done ‘terrific’ work in the Northern Territory, emphasised that staff turnover in ATSIHSs made close and ongoing liaison with such services essential. A number of health services, it was said, had no single or stable staff position responsible for dealing with Medicare matters; in some cases GPs finished up having to take on relevant administrative responsibilities. The process of submitting claims could still be very disorganised in health services which have no dedicated Medicare worker. Services may find it difficult to judge what level of claims they should expect to make; levels of claims by mainstream service providers do not provide a meaningful benchmark for ATSIHSs. For one thing, the burden of chronic disease in Indigenous communities creates a different context for the use of Medicare. Further, Indigenous patients are much more likely not to seek health care until they feel seriously ill.

In Katherine West, it was reported, obligations relating to Medicare claiming were written into the health service’s contracts with GPs.

In general Medicare claims from ATSIHSs are submitted manually to the Regional Office, where they are checked for completeness as well as for any specific errors. Where a claim needs some correction this can be done in the Regional Office; ‘This way we can fix it all as it occurs’; ‘It’s a fantastic system’. There are few such claims which need to be rejected. However, the Regional Office has no involvement with claims submitted electronically, and staff were uncertain whether there are quality control problems with those.

One form for multiple claims is widely used in the Northern Territory. The DHCS has developed a simpliﬁed version of the Medicare Toolkit, and this was said to have been useful.

Workforce issues were identiﬁed as an enormous problem in Indigenous health in the Northern Territory. GP coverage outside the urban areas is ‘very patchy’, and specialists are ‘just not there’.

34 However, discussions in Queensland indicated that some confusion can arise when a family with an unnamed newborn moves into that State from the NT.

80 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 Scope of Medicare

Numbers of those who were interviewed in Darwin, and elsewhere in the Northern Territory, identiﬁed what they saw as problems or limitations in the applicability of Medicare in to situations encountered in the Territory. For example, it was often noted that a telephone consultation, involving a nurse or AHW working with the patient and the GP participating by telephone from elsewhere, is a common mode of service delivery in isolated areas, but is still not covered by Medicare.

More generally, work with a single patient at an AMS may involve work on multiple issues by various members of the health care team, but in general the work can only be claimed as a single GP consultation. While ‘The AHW and the nurse can do just about everything’ that an adult health check requires, no Medicare rebate can be claimed without a doctor’s involvement. Yet ‘you just haven’t got enough doctors out there’; registered AHWs are often the only health professionals in remotely located health services. The wound management by AHWs that can be claimed, said one experienced worker, is ‘the easy bit’ of the numerous and demanding tasks that AHWs have to undertake every day.

3. Danila Dilba Health Service

The Danila Dilba Health Service is located close to the Darwin city centre. Among other things this means that it is a long way from where many of its clients and potential clients live; accordingly it provides transport services to get people to and from the health service. It also provides a mobile service involving a nurse and an AHW, that operates daily and visits a number of camps and communities in the Darwin area. Since a GP is involved only on a part-time basis if at all, the work of the mobile service generates little Medicare income (it does receive some Territory Government funding).

Apart from these core primary health care services, other Danila Dilba services include a women’s health unit, men’s health centre, specialist ear health and eye health services, and an emotional and social wellbeing centre.

Danila Dilba reports having about 10,000 active patient records – that is, records for people who have used its services in the past three years. Its medical staff include ten full-time AHWs, two casual AHWs, and one nurse; an average of two GPs are on duty at any one time. Total funding for Danila Dilba’s clinical services is over $2 million per annum. As one observer saw it, it is ‘absolute missionaries’ who work for Danila Dilba at present; ‘The money just isn’t there for the size of the task’, and ‘the situation can’t be sustained’. Staff turnover was described as high.

Most ‘traditional’ Aboriginal people, it was suggested, seek health care from either Danila Dilba or the Bagot health service. ‘Urbanised’ Aboriginal people may be happy to use a mainstream GP who bulk-bills; however the number of bulk-billing practices has declined and there are currently few bulk-billing GPs in Darwin.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 81 Several staff expressed the view that the Medicare system does not reﬂect Danila Dilba’s health care model or its holistic approach. Danila Dilba services are focussed on its AHWs, who carry out a wide range of tasks without a GP necessarily having any involvement; the GP may well be ‘the last port of call’35. Medicare, however, gives centre stage to the doctor. While AHWs ‘are basically the same as a nurse here’ at Danila Dilba, only very little that the AHWs do can be claimed against Medicare. AHWs do extensive work in preventive health, for example, that is not claimable. The consequence is that supporting the AHWs to do their job involves a quite different approach from maximising Medicare income.

Use of Medicare

In the 2004-05 ﬁnancial year Danila Dilba claimed around $600,000 in Medicare rebates; in the current year, it was said, this ﬁgure will go down because Danila Dilba has had the services of fewer GPs.

Medicare income is important to Danila Dilba; for example the 2004-05 Annual Report indicated that income from Medicare helps the service to provide medications free to patients (see below). But some staff stated that claiming Medicare rebates was a cumbersome and time-consuming affair (‘so many processes, so much gobbledegook’). They believed that pooled funding at an appropriate level was what was required to provide health care on a equitable basis for Indigenous Australians. A senior staff member at Danila Dilba thought it ‘appalling’ that Medicare, a mainstream private practice model, should be applied without signiﬁcant modiﬁcation to an Aboriginal community controlled health service. Accreditation for the purposes of PIP, for example, requires conformity to a set of standards developed in an entirely different context: ‘What a ludicrous way of trying to do it’.

Some Danila Dilba staff believe that it is entitled to a higher level of Medicare income than it succeeds in claiming. The doctors ‘try really hard’, it was said, but they are under a lot of pressure and the system is not simple. PIP items, for example, are not easy to claim, though Danila Dilba is an accredited practice. PIP was seen as less significant, however, than use of EPC items such as care plans and adult health checks. Services such as adult health checks reflect the type of work that Danila Dilba has done in the past, and staff say that items like this are both good for patients and also financially worthwhile.

Danila Dilba has an energetic Medicare officer, but his job can be complicated by GP shortages and the need to make use of locums. Medicare claims are submitted electronically. HIC online was said to work well for Danila Dilba, and is much simpler than the previous manual system. Payments are also received much faster than before (3 days instead of 3 weeks). If a claim is rejected it is usually a simple matter to fix the problem. Danila Dilba staff also reported finding it fairly straightforward to chase up correct Medicare numbers and related information when required.

The Medicare ofﬁcer has recently begun providing feedback on levels of claims among the service’s doctors, with the aim of encouraging more systematic claiming.

Danila Dilba AHWs have provider numbers which enable them to claim for the services that they provide ancillary to care plans. It was expected that from early in 2006 Danila Dilba AHWs would be able to claim for wound dressings and immunisations, and that this would generate some worthwhile additional income.

35 Danila Dilba Health Service’s Annual Report 2004-2005, for example, states on p1 that the service ‘operates an “Aboriginal Health Worker First” policy which means that Aboriginal Health Workers are the ﬁrst and sometimes the only point of contact for clients’. AHWs are described as ‘the ﬁrst line’ in providing health services to the community.

82 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 Medications

Danila Dilba maintains a substantial internal stock of medications, which it purchases from Royal Darwin Hospital at a cost of around $120,000 a year. Danila Dilba also covers the cost of co-payments for patients’ prescriptions dispensed by two Darwin pharmacies (one at nearby Stuart Park and one at outer-suburban Palmerston).

One of Danila Dilba’s AHWs is responsible for managing its pharmacy room. Drugs are ordered on a monthly basis from Royal Darwin, and the AHW restocks the pharmacy daily. She liaises with the two community pharmacies which prepare Webster packs for Danila Dilba. Medical staff are authorised to take medications from the pharmacy, label them and give them to a patient. There are limits, however, on the drugs that AHWs are authorised to distribute. Staff are required to enter details of all the medications they use, and in general this information is recorded on computer as well as in written form. Where necessary an AHW reﬁlls dosette boxes.

Danila Dilba makes co-payments not just for prescriptions dispensed at the concession rate, but in some cases for full-price prescriptions that patients just cannot afford. This practice reﬂects the view that many patients would not use prescribed medications if they were not provided free. Danila Dilba’s total expenditure on medication is around $400,000 per years – ‘a real investment in people’s health’, but a heavy ﬁnancial burden36. It was argued that removal of this co-payment expense, eg through access to the S100 arrangements, would make a major difference to the level of service that Danila Dilba can provide. Outside observers commented that Danila Dilba had had to cut back on other important services in order to continue making the PBS co-payments.

Ineligibility for the S100 arrangements was seen by a number of observers as anomalous. ‘If they moved Danila Dilba to Knuckey’s Lagoon (that is, just outside Darwin) they could claim Section 100’, commented one senior health bureaucrat. Further, Danila Dilba was called on to provide services for many Aboriginal people who visited Darwin from rural or remote locations where they were eligible for free medications under S100.

It was reported that Danila Dilba has been able to initiate a few Home Medicine Reviews.

4. Bagot Community Health Centre

The Bagot Community Health Centre is located at Ludmilla, an inner suburb of Darwin, and operates under the aegis of Bagot Community Council Inc. It primarily services three local communities of Indigenous Australians – Bagot itself, Kalaluk and Minmarama Park. It has around 500 patients on its books from these communities, but also reports seeing signiﬁcant numbers of other Darwin residents and also people visiting Darwin from communities elsewhere.

The medical staff at Bagot consists of two registered nurses and three full-time and some casual AHWs (one AHW serves as a Diabetic Educator). There are three 4-hour sessions each week conducted by visiting GPs.

Staff interviewed at Bagot Health Centre believed that very few people in the communities that they were familiar with would make any use of GPs; if not using Bagot, the other services likely to be relevant were Danila Dilba or outpatient services at Royal Darwin Hospital.

36 An outside observer suggested that this expenditure probably saved the Government a much larger sum in hospitalisation and other treatment that would otherwise be needed.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 83 Bagot staff say that their patients have reasonably good access to a range of medical specialists at Royal Darwin Hospital and the Darwin Private Hospital – though there can be long waits for appointments. Psychiatric services was one area where little specialist care was available. Pathology services are provided by Western’s Diagnostic Pathology in Darwin – usually at no cost to Bagot or the patient.

Bagot Community Health Centre has only begun to claim Medicare rebates over the last few months. The Darwin MLO ofﬁce has been ‘extremely helpful’ to Bagot in providing relevant information, obtaining the necessary provider numbers and helping to get appropriate systems into place: ‘We’re really happy with the relationship’. An MLO representative was expected to visit the centre in the near future to provide in-service training for staff.

Staff interviewed at Bagot regarded income from Medicare rebates as very important in terms of the centre’s capacity to provide appropriate services, and were keen to use the Medicare system as effectively as possible – for example through building up EPC services such as health assessments and care plans. As well as claiming for GP consultations, Bagot reports claiming rebates for immunisation and other services provided by its nurses and AHWs. As staff saw it, however, Medicare’s focus on the role of the GP limited its usefulness to the health centre. Having to have a (visiting) GP sign off every Medicare claim did not reﬂect the realities of the health care services provided by the centre, and valuable GP time was taken up with paperwork.

Medicare claims are made manually, which means that the Darwin MLO ofﬁce can check them.

Medications

Being located in an urban area, Bagot Community Health Centre is not covered by the S100 PBS arrangements. For patients from within Bagot’s own three communities, the visiting GPs write prescriptions which Bagot staff take to be dispensed at a nearby community pharmacy; they then deliver the medications to patients either at the health centre or at home. Bagot takes responsibility for the co-payments on many of these prescriptions. If patients from elsewhere in Darwin, however, receive a prescription from a Bagot GP, it is their own responsibility to get it dispensed. As at Danila Dilba, difﬁculties arise with patients who are visiting Darwin from remote areas where they are accustomed to receiving free mediations under the S100 arrangements. In some cases the home health service may have an arrangement for supply through a particular Darwin pharmacy, but in other cases Bagot takes responsibility for making the co-payments on behalf of these out-of-town patients. Study of records for the period November 2003–October 2004 showed over 2000 consultations at Bagot involving patients classiﬁed as ‘transient’ – many of them from remote areas37.

Bagot spends around $18,000 a year on these PBS co-payments. The Centre purchases non-S100 medications (for example pain relief tablets, Calamine lotion) wherever it can ﬁnd them most cheaply – including supermarkets in some cases.

37 See report prepared for Bagot Community Health Clinic by Rollo Manning of Mirrinji Consultancy, 20 November 2004.

84 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 5. Mainstream Services

In the view of a number of Darwin stakeholders, most local Aboriginal people seek health care services either from Danila Dilba, Bagot, Royal Darwin Hospital, or not at all. That is, relatively few Aboriginal people were believed to use the services of private GPs – especially since so few of these now bulk-bill. The low incidence of bulk-billing was identiﬁed as one signiﬁcant barrier in terms of access to Medicare services38.

It was thought that private GPs in Darwin have to date made relatively little use of EPC items such as the Health Adult Check.

Royal Darwin Hospital

Some Indigenous Australians seek treatment at Accident and Emergency at Royal Darwin Hospital, but the very long wait for attention can be a disincentive.

Over half the inpatients at Royal Darwin Hospital are Indigenous. Given cultural and English literacy issues and the fact that many people live a long way from Darwin, the hospital pharmacists regarded Aboriginal patients as being at particular risk in relation to medications after discharge from hospital. On discharge the hospital will normally provide the patient with a week’s supply of drugs, which may be different (or may look different) from those he or she was using before admission. It may be two or three weeks, however, before the patient reaches the home community, and in the meantime there is a high risk of confusion and non-compliance, and continuity of care is lost. One way of alleviating these problems, it was suggested, was for the hospital to be able to use the S100 arrangements in some way to cover the dispensing of a month’s supply of drugs on discharge, for the patients of remote area health services.

The point was made that mainstream health services can appear threatening to Aboriginal people. Royal Darwin Hospital itself, for example, is an air-conditioned 8-storey structure that may well seem strange and unsympathetic to people from rural or remote locations. Further, all communication at the hospital is in English – which may be an Indigenous patient’s third language.

6. Medications

In relation to Territory-run clinics, the Northern Territory DHCS originally set up S100 contracts which required the relevant community pharmacy to visit the health service at six-monthly intervals, and to provide information or advice by telephone as necessary. It also retained a prescription-based model. In its most recent tender process DHCS has sought to spell out in more detail the pharmacist’s obligations to provide advice and support. Packing of dose administration aids will now be the responsibility of the pharmacy, not staff at the health service.

38 Of several Aboriginal people in senior positions who were interviewed in Darwin, only one reported having a private GP; the remainder typically used an AMS. Several people emphasised that there were ‘not very many GPs in Darwin at all’ who bulk bill.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 85 As previously noted, a major issue in Darwin was the fact that the two ATSIHSs in the city – Danila Dilba and Bagot – both see many patients who have come to Darwin from remote areas. In their home communities these people are entitled to receive free medications under the S100 arrangements, but this does not apply when they attend a health centre in town. The nett result is that the Darwin clinics have to ﬁnd money to make the co-payments for the medication that such patients require. This was described by (GP organisation) as ‘a real anomaly’ since ‘they service a similar population’ to health centres in remote areas. Making these co-payments, said one senior Commonwealth representative, ‘costs Danila Dilba a fortune’. However, ‘You’ll ﬁnd scripts in the rubbish bin’ if Danila Dilba ceases to cover the co-payment.

Apart from the cost of medications, long distances and limited public transport in Darwin were said to add to people’s difﬁculties in getting prescriptions dispensed by a community pharmacy.

A community pharmacy

Members of the study team discussed medication issues with a Darwin community pharmacist who provides S100 services to the Wurli Wurlinjang Health Service in Katherine, and who also dispenses most of the prescriptions written at Danila Dilba (prescriptions for which Danila Dilba makes the co-payment).

In relation to the S100 arrangements, this pharmacy seeks to offer more frequent visits and a greater contribution to staff training and support than is ofﬁcially required. Nevertheless the pharmacist who was consulted expressed concern at the absence of dispensing records, lack of advice at point of dispensing, inadequate labelling and the lack of control that he observed over who received what medications. The quality of the system was thus, in his view, highly questionable; it was a system that would not be considered acceptable in the mainstream.

On the other hand, Danila Dilba patients, without access to the S100 arrangements but with their co-payments covered, received the same kind of pharmacy service as the rest of the Darwin community, with appropriate labelling, reliable records kept, and information and advice offered by the pharmacist as appropriate. Thus the full dispensing fee payable in relation to prescriptions from Danila Dilba was said to buy a much superior pharmacy service.

It was argued that the QUM elements of the S100 arrangements needed to be substantially strengthened; given that the Australian Government has acknowledged that PBS expenditure per head for Indigenous Australians is only around one-third of the expenditure for other Australians, there could hardly be any justiﬁcation for the Government’s failing to spend more to improve medication services.

The ATSIHSs pay the pharmacy additional fees for packing dose administration aids for selected patients. The pharmacist regarded bubble packs as particularly good for use in remote communities – ready-packed on arrival, sealed, simple to use. Dosette boxes, by comparison, were not child-proof or water-proof and could also be affected by sand, insects and the like.

Problems often arose with the names recorded on Medicare cards and/or concession cards; for example a customer may be called XY in the pharmacy’s Medicare-based records, but XYZ on her health care card. Enquiries or requests for assistance with card numbers, patient identity and the like are generally directed either to the general Medicare information line or the special Indigenous service. The pharmacy tries to ensure that Danila Dilba, which makes most of the co-payments, gets the beneﬁt of the concessions that its patients are entitled to.

86 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 The pharmacy has also done some work on medication education with Danila Dilba AHWs, including the pharmacy worker. A Memorandum of Understanding between Danila Dilba and the pharmacy is being developed.

Even with the health service picking up the co-payment, there were some prescriptions written at Danila Dilba which were never presented for dispensing. This was thought to reﬂect a range of factors including, for example, patients not appreciating the importance of taking the full course of certain medications.

7. Community perspectives

Conduct of one of the Darwin community discussion groups, involving mostly older people from outer suburbs, highlighted a lack of knowledge and confusion about the PBS Safety Net provisions and various other aspects of PBS or Medicare. Two people in a second discussion group, however, were getting the beneﬁt of the PBS Safety Net.

Other issues that emerged in discussion with community members included the following:

The decline in the number of bulk-billing GPs in Darwin has led to some Aboriginal people starting to go to Danila Dilba or Bagot instead. The fact that medications are provided free to Danila Dilba and some Bagot clients is another incentive, together with the availability of transport services, a culturally appropriate setting and welcoming and helpful staff, the availability of both male and female doctors and of special clinics for men and for women (no appointment required).

Introduction of an appointments system for general health services at Danila Dilba was said to have created problems for transient people or ‘long grassers’ in particular.

Along with the cost of medications, inadequate public transport was another factor limiting access to community pharmacies.

Patients discharged from hospital with only a few days’ supply of drugs sometimes fail to understand they needed to continue with the treatment.

There were said to be few health resources available for people with limited English. Information and instructions relating to pharmaceuticals, for example, were invariably in English. (The Webster pack was a good example of effective non-verbal communication.)

While the need for a Medicare card is well understood in Darwin, people have to manage too many separate cards, eg for Centrelink, the National Diabetes Service Scheme, health care card, seniors’ card and the like. Combining several cards into one would make things simpler.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 87 Nhulunbuy, Northern Territory – Remote

1. Background

Nhulunbuy is a small town located at the north-eastern tip of the Gove Peninsula, about 1,000 km east of Darwin. It was established in 1971 to service a large bauxite mining operation managed by the mining company Nabalco. Most of Nhulunbuy’s inhabitants (3,500 people at the time of the 2001 census) are non-Indigenous employees of or contractors to the bauxite mining operation.

As the only town of any size in East Arnhem Land, Nhulunbuy functions as the main service and supply centre for the region. There are daily ﬂights between Nhulunbuy and Darwin and between Nhulunbuy and Cairns; road links to Nhulunbuy, however, are often ﬂooded during the wet season (December–April).

Although the Indigenous population of Nhulunbuy itself is relatively small, there are numbers of Aboriginal communities and homelands in the region, with residents from diverse clans and language groups. These include Galiwinku (Elcho Island, with a population of nearly 2,000 people), Gapuwiyak, Numbulwar and Maningrida. Two Aboriginal communities located close to Nhulunbuy are Yirrkala (some 14 km south-east, with a resident population of around 800 people) and Marngarr (some 10 km from Nhulunbuy, with a population of around 170).

Nhulunbuy has three main providers of health services – a General Practitioner, the 30-bed Gove Hospital, and an Aboriginal Community Controlled Health Service (Miwatj Health). Around 80% of Gove Hospital admissions are reportedly of Aboriginal patients, from the town and surrounding area. There are no resident specialists in Nhulunbuy, but specialists from Darwin (for example paediatrician, eye specialist, cardiac specialist) visit to conduct clinics at the Hospital.

There are currently seven Aboriginal health services in East Arnhem Land that are run by the Northern Territory Government and staffed by Territory-employed doctors. In general the Medicare income generated by these doctors is used to fund administrative support services within the health services. There are two other Territory-run health services where medical services are provided by a doctor employed by Miwatj, and there are also several community-controlled health centres. There is continuing difficulty in filling available GP/Medical Officer positions in remote-area clinics of this kind. Around one position in five is said to be unfilled, while there are some remote-areas positions that have never been filled.

88 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 2. Miwatj Health Aboriginal Service

2.1 Nature of the service

At the time of the 1997 study there was no Aboriginal Health Service operating in Nhulunbuy. However the Miwatj clinic was established shortly thereafter, and now provides primary health care for most local Aboriginal people, as well as outreach services to a number of other communities. Miwatj workers estimated the total Aboriginal population of their region at around 8,000 people, and reported that at the Nhulunbuy clinic they see patients from ‘all over’. Because of high demands on the only General Practice in Nhulunbuy, Miwatj’s services are also sought by numbers of non-Indigenous residents. Miwatj staff see this as a problem (‘It chews up our resources’), but ﬁnd it difﬁcult to deny care.

Miwatj does not use an appointment system. Patient records are paper-based, though FERRET provides a simple recall system. Apart from primary health care, Miwatj’s services include various specialist programs (eg sexual health, hearing health program).

Miwatj’s medical staff in Nhulunbuy itself currently consists of two doctors, four AHWs (one of whom works as Eye Health Co-ordinator) and one enrolled nurse. A GP Registrar from Gove Hospital works at the centre two days a week; Miwatj staff welcomed the subsidy which makes this possible. As indicated above, recruiting and retaining medical staff is a major problem for Miwatj.

Health care concession cards become relevant for Miwatj when a patient needs glasses39 or needs dental care from the town dentist. Centrelink is located next door to the dentist, and if necessary a patient can call in there to sort out a health care card issue. A Darwin-based optometrist visits Miwatj as part of a circuit of Aboriginal communities; consultations are normally bulk-billed.

Transport of patients to Darwin can be arranged through the Gove Hospital; sometimes the system works smoothly, sometimes not.

2.2 Use of Medicare

Miwatj’s Primary Health Care Grant from OATSIH is around $1.4 million a year. The service has been receiving some income from Medicare rebates since the mid-1990’s. Current Medicare income was estimated at about $70,000 per GP per year – which is not sufﬁcient to cover salary costs. Medicare is used as a ‘top-up’ to cover some salary and administration costs – which staff argue should be adequately funded. Paying Miwatj doctors reasonable salaries was said to depend on receipt of a Remote Area Grant through General Practice and Primary Health Care NT40.

39 People aged over 60 who have a concession card can obtain spectacles without charge. Miwatj assists other patients by obtaining cheap spectacles and selling them at cost. 40 General Practice and Primary Health Care Northern Territory (GPPHCNT) is the peak body representing the Territory’s non-government General Practice and Primary Health Care sector. It was created through the merger, in 2004, of General Practice Divisions in the Northern Territory and the NT Remote Health Workforce Agency. Among other thing’s GPPHCNT provides Remote Area Grants to support GPs in a number of remote locations across the Territory. While doing so, it nevertheless aims to encourage health services to maximise their income so as to reduce reliance on recurrent funding grants of this nature.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 89 Miwatj records patients’ Medicare numbers in its FERRET system. If staff are unable to establish Medicare details for a particular patient they use the 1800 enquiry line service provided from the MLO office in Darwin. Medicare enrolment or identification problems are said to arise with a substantial minority (perhaps 20%) of patients in remote homeland areas. Medicare cards for itinerant patients may be attached to the patient file at Miwatj.

All Medicare claims for the Nhulunbuy clinic, and some from elsewhere, are submitted electronically.

Staff who were consulted had varying views on the extent to which Miwatj claims the Medicare income that it is entitled to. It was reported that many long consultations are claimed, though staff indicated that they try to set some limits to this in order not to set off ‘alarm bells’ at Medicare. It was also said to be quite common for a consultation to run longer than the longest claimable time (Item 44). Miwatj staff mentioned making use of the entitlement relating to ﬁve allied health or AHW services a year for patients with care plans.

Medicare income that is generated by a Miwatj doctor’s work in an outlying community comes back to Miwatj. Where a nurse employed by a local clinic in such a community generates a Medicare claim (eg for wound care or a Pap smear) that is signed off by a Miwatj doctor, the arrangement is that the Medicare income is shared equally between the two clinics (the amount of money involved is not large).

EPC items such as the Adult Health Check were described as being consistent with the kind of approach that Miwatj likes to take: ‘We do most of that stuff anyway’. However, staff said that satisfying every requirement of a Medicare item like this could be difficult (for example, there might be a problem in conducting some specific test in the form specified), with the result that only a long consultation could be claimed. Further, doctors’ schedules were crowded, and patients were often not responsive to the possibility of a relatively time-consuming health check.

Miwatj is an accredited practice, and claims some PIP payments such as those related to teaching. It makes little if any use, however, of other PIP items such as those relating to diabetes, asthma or mental health, because the processes required are seen as too difﬁcult and demanding. Similarly the Asthma 3+ program has no practical application among Miwatj patients because of its dependence on return visits within a particular timeframe.

A major limitation to Miwatj’s use of Medicare lies in the large amount of clinical work that is done by AHWs. Staff emphasised, for example, that Miwatj patients see a doctor only if this is clearly necessary; many day-to-day tasks (treating a boil, for example) are attended to by the AHW with no GP contact. Thus staff members believed that Medicare items based on GP consultations failed to reﬂect much of the work that Miwatj does.

Several of the staff-members interviewed at Miwatj were critical of Medicare as a mechanism for generating income for their service, believing that a pooled funding arrangement would be far preferable. In particular they emphasised the fact that complying with Medicare requirements was extremely difﬁcult when a GP was providing services in a remote homeland – possibly sitting under a tree, with little equipment and no privacy, surrounded by numerous patients and numerous dogs. Several people commented that in this context the patient’s signature on the Medicare form does not indicate any genuine understanding or agreement.

Medicare training and updates are provided face-to-face once each year, when staff from the Darwin MLO ofﬁce visit. These visits were seen as clearly helpful.

90 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 Medications

The S100 scheme was said to work well for Miwatj. It has a contract for supply of PBS medications from the town’s community pharmacy, and it purchases non-S100 items from Gove Hospital at a cost of around $15,000 a year. Some of these medications go out to various homelands with Miwatj GPs.

Some individual scripts are written and sent to the local pharmacy in situations where the doctor does not want to wait until the S100 order arrives. A few Aboriginal customers take prescriptions to the pharmacy; problems relating to their Medicare numbers were said to be fairly common (especially with someone who had been to the local GP rather than Miwatj). When he has a problem with Medicare numbers etc the Gove pharmacist uses the general Medicare information line – but ﬁnds it ‘not great’. The pharmacist described the system of payment for the S100 service as ‘fairly archaic’; for example, unlike other aspects of the PBS, he is paid in relation to the S100 arrangements by a monthly cheque.

Compliance

As with all or most other health services visited, Miwatj staff identiﬁed compliance as a signiﬁcant problem. Where it was possible to administer a drug by injection, for example, this option was often taken. Other approaches were to give only one or two days’ supply of a drug and to offer the patient transport to return to Miwatj for more.

Webster packs and dosette boxes are used, but sometimes with little effect; for example, a dosette box may come back to the clinic with unused tablets, and ‘full of sand’. It is reportedly quite common to see medications discarded on the roads near the clinic. Alcohol misuse was seen as one factor in poor compliance. Some staff thought that compliance was generally better in the smaller communities – some of which are ‘dry’ – where nurses or AHWs could offer patients a ‘more personalised’ service.

3. Other Aboriginal Health Services

As noted above, there are other ACCHSs or Territory-controlled health services operating in a number of other East Arnhem Land communities. Two of the services based close to Nhulunbuy are discussed below.

3.1 Yirrkala Health Centre

Yirrkala is an Aboriginal community of around 1,000 people, located around 14 km from Nhulunbuy. The Yirrkala Health Centre is funded and run by the Northern Territory Department of Health and Community Services (DHCS). Its medical staff currently include two Medical Ofﬁcers (who visit from Gove Hospital), one full time nurse, a second nurse who is on a short-term contract and specialises in sexual health, and 3.5 FTE AHWs.

The Centre has a part-time (3 days a week) Medicare/administration ofﬁcer, whose salary is funded from Medicare funds generated by doctors employed by DHCS. Staff at Yirrkala believed that this part-time clerical salary is considerably less than the amount of Medicare income generated through the Health Centre; they also stated that none of the additional costs related to the position (‘no desk, no chair, no IT’) are paid by the Territory Government. Compromising on administrative support was described as short-sighted, since such support is relatively cheap and can save large amounts of professional time.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 91 Apart from patients who live in Yirrkala, the Health Centre also sees a signiﬁcant number of people who visit the community from outlying homelands (in effect, staff say, they share the care of these people with the health service provided by the Laynhapuy Homelands Association – see section 3.2 below). In total Yirrkala Health Centre has active records for about 2,000 patients. Patient lists are regularly checked and updated with the help of the local Medicare Co-ordinator employed by DHCS.

All Yirrkala’s patient files are kept in paper form, except for the Chronic Disease Register which is computerised and which is used to generate prescriptions electronically. Many of the paper files are large and unwieldy, and staff commented that the difficulty of retrieving medical history has a negative effect on ongoing patient care.

Staff interviewed at Yirrkala said that they were strongly committed to Medicare billing in the hope of being granted full-time administrative support in due course. However, they said, the salaried Medical Ofﬁcers who provide the centre’s GP services are in general not enthusiastic users of the Medicare system, and the making of Medicare claims depends heavily on education/encouragement/assistance provided by the Medicare ofﬁcer. The rate of claiming is said to be quite high so long as the Medicare worker is on duty.

According to those interviewed, Medical Ofﬁcers do not see use of EPC items such as the Adult Health Check as a high priority: they were said to be more interested in ‘the straight medical side’ and inclined just to claim standard consultations, despite the relevance that care planning and the like have for Aboriginal people. Further, staff said, the detail of EPC items is demanding, and good administrative systems are necessary to use and claim for these.

All Medicare claims are submitted manually.

The knowledge required by the Medicare officer is substantial: ‘It’s a specialised job’. She has been trained by the Territory-employed Medicare Co-ordinator for the region (based at the Gove Hospital), and relies day-to-day on the Medicare manual – which is not easy to use, however. The job requires both a good knowledge of Medicare and the confidence and experience to work effectively with the Medical Officers.

Medical Ofﬁcers visiting Yirrkala are very pressed for time and cannot realistically be expected to do much in the way of preparation or follow-up; much of this work therefore falls to the nurse or AHW. An ‘enormous amount of work’ with patients that needs to be done by nurses and AHWs cannot be reﬂected in Medicare claims – for example discharge planning from Darwin hospitals, patient transport arrangements, liaison with specialists, ensuring that patients keep appointments with specialists, and so on.

The Nhulunbuy dentist visits Yirrkala Health Centre for one half-day a week. Dentistry for children is provided free, but adults need to show their health care card. Pathology from Yirrkala Health Centre normally goes to a private- sector laboratory in Darwin and is bulk-billed.

Yirrkala Health Centre reports that it achieves high levels of child immunisation, but that the GPII target of 90% is very difﬁcult to reach among a transient population.

Despite problems and limitations, said Yirrkala staff, the capacity to claim Medicare – and to employ a worker who performs some general administrative tasks as well as handling these claims – puts the Health Centre ‘way ahead’ of where it used to be.

92 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 Medications

The Yirrkala Health Centre receives PBS medications under a S100 contract with a large pharmacy in Darwin; deliveries come by barge, at least fortnightly. Except for standard CARPA treatments, Yirrkala Medical Ofﬁcers write prescriptions for all medications (the normal practice in Territory-funded health services). Patients with a chronic disease have a standing prescription, with drugs ordered monthly. Representatives of the contracting pharmacy visit Yirrkala twice a year, but it was said that these one-day visits were too rushed to provide effective staff education.

Dispensing of S100 drugs is the responsibility of Yirrkala nurses and AHWs; in each case two people are involved in checking the medication. The Health Centre packs some 80 dosette boxes a week. Inadequate storage for medications is a problem at Yirrkala.

Purchase of non-S100 medications from the Gove Hospital (eg rubbing medicines, antifungal creams, eardrops, eye-drops, hand wash, some scabies treatments) was said to cost the Health Centre a lot of money. However, staff believe that supplying these to patients is important and that it is often preferable to use these rather than ‘full-on medications’.

3.2 Laynhapuy Homelands Association

The Laynhapuy Homelands Association provides health services for the 800 or so people who live in some 20 homelands dispersed across East Arnhem Land. This is an OATSIH-funded, community controlled service, which operates from an administrative base at Yirrkala; it also receives some funding from DHCS. The service has a manager, two registered nurses and an AHW aide (employed through the CDEP); two days a week it has the services of a doctor who is employed by Miwatj Health.

Medicare claims are made for at least some of the work done by the GP, but he says that it is ‘a nightmare’ to have to make claims in the conditions surrounding his work in the homelands41. The income generated goes to his employer, Miwatj. Laynhapuy is keen to employ its own full-time doctor, but staff say that OATSIH advises them they would have to raise the cost of a GP salary from Medicare claims – which does not seem feasible.

In relation to EPC items such as care plans for chronic illness, it was said that Laynhapuy nurses and AHWs are capable of doing everything that is required. However, they cannot make a Medicare claim without sign-off from a GP, and this was a problem because the GP’s visits (two days a week) were so crowded and rushed that paperwork had to take a back seat. Claims relating to immunisation, Pap smears and wound care provided by Laynhapuy nurses likewise have to be signed by the GP.

Laynhapuy Health Service has a S100 contract with the Gove pharmacy. Its nurses ‘dispense’ the drugs at Yirrkala and take them out to the homelands. ‘We couldn’t operate without Section 100’, staff said. Laynhapuy purchases non-S100 drugs (for example cough medicines, creams, lice treatments) from Gove Hospital.

41 Government-employed Medical Ofﬁcers who previously worked with Laynhapuy were said to have made very few Medicare claims.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 93 4. Medical staff at Gove Hospital

A number of District Medical Officers at the Gove Hospital also work with Aboriginal people in other settings. Some are GP Registrars who also work at the local General Practice and/or at Miwatj. Several of the DMOs spend part of the week working with one or other of the small community clinics across East Arnhem Land. Those who spoke with the study team emphasised that Medicare paperwork was very difficult to fit into a crowded and sometimes chaotic day’s work in a community or homeland. When a GP or Medical Officer visits a remote area clinic, for example, it is naturally important for the nurse to discuss a range of patient issues with him or her, to go through pathology results and the like. Two hours of a six-hour visit can easily be spent on such matters, but Medicare claims can only be made for time spent in patient consultations. In a region like this, the MOs argued, Medicare was a cumbersome and inappropriate system – an ‘artificially imposed system’, ‘a pain in the neck’. ‘Our people don’t get the quality of service they deserve’; ‘We can’t claim at a realistic level for the service we provide’. In general, these Medical Officers believed, pooled funding was clearly ‘the way to go’.

Having the patient sign a Medicare form on each occasion of service was seen as a meaningless process: why could the patient not sign a once-off consent? Another issue raised was the length of time that a doctor might have to spend with a seriously sick or injured patient awaiting transportation, eg to hospital in Darwin. The maximum claim of $626 for ‘more than 5 hours’ was inadequate in many situations arising in remote areas. The thinking behind the schedule of Medicare items, it was said, generally bore little relationship to the realities of health care in East Arnhem Land. Care plans for chronic disease, however, were seen as a useful innovation. One DMO at Gove Hospital reported that while she attempted to use EPC items such as care plans and Adult Health Checks, there were practical difﬁculties such as particular equipment not being available in a remote area.

When there is no Medical Ofﬁcer in attendance at a remote area clinic, the nurse or AHW will often telephone one of the doctors at Gove Hospital for assistance or advance. It was argued that telephone consultations of this kind should be claimable on Medicare42.

Dosette boxes (packed by the local nurse or AHW) were commonly used to distribute S100 drugs in the larger outlying communities, and it was said that this did help improve medication compliance. In the small homelands, however, distribution of medications was described as ‘ad hoc’ and compliance as ‘very erratic’.

42 For example, said one doctor,’ I can claim for my role in a telephone case conference discussion with a Darwin specialist – why not for my role in a telephone consultation with a patient and the clinic nurse?’

94 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 Port Augusta, South Australia - Regional

1. Background

Port Augusta is located at the head of Spencer Gulf, about 300 kilometres north-west of Adelaide; it stands at the intersection of highways heading west (ultimately to Perth) and north (to Alice Springs and beyond). Port Augusta is a regional centre providing a range of services to smaller towns and communities nearby, such as Quorn and Hawker. It also services a number of remote communities much further north, such as Leigh Creek and Copley (380 km), Marree (496 km), Nepabunna (460 km) and Oodnadatta (770 km).

The population of Port Augusta at the 2001 census was recorded as 13,516, with over 2000 persons identiﬁed as being of Aboriginal or Torres Strait Islander descent. People consulted during this study estimated the Aboriginal population as considerably higher, at around 5,000, subject to variation over the course of the year. Several hundred Aboriginal people live at the Davenport community about 7 kilometres from the centre of town.

Port Augusta has a hospital (opened in 1997) with some 80 beds, serving the town and region; Aboriginal patients account for a signiﬁcant percentage of admissions. There are also a number of General Practices in the town.

Quorn, some 40km from Port Augusta, has a population of around 1,500 people. It has a community health centre and small hospital. Hawker is just over 100 kilometres away and has a population of around 350 (about half of whom are Aboriginal). Leigh Creek (site of another small hospital) and Copley are about 380 kilometres away and have a permanent population of about 1000.

2. Pika Wiya Health Service Inc

Nature of the Service

The origins of the Pika Wiya Health Service go back to the establishment of South Australia’s ﬁrst Aboriginal Medical Service at Davenport, in the mid 1970’s. By 2004-05 Pika Wiya had a total of 78 full-time or part-time employees (two-thirds of them Indigenous), and was receiving Commonwealth and State grants totalling around $4.5 million a year. It currently provides health services at four locations – in Port Augusta, at the nearby Davenport community, and in the small communities of Copley and Nepabunna in the north-east of the State.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 95 At the time of the study team’s visit in February 2006, Pika Wiya’s medical staff included four GPs, three nurses and over 20 Aboriginal Health Workers. The GPs and nurses provide regular services at the Port Augusta and Davenport clinics, plus visiting services to Copley and Nepabunna (in theory at 6-weekly intervals, though staffing pressures have meant less frequent visits over recent months43). Some of the Pika Wiya AHWs work closely with the doctors and nurses in the clinic setting, with patients normally seeing an AHW before seeing the doctor. However, numbers of the AHWs are responsible for delivering specific health programs such as an Antenatal and Postnatal Program, Diabetes Program, Hearing Health Program, and Healthy Lifestyle and Sexual Health Program. Pika Wiya also provides a dental service for health care card holders (two clinics a week for adults, five morning clinics for children); the State Government contributes to the costs of operating the dental service. Community members noted that dentistry is very costly ‘if you can’t get into Pika Wiya’. Even apart from cost, it was said that the availability of dental services in Port Augusta was inadequate.

Pika Wiya’s Port Augusta clinic operates on an appointments system, and is open Monday to Friday and Saturday mornings. The Saturday clinic has been provided over the past couple of years – at signiﬁcant expense – because the Port Augusta Hospital reported that it had experienced many Aboriginal people presenting, with relatively minor problems, at the weekend.

The Pika Wiya doctors (all of whom work full-time or nearly full-time at the Service) share ‘on call’ responsibilities at the Port Augusta Hospital with other local GPs.

A pharmacist based at the Port Augusta Hospital provides regular visiting services at Pika Wiya – for example monitoring the use of medications kept in stock and providing medication information for the Health Workers.

Pika Wiya reports that it has active patient records for some 4,000 people – the great majority of them Aboriginal. Thus most local Aboriginal people are users of the Pika Wiya service, but a signiﬁcant minority use the services of Port Augusta’s private GPs.

Use of Medicare

Medicare enrolment rates among Pika Wiya patients at the time of this study were reported to be very high; ‘nearly everyone’ is enrolled, it was said. Where a patient is not enrolled or the appropriate Medicare number is not readily available, there was said to be little difﬁculty in solving the problem, usually by contacting the ‘very helpful’ MLO ofﬁce in Darwin. Community members who took part in the Port Augusta discussion groups reported few problems with enrolling in Medicare, obtaining a replacement Medicare card or the like.

Pika Wiya submits its Medicare claims electronically. To a large extent it relies on its GPs to submit correct Medicare claims; however, these are channelled through an administrative staff member who may query or check particular claims. The Darwin MLO ofﬁce assists with telephone enquiries as required; rejection of Pika Wiya claims is uncommon.

Pika Wiya’s current annual income from Medicare was reported to be around $400,000; this ﬁgure was said to have increased signiﬁcantly over recent years. Among other things the income from Medicare enables the Service to employ four doctors, when it is only funded for three. It was said that Medicare income also assists Pika Wiya in providing its dental services. Pika Wiya staff noted that it receives $20,000 a year through the Rural Doctors Workforce Agency to ‘top up’ its GP salaries.

Pika Wiya representatives reported few problems in using the Medicare system in relation to GP consultations; for 43 The unsealed access road to Nepabunna is unusable after heavy rain or storms. The airstrip in this area has been out of service for some time.

96 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 example, it frequently claims for long consultations. However, it was suggested that the Service almost certainly under-claims in relation to eligible services delivered by practice nurses. The point was also made that AHWs get annoyed and frustrated that a Medicare rebate can be claimed for certain services provided by nurses but not by themselves.

As at other ACCHSs, there were said to be many services provided by both nurses and AHWs at Port Augusta and Davenport (for example, removal of stitches) that do not involve a GP and therefore fall outside the scope of Medicare. Given that there are very limited GP visits to the remote locations of Copley and Nepabunna, there is hardly any opportunity to generate Medicare income for the work of those clinics. The point was also made that when GPs do visit these clinics, the cost in travel time has to be borne by the Service without any assistance from Medicare. The work that GPs do on referrals to specialists can be claimed from Medicare to the extent that it occurs within a patient consultation, but staff commented that there is often additional work required (eg follow-up telephone calls and other administrative work) that is not claimable.

EPC items

Pika Wiya makes some use of EPC items such as Adult Health Checks, but staff said that it needs to ‘gear up’ to do so in a more systematic way. Given the difficulty of encouraging patients to make, and attend for, follow-up appointments44, Pika Wiya medical staff have in some cases attempted to provide such services opportunistically, but fitting them into a busy schedule is difficult45. For one thing, it may be necessary to provide either a male or a female AHW, of appropriate age, to work with a particular patient. Further, some AHWs have limited computer skills which may affect their capacity to play a role in fulfilling EPC item requirements. (For these and various other reasons, it was said, a substantial proportion of the adult or aged person health checks undertaken by Pika Wiya remain unclaimed because some part of the process is incomplete, even through the substance of the work had been done.) Care plans are particularly difficult for Pika Wiya to implement. With ‘all the acute things coming through’, doctors and other staff may find it hard to see the value in making time for such things; some doctors may in fact take the view that there is no firm evidence of the effectiveness of care plans and similar interventions.

The comment was made that over recent years ‘so many changes’ affecting medical practice had been introduced by the Commonwealth, so quickly, that it was difﬁcult for a health service like Pika Wiya to get on top of it all (a point that is also often made by mainstream practices in relation to EPC items, PIP and the like). Ongoing changes to the system (such as the introduction of new Chronic Care items in 2005) may be desirable improvements in themselves, but they add to the administrative and organisational challenge.

44 Especially when there is no immediate or obvious beneﬁt to the patient and ‘they’re not feeling sick’. 45 It was reported that on one occasion when all the GPs were on duty at the same time, the Service had ‘managed’ to have one GP devote a whole session to health assessments.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 97 PIP

Pika Wiya is accredited in accordance with RACGP standards, and participates in the Practice Incentive Program46. It receives payments under PIP in relation to its IT system, training role and employment of AHWs, for example, and it is able to make some PIP claims relating to the diabetes cycle of care, which can be managed over the course of a year. Other PIP components, however, such as the Asthma 3+ program, entail speciﬁc requirements in terms of follow-up visits and the like which in practice make it very difﬁcult for Pika Wiya to claim.

Immunisation

Pika Wiya has a nurse speciﬁcally responsible for its immunisation program; she immunises several hundred children a year at the Port Augusta and Davenport clinics, as well as giving adult ﬂu vaccinations and the like.

Children requiring immunisation are normally identiﬁed through the Australian Childhood Immunisation Register (ACIR); Pika Wiya records in themselves are not sufﬁcient because some children may receive immunisations elsewhere from time to time – for example at another AMS, a hospital or private GP. The nurse follows up children who are due for immunisation, by telephone if available or otherwise face-to-face. She visits Copley and Nepabunna only once or twice a year; children in those communities are mostly immunised at the Leigh Creek hospital, though some are also picked up by Pika Wiya when visiting Port Augusta.

The nurse enters details of her immunisations into the ACIR. The Medicare incentive for completion of an immunisation schedule is claimed in the name of the GP on duty, and these payments are received monthly by Pika Wiya. Over the past couple of years Pika Wiya has achieved immunisation rates of over 90% for the children under 7 years on its books, and has accordingly been eligible for the additional outcomes payment.

As noted above, some children may receive all their vaccinations at Pika Wiya, but others may receive immunisations from other clinics, from GPs or while in hospital. It was said that some Aboriginal parents who use GPs most of the time may nevertheless choose to bring their children for immunisation at Pika Wiya – possibly because the nurse has been doing this work for a long time and is well known and well regarded in the community.

Community members commented that Pika Wiya was very thorough in following-up when further vaccinations are due.

Workforce problems

Like many other ACCHSs, Pika Wiya reported difﬁculties in recruiting and retaining doctors: ‘They stick around for a while, and then they go’ – possibly some months after gaining full Vocational Registration if they did not previously have that status.

It was noted that one of Pika Wiya’s nurses has ofﬁcially retired, but continues to work at the Service because it can ﬁnd nobody to replace her.

46 It was said that gaining initial accreditation took a lot of time and effort (though ‘we passed with ﬂying colours’), in part because those responsible for the accreditation were unfamiliar with an operation like Pika Wiya.

98 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 Medicare training

The Pika Wiya staff member who is directly responsible for handling Medicare claims states that she has largely taught herself about the system ‘through the Bible’ – that is, the Medical Beneﬁts manual – but that essentially she relies on the knowledge of the GPs. No reference was made to use of the Medicare Toolkit (‘Maybe I’ve seen it, but I don’t use it’). Although a representative from the Darwin MLO ofﬁce visits Pika Wiya once a year, some staff believed there was a need for additional and more regular training on Medicare.

Advice about EPC items is normally sought from the Aboriginal Health Council of South Australia, in Adelaide, which evidently has a relevant OATSIH-funded position.

3. Medications

Pika Wiya has Section 100 arrangements in place for its outlying clinics at Copley and Nepabunna. However, because the AHWs who run these clinics day-to-day have limited skills and experience in medications, the scheme can be used only on a small scale; it was said to involve supply of medications worth around $4,000 a year. Section 100 would have wider use in Copley and Nepabunna if the clinics could be staffed by qualiﬁed nurses.

The Port Augusta and Davenport clinics are not covered by S100; instead Pika Wiya pays the cost (co-payment) of community pharmacy dispensing of prescriptions for all patients who have a Commonwealth health care card; this arrangement is said to cost Pika Wiya of the order of $70,000 a year47. Although this is a signiﬁcant expense, Pika Wiya management believes that it is essential if many of its patients are not to miss out on necessary medications: ‘We can’t afford to stop supplying it’. Pika Wiya also spends nearly $40,000 a year to maintain an imprest stock of both PBS and some non-PBS medications for use at its various clinics. A nurse at Pika Wiya made the point that several other nearby towns such as Whyalla and Port Pirie do not have AMS services on the scale of Port Augusta (for example, having no GPs), and that Aboriginal people in Port Augusta therefore receive a much better level of care and enjoy better access to Medicare and the PBS. Aboriginal people in Whyalla, for example, do not have access to free medications.

Pika Wiya patients can present their prescriptions (and have the co-payment covered) at any of the town’s community pharmacies, but many use a particular pharmacy that is located close to the clinic. Further, it is common for Pika Wiya to have its drivers drop off scripts and collect medication for patients needing such assistance, and the drivers always use this particular pharmacy – which therefore has a close working relationship with Pika Wiya.

Staff at the pharmacy report that prescriptions sometimes do not give the full and correct Medicare or health care card number or the expiry date, and that this can involve extra work for them48. If Pika Wiya is unable to provide the missing information, the pharmacy will call the general Medicare enquiry line (IME – a 1300 number) for either Medicare or health care card information; staff were not aware of the dedicated 1800 line for Indigenous Medicare enquiries. This pharmacy commented that calling the IME line ‘two or three times a day’, rather than occasionally as most pharmacies might do, added to its costs in staff time as well as telephone (1300 number) costs.

47 Pika Wiya has a ‘discreet’ system of simply stamping a prescription to indicate that the patient is entitled to have Pika Wiya cover the co-payment. 48 Pika Wiya produces its prescriptions on the Medical Director system; since this does not have a space for the concession card expiry date, this has to be added manually.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 99 Evidently there are few serious difﬁculties in obtaining Medicare and concession card information for people living in the Port Augusta area, but there can be problems with people visiting from remote areas such as the APY Lands in the far north of the State. If the pharmacy’s enquiries reach a dead-end, it can resort to the use of an emergency number; the other possibility is for Pika Wiya to supply the medication from the imprest stock that it maintains. If the patient’s Medicare details are available but not his/her health care card information, the patient can make the full co-payment and later seek a refund of ‘the difference’ through Medicare. However in this situation the customer, and not Pika Wiya, will end up paying the concessional fee of $4.70. If health care card information cannot be obtained, the pharmacy is in practice likely to refer the customer to Centrelink to get the matter sorted out.

Given its role in relation to co-payments met by Pika Wiya, this community pharmacy is in a position to keep full records of payments made, and can therefore ensure that Pika Wiya gets the beneﬁt of a patient’s reaching the concession card Safety Net threshold. The system works reliably for those patients whose prescriptions are delivered to the pharmacy by a Pika Wiya driver; patients who get their own prescriptions dispensed, however, may do so at any pharmacy, in which case it may not come to attention that the Safety Net ﬁgure has been reached, and Pika Wiya may end up paying unnecessarily.

It was noted that few if any Aboriginal customers keep their own co-payment record. Indeed, it was said to be unusual for any customer, Indigenous or otherwise, to claim Safety Net benefits except in the situation where a particular pharmacy could advise them they had reached the threshold. The community discussion groups in Port Augusta confirmed that by no means everybody knew of the PBS Safety Net system. In a group discussion with generally well-informed people, held at the Bungala CDEP, only one of the participants had heard of the PBS Safety Net. Even where people were aware of the Safety Net, they said that it was hard to qualify: one woman said that her family had on one occasion qualified for the Safety Net – but only right at the end of the year, so that it was of little benefit to her.

This pharmacy had no Indigenous-speciﬁc information materials on medications or the PBS available for customers.

Doctors at Pika Wiya sometimes recommend that a patient purchase an over-the-counter item (vitamin supplements are one example). If the cost is reasonably low (say under $7), Pika Wiya may agree to cover the cost of this. It was said, however, that it was uncommon for Aboriginal customers to approach a pharmacy of their own accord to seek health advice or purchase an over-the-counter medication; this was far more common among non-Indigenous customers.

Pika Wiya representatives referred to the ‘anomaly’ that when people from remote areas were visiting Port Augusta – for example at holiday periods or for various family reasons – they expected to have access to free medications under the S100 arrangements. Since these arrangements do not currently apply in Port Augusta, however, Pika Wiya ﬁnds itself needing to make the concessional co-payment for such people when they require either a new or repeat prescription49. Pika Wiya representatives were very keen to see the section 100 scheme extended to centres like Port Augusta; that would be ‘tremendously helpful’, said a Pika Wiya doctor.

49 In any case, as noted elsewhere, obtaining concession card information for mobile or transient patients like this can be a challenge.

100 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 Another option, some suggested, would be for the Government to provide funding to Pika Wiya to cover the cost of the PBS co-payments that it makes on behalf of health care card holders. Again this would represent a major beneﬁt to Pika Wiya and its patients – particularly if coverage of co-payment costs was supported by a grant of funds to provide appropriate QUM initiatives (which could be overseen by either a community pharmacy, hospital pharmacy or other suitably qualiﬁed agency).

Among the people interviewed in Port Augusta there was some criticism of the Section 100 scheme from a quality/ equity perspective: ‘Just providing drugs is not the whole answer’. The Section 100 arrangements were said to involve ‘a two-tier system’ in terms of quality use of medicines. It was suggested that a standardised program of medication training for AHWs could make a significant contribution to improved medication outcomes. There were specific suggestions for training of nurses and AHWs to achieve competency in management of medications; a written submission forwarded to the study team stated that ‘a model for this competency training already exists’ in services provided by the Port Augusta Hospital to its outreach sites. It was argued that where an Aboriginal health service is staffed by people who have achieved the appropriate competency standard, it could receive Medication Management Accreditation. Among other things this would overcome the present restrictions on the drugs that can be handled by AHWs at the remote sites of Copley and Nepabunna. More generally it could significantly improve the quality of medication supply and patient information and advice in the operation of the Section 100 arrangements. A series of 20 or so teaching sessions has already been prepared for providing medications training to Pika Wiya AHWs, and is available on CD.

Some of those interviewed in Port Augusta regarded it as particularly important that AMSs have effective access to an appropriate source of pharmacy advice and support, whether from community pharmacies or otherwise. It was argued that the centring of the current S100 arrangements on privately owned community pharmacies imposed unnecessary limitations on the range of assistance and expertise available to AMSs.

Another point strongly emphasised among those consulted in Port Augusta was that the cost of prescriptions could be a major health care barrier for Indigenous Australians who were on low incomes but not entitled to a health care card – particularly those who just failed to qualify for the concession, for example as a result of receiving a wages ‘top-up’ through the CDEP. Given many competing priorities within a limited budget, such people might well avoid or put off having a prescription dispensed (‘Maybe I’ll get the antibiotics, but I can’t get the rest this week’). Several participants in the community discussion groups in Port Augusts referred speciﬁcally to the problems faced by people who might have a job but needed to take a number of drugs for chronic illness, or who had children with various medication needs. A Pika Wiya staff-member suggested introducing a lower safety net ﬁgure for Indigenous Australians with a chronic illness.

In Port Augusta it was also noted that the current Home Medicines Review (HMR) model is not very suitable for Indigenous patients, especially in isolated or remote locations.

Compliance

Compliance with instructions for correct storage and use of medications was identiﬁed as a signiﬁcant problem among Pika Wiya patients – for various reasons, including costs for people without a health care card. The term ‘concordance’ was also used, to refer to the broader issue of a gap between mainstream expectations and understanding about medication use and those of some Indigenous patients. Apart from taking responsibility for concessional co-payments, Pika Wiya’s strategies for supporting consistent and correct patient use of medications include the use of dose administration aids such as bubble (Webster) packs, and home visits to supervise medicine- taking by patients at risk.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 101 4. Use of mainstream GP services

Port Augusta has a number of general practices of varying size, some of which offer bulk-billing (at least for children and concession card holders). There were various reasons suggested as to why Aboriginal people might choose to go to a mainstream GP rather than to Pika Wiya – for example, feeling that one had more privacy at a mainstream practice, or valuing the continuity of a relationship with a particular GP. (Elderly people, some said, can get quite confused by the various doctors they are likely to see at Pika Wiya.) Sometimes it is easier to get an appointment with a GP than at Pika Wiya. One community member said she preferred to visit a GP because she was then not limited to the generic drugs that Pika Wiya generally prefers for ﬁnancial reasons.

Reasons for people preferring to use Pika Wiya, on the other hand, included the fact that it was an Indigenous- specific and culturally appropriate service, that concession card holders had access to free medications, and that Pika Wiya offered a number of ‘fringe benefits’ such as local transport services. Some said that specialist referrals tended to be quicker through Pika Wiya; further, if you were referred to a specialist in Adelaide, Pika Wiya could provide transport and other assistance that a private GP could not. Another benefit of using Pika Wiya, it was said, was that the staff readily acknowledged that you might need some help in completing various forms – including Medicare enrolment, for example. Several people in the community discussion groups at Port Augusta spoke of using both private GPs and Pika Wiya at various times and for various purposes. A local GP likewise commented that individuals may choose between using Pika Wiya and going to a private doctor for particular health matters.

As indicated above, people with a health care card have a particular incentive to use Pika Wiya rather than a mainstream practice, because of Pika Wiya’s arrangement to cover the concessional co-payment on prescriptions dispensed. In general it was suggested that the most disadvantaged or vulnerable members of the Aboriginal community were likely to be reliant on Pika Wiya; Aboriginal people who regularly used private GPs possibly tended to be younger than typical Pika Wiya patients, and more likely to be employed.

The impression received in Port Augusta was that there were relatively few complaints about the standard of service provided by local GPs to their Aboriginal patients, and also that there were generally quite positive relationships between Pika Wiya and the private practices. (For example, a GP whose patient found it difﬁcult to pay for prescriptions might request Pika Wiya to provide medication from its imprest stock.)

The local Division of General Practice has a Memorandum of Understanding with Pika Wiya, and reports having a strong focus on issues of Indigenous health. The comment was made that Pika Wiya is an established service that is well-regarded by other health service providers, that GPs working at Pika Wiya generally feel ‘part of the Division’, and that there is a degree of ‘crossover’ work between Pika Wiya and private practitioners. Some of the private GPs have previously worked at Pika Wiya. (‘In some other places the Division and the AMS can be separate worlds’.)

Discussion group participants who reported using mainstream providers (hospital and community health centre) at the nearby town of Quorn were very satisﬁed with the services they received. There are never any problems, said one – ‘so long as you have that Medicare card’.

102 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 5. Aboriginal Health Worker in General Practice

The Division of General Practice in Port Augusta has recently introduced a scheme to provide AHW assistance to private practices, with the particular aim of increasing their use of EPC items like the Indigenous adult health check, the older person’s health check for Indigenous Australians over 55, and care plans for people with chronic illness. With funding support from the SA Health Department, Port Augusta Hospital and OATSIH, the Division has employed an experienced AHW who will, over the coming 12 months, spend time in a number of the local practices to promote and support GPs’ use of these EPC items. At this stage the ﬁnancial arrangement is that the practice will claim the item and transfer 20% of the payment back to the Division. The hope is that the system will ultimately be self-supporting. (Development of this initiative has been inﬂuenced by a comparable program being conducted in Perth through the Canning Division of General Practice – see notes in the Perth case study.) There was said to have been little use of these EPC items in local general practices to date; one issue mentioned in this context was that GPs do not necessarily have reliable records on whether particular patients are Indigenous or not.

Pika Wiya is represented on the steering group for this initiative.

6. Specialists

The availability of specialist services in Port Augusta was described as reasonably good through the local hospital. There were some gaps, however; for example, the hospital has no visiting Dermatologist and has just lost the services of a very experienced Physician. Specialist services for Pika Wiya patients are generally bulk billed, and pathology services are normally available on a bulk-billing basis.

7. Community awareness and understanding

The discussion groups in Port Augusta, as elsewhere, often revealed confusion or misunderstanding in the Indigenous community about various health beneﬁts or entitlements – for example in relation to bulk-billing procedures, the PBS Safety Net, varying brands and prices of medications, different services or entitlements that seemed to apply from place to place, and the fact that some essential drugs seemed not to be available through the PBS.

Pika Wiya staff said that Well and Good magazine had been well received by patients while it was available. In general, several people suggested, Indigenous radio was the best communication medium available for disseminating health information to the community.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 103 Halls Creek, Western Australia - Remote

1. Background

The town of Halls Creek is located in the East Kimberley region, in the north of Western Australia. It is approximately 550 km east of Broome and 300 km south of Kununurra, and lies on the Great Northern Highway between two other small towns, Warmun (Turkey Creek) and Fitzroy Crossing. At the time of the 2001 census the Halls Creek population totalled just over 4000 people, of whom some 70% identiﬁed as Indigenous. (The Aboriginal population of the Halls Creek Shire is around 85%, and around 50% in the town.)

Halls Creek has daily bus connections with Perth and with Darwin. While there are good-quality roads linking the town with Broome to the west and Kununurra to the north, ﬂooding can make roads impossible during the wet season. Kununurra airport is some three hours drive from Halls Creek. The main local industries are tourism and cattle; there is also some gold mining. Halls Creek functions as a local service centre, with several stores and roadhouses, cafes and two schools. There are several Aboriginal community services or facilities based in the town, including a radio station, CDEP and a cultural centre.

The health services available in Halls Creek include a small hospital and Community Health Centre (both operated by the WA Sate Government) and the Aboriginal Health service Yura Yungi. There are reportedly some 60 small Aboriginal communities or homelands in the Halls Creek Shire, four of which have a nursing post. Some people from these small settlements will move into Halls Creek during the wet season.

Other facilities in Halls Creek include a drug and alcohol service/drop-in centre, which is moving towards providing broader family support services. Both Yura Yungi and the Community Health Centre provide some health education and services at this centre.

The nearest community pharmacy is located at Kununurra – some 3-4 hours by road. People in Halls Creek who need a prescription dispensed (eg for something not stocked by the hospital or Yura Yungi) normally take it to the small shop located at the local caravan park, which sends off scripts to the pharmacy in Kununurra once a week, and receives the medicines back by post a few days later; patients then pick up from the shop. Concession cards or photocopies thereof are sent to Kununurra with the prescription. The price paid is the standard pharmacy charge plus a small fee for transport.

The caravan park shop has a Schedule 2 licence which authorises it to sell certain types of medication including, for example, cough medicines, anti-fungal treatments, pain killers, nasal sprays.

There are no midwifery services in Halls Creek, and expectant mothers are normally transported to Derby or Kununurra a couple of weeks before they baby is due. Several community members were keen to see a birthing centre established at Halls Creek.

104 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 2. Yura Yungi

Yura Yungi Health Service has two GP positions – one of which was unﬁlled at the time of the study team’s visit – together with a GP Registrar, two nurses (one based at the community of Ringer Soak), and six AHWs (again one at Ringer Soak). The clinic staff totals about 20 people in all. A GP makes a fortnightly visit to Ringer Soak, which is about 170km from Halls Creek, and there are some GP visits to other small communities. High turnover of GPs is a major problem for Yura Yungi.

Normally Yura Yungi patients will initially see an AHW, going on to see the GP if necessary. Older Indigenous Australians, it was said, often feel more comfortable with an AHW than with the doctor. People in the community discussion groups echoed this, saying there was a ‘stronger bond with the Health Workers’; ‘Doctor use hard English’.

Yura Yungi reports that it has approximately 5000 patients on its books. Apart from specialist appointments, the service operates on a drop-in basis. During the 2005 calendar year client contacts totalled some 9700. Around 15% of Yura Yungi’s patients are non-Indigenous – for example travellers passing through Halls Creek. Computerised records at Yura Yungi are used for patient recall.

Yura Yungi management is keen to maximise income from Medicare rebates. It was reported that claiming levels had increased since a recent training visit from the Perth-based MLO. Last ﬁnancial year income from Medicare was around $160,000, out of a total Yura Yungi budget of around $1.2 million. The service reports claiming a fairly large number of long consultations; some Medicare claims are made for outreach work by the GPs. In general Yura Yungi tries to make sure it claims the additional rebate payable for a health care card holder.

There have to date been few Yura Yungi claims for services provided by nurses, and there seemed to be some uncertainty on this matter. Yura Yungi staff believe the service is not eligible to claim for services provided by AHWs ancillary to care plans for patients with chronic disease (this seems to be a misconception). Staff commented that in an area like Halls Creek this ‘antenatal attendances’ can take up a lot of time, but that the standard Medicare rebate is only $25.

The usual system for claiming rebates is that the doctor ﬁlls out the Medicare form, identifying the appropriate item number(s); this form goes back to the receptionist (who also serves as the Medicare ofﬁcer), who gets the patient to sign the form. ‘They all like to get you to sign that form’ at Yura Yungi, commented one community member.

Enquiries about missing Medicare cards or numbers are directed to the MLO’s ofﬁce in Perth, which is ‘very good’ and usually able to assist. Medicare claims are lodged electronically, with few rejections.

Yura Yungi staff reported that, in light of training about Medicare, they are making increasing use of EPC items. ‘There’s a lot of work involved’, however, in satisfying all the requirements of an EPC claim. Explaining to the patient the value of, say, a health assessment can be quite difficult and time-consuming. Further use of the Adult Health Check will require Yura Yungi to develop specific arrangements to fit these in efficiently.

Childhood immunisation is mostly carried out by the Community Health Centre, working with the school nurse.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 105 A dentist from Kununurra visits the Halls Creek Hospital once every three months. This is not sufﬁcient to meet the community’s needs, and dental care is ‘a huge problem’; people have to put up with problems and pain which can easily lead to more serious conditions.

A similar situation arises with other conditions, such ear and eye problems. So far as Yura Yungi staff were aware, there was no audiologist available in the Kimberley. The Australian Hearing Service was reported to visit twice a year, from Darwin – useful but by no means sufﬁcient. Some people with hearing problems need to be transported to Derby for treatment.

3. Halls Creek Hospital and Community Health Centre

The Halls Creek Hospital has eight acute and four boarder beds, a nursing staff totalling 13, and three doctors (one permanent, two locums). Almost all patients are Aboriginal people from the town or surrounding communities. The hospital is open 24 hours a day and provides an after-hours emergency service. It also operates a GP outpatients clinic Monday to Friday.

Relationships between the hospital and Yura Yungi were described as not particularly close at present; there has evidently been more interaction in the past. Although many patients make use both of Yura Yungi and of the hospital, there are no common patient records between the two, which can create practical problems. Community members said that it was usually quicker to seek treatment at Yura Yungi than at the hospital; however, some patients reportedly choose to use the hospital because they believe it can offer them greater privacy. Since Yura Yungi provides no after-hours service, patients needing assistance at weekends or in the evening must go to the hospital. Further, through the State-funded Patient Assisted Travel Scheme (PATS), the hospital is in a better position to arrange patient transport to other centres (eg to Derby Hospital) if required. Patient transport is by bus, or by the RFDS ambulance service for urgent cases. Transport is provided free for concession card holders (help may be needed from Centrelink to establish people’s entitlement), and is funded from the hospital budget.

The chief relevance of Medicare at the hospital is in relation to some specialist and pathology services. People who took part in community discussions stated that access to specialists was poor, despite periodic specialist visits (eg by an eye specialist and a paediatrician) to the hospital. Among other things it was said that there is no reliable way of individuals knowing which specialists are due in town when50.

The Community Health Centre is physically attached to the hospital and works closely with it. It is staffed by ﬁve nurses and an AHW. Its areas of work include immunisation, chronic disease nursing, school health, STIs and antenatal and child health services. Various members of staff visit outlying communities on a fairly regular basis. Some of the Community Health Centre staff also conduct clinics at Yura Yungi.

The only role played by the Royal Flying Doctor Service in Halls Creek is providing transport.

50 One woman recalled having a prescription for her child written by a visiting paediatrician; she lost it and then had no way of getting a replacement because the specialist had departed.

106 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 4. Medications

Yura Yungi has s100 arrangements with the Amcal community pharmacy in Kununurra. Orders are placed every couple of weeks, or more often if necessary. Yura Yungi is aiming to use no larger range of medications than is necessary, and staff refer for guidance to the Kimberley Standard Drug List developed by the Kimberley Aboriginal Medical Service (KAMS). The health service also purchases non-s100 drugs, from the Kununurra pharmacy or elsewhere. Both s100 and other medications are ordered separately for the clinic at Ringer Soak.

Drugs are dispensed by Yura Yungi AHWs on instructions from the GP. The medication is labelled and instructions provided, and the details recorded. Packing dosette boxes takes a lot of AHW time. However, Webster packs come pre-packed by the pharmacist in Kununurra, at a cost of $5 per pack.

Yura Yungi will supply s100 medications to non-Indigenous patients in certain cases. If the patient is in employment, however, a prescription will be written in the ordinary way.

The outpatient clinic at the hospital can dispense a ‘starter pack’ of medication (ie two or three days’ worth of drugs). After that the patient needs to get a prescription dispensed, through the shop at the caravan park (see section 1).

Some people may prefer to seek treatment at the hospital, yet still want free medication. Medications are available free from Yura Yungi under the S100 arrangements, but only after the patient sees a Yura Yungi doctor. Therefore if the hospital sees a patient who the goes to Yura Yungi to take advantage of free medication, the patient needs to be seen again by the Yura Yungi GP – obviously a wasteful and potentially confusing situation. Things would be simpler for the hospital if it could itself dispense medication under the S100 arrangements; it was reported that the hospital at Fitzroy Crossing does make use of S100.

Compliance with instructions in relation to treatment for STIs was identiﬁed as a problem, with patients often not completing the course of treatment. People in one of the community discussion groups referred more generally to the fact that local people do not necessarily follow medication instructions: ‘They just take it till they feel all right’. Alternatively they might miss a couple of days and then take a triple dose.

When Yura Yungi patients have to travel to urban centres such as Geraldton or Perth, it was noted, they cannot get free S100 medications.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 107 Perth, Western Australia - Urban

1 Background

Perth has a population of around 1.4 million people (2001 census), of whom about 3% are identiﬁed as Aboriginal or Torres Strait Islander. While there are small numbers of Aboriginal people living in most suburbs and a number of people still live reasonably close to the city centre, there are several areas with signiﬁcant Aboriginal populations located in the outer suburbs.

2 Derbarl Yerrigan Health Service Inc

ACCHS arrangements in Perth have changed considerably since the time of the 1997 study. In 1997 the Perth Aboriginal Medical Service (PAMS) operated from a single, inner city site. In 2006 Derbarl Yerrigan Health Service (formerly PAMS) has three clinic locations – one in new, purpose-built premises in East Perth, one at Mirrabooka in the northern suburbs, and one at Maddington in the south-west. (For a time it also operated a fourth clinic in the north-eastern suburb of Midland.) All three sites were visited by the study team in march 2006.

All three Derbarl Yerrigan clinics operate on an appointment system, but with some slots reserved for ‘walk-ins’. Each of the three clinics has its own Health Services Manager. The central clinic has four FTE GPs, two FTE registered nurses, and three AHWs; stafﬁng levels both at Mirrabooka and at Maddington are around half of this. Like numbers of other ACCHSs, Derbarl Yerrigan employs AHWs and some nurses to run various specialised programs such as Child and Maternal Health, Ear Health and Diabetes Education. It also employs several allied health workers, such as a physiotherapist and a podiatrist. Dental services are provided 5 days a week at the city clinic. Derbarl Yerrigan Home and Community Care (HACC) is another signiﬁcant aspect of the work of the health service.

Staff members reported difﬁculties in retaining experienced and Vocationally Registered GPs.

Derbarl Yerrigan patients normally see an AHW for screening purposes (eg checks of weight, blood pressure etc) before seeing a GP. In some circumstances the AHW may also see a patient after a GP consultation.

In total the three Derbarl Yerrigan clinics reported seeing some 7,300 individual patients in 2004-05; a total of 47,215 ‘client encounters’ was recorded (around 95% of them with Aboriginal or Torres Strait Islander clients). In line with stafﬁng levels, the inner-city clinic accounted for about the same number of client encounters as the other two clinics combined. Staff estimated that between them the three clinics have a core client group of around 5,000- 6,000 patients, and have seen a total of around 14,000 patients over the past three years. The vast majority of patients are Indigenous.

Derbarl Yerrigan employs drivers who provide transport for patients throughout the metropolitan area, including transport to hospital and specialist appointments as well as transport to and from Derbarl Yerrigan itself. Drivers also pick up and deliver medical supplies to patients.

108 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 Perth is by far the dominant urban centre in Western Australia, and it provides a far wider range of health and other services than are available elsewhere in the State. Accordingly substantial numbers of people, both Indigenous and non-Indigenous, travel to Perth for longer or shorter periods of medical care. For example, Derbarl Yerrigan manages the Elizabeth Hansen Autumn Centre which provides residential care for Aboriginal people from elsewhere in the State – mostly long-term renal patients.

It was emphasised that bulk-billing GPs are increasingly hard to ﬁnd in Perth, which tends to narrow the primary health care options for Indigenous patients. Staff at Derbarl Yerrigan believed there had been a consequent increase in attendance at its own clinics and at Hospital Emergency services. It was noted that Royal Perth Hospital now offers an after-hours GP clinic designed to ease pressure on its Emergency service.

Derbarl Yerrigan is not an accredited practice and therefore cannot access the Practice Incentives Program; it hopes to gain accreditation by the end of 2006.

Diabetes services

Derbarl Yerrigan employs a dedicated diabetes worker four days a week.

Glucose levels are checked as part of standard screening of Derbarl Yerrigan patients – along with blood pressure etc. Other relevant services include diabetes education, podiatry services and retinal screening. Diabetes patients also make substantial use of the services of an independent optometrist who practices three days a week at Derbarl Yerrigan.

Derbarl Yerrigan has been a participant in the trial of point-of-care diabetes testing, but tends to use this facility mostly in cases where staff are not conﬁdent that the patient is likely to return to collect pathology results.

Derbarl Yerrigan is a sub-agent for the National Diabetes Supplies Scheme (NDSS). It registers patients for the scheme, provides them with a card, and orders and provides patients with the relevant supplies (eg strips for home testing of blood). There are speciﬁed prices for NDSS supplies for various patient groups (eg pensioners, people with health care cards). However, Derbarl Yerrigan provides these supplies at no cost to patients (who often have other signiﬁcant health problems and little income), and raises the necessary funds in other ways. One of the advantages of participating in the NDSS is that it ensures regular contact between Derbarl Yerrigan staff and diabetic patients.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 109 3 AMS Use of Medicare

Derbarl Yerrigan

Derbarl Yerrigan (or PAMS as it then was) was receiving some Medicare income at the time of the 1997 study. Since that time its Medicare income has increased, though not as much as might have been expected.

Medicare income recorded in 1995-96, for example, was already around $250,000 (see Keys Young’s 1997 report). At the time of the present study Derbarl Yerrigan’s annual Medicare income was around $400,000; a significant increase was expected when patient records were fully computerised (using the Communicare system), but this has not eventuated. Seven FTE GPs, staff believed, should be generating considerably greater Medicare income; limiting factors were seen as including time pressures, insufficient understanding of the Medicare schedule among some GPs, and little use (or little claiming) of ‘premium’ items such as EPC care plans. Other people consulted in Perth agreed that there was significant under-use of the MBS by Derbarl Yerrigan, and believed that outside assistance and training were required to assist the Service to achieve significant changes.

The Perth-based MLO had visited Derbarl Yerrigan about a year before to offer Medicare information and training; it was time for another visit, staff said. The MLO had provided some ‘quick-reference’ material on the use of Medicare. Staff at Derbarl Yerrigan had little recollection of seeing the Medicare Toolkit. The information kit originally received about EPC items now needed updating in light of the changes made to care plans in 2005.

The Adult Health Check, it was said, is ‘taking off slowly’, but its requirements are quite demanding. There was said to be a need for further clariﬁcation of the potential role of nurses and AHWs in providing EPC services.

Some claims are made for nurses providing wound care and immunisation, but this tends to ‘depend on the individual’. It was noted that, in the absence of an agreed system of accreditation, AHWs in Western Australia are unable to claim rebates even for services such as wound care and immunisations.

The GPs have ‘paperwork’ time, and can all access the IT system direct from their desks. Derbarl Yerrigan also provides its doctors with regular feedback about level of rebates claimed.

Derbarl Yerrigan, like many ACCHSs, relies to a signiﬁcant extent on overseas-trained GPs. Since these may have little familiarity with the Medicare system, there can be particular problems in ensuring that they use Medicare fully and accurately. In any case, some overseas-trained doctors may only work on a part-time or sessional basis at the health service, which further limits its opportunities to inform and educate them about Medicare claiming issues. It was also suggested that some doctors have a ‘mindset’ that community controlled health services are fully funded by government.

GPs at Derbarl Yerrigan, who pay their own professional indemnity insurance, also argue that they have a conﬂict of interest in that their insurance premiums increase as they do more Medicare work. For some GPs, it was said, ‘Medicare is a bit of a pain’.

Derbarl Yerrigan’s current patient records are maintained in electronic form, though past records remain on paper. Medicare numbers for regular patients are kept on electronic ﬁle, and Medicare claims are now submitted on-line; this was said to have reduced the rate of rejected claims. Some 5,500 claims were made in the six-months period July to December 2005.

110 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 Staff often call the 1800 access line to check on missing or invalid Medicare numbers, expired cards and the like; usually the problem is fairly easily solved. A senior staff member at Derbarl Yerrigan commented that the service provided by the MLO and his staff represents ‘a huge improvement’ on what was available in the late ‘90s. It is easy to contact the service and the response is prompt; ‘That side of it is not an issue’.

If a newborn child is not enrolled in Medicare while the mother is in hospital after the birth, it will usually be enrolled the ﬁrst time the baby is brought for a check or for health care.

There was favourable comment at Derbarl Yerrigan on the extension of Australian Hearing Services eligibility to CDEP participants. It was also said that children’s ear health had greatly improved over recent years as a result of a strong focus by various programs and services; both parents and schools were said to be much better informed about the issues these days, and more active in seeking help.

WA Health Services in General

The Perth-based MLO noted that levels of Medicare claiming are very variable from one health service to another, and also that there are certain entitlements (eg the additional rebates for children and concession card holders that were introduced in 2004) that many fail to claim. It was said that resource limitations prevent the MLO and his colleagues from providing the level of ongoing Medicare education and support they believe is necessary.

Representatives of the WA Health Department similarly emphasised that there was substantial ATSIHS underclaiming of Medicare rebates, and that further training and support were necessary to signiﬁcantly improve the situation. They also made the point that adapting to the requirements of the Medicare system could require considerable cultural and organisational change, and that it was not realistic to expect health services to achieve this without substantial assistance. (Telling people that ‘It’s on the web’ was certainly not adequate.) Promoting a better exchange of information and experience among health services would be one useful approach. The AMS at Derby, for example, was seen as something of a Medicare leader among health services in Western Australia.

Certain key factors for effective take-up of Medicare were suggested – for example: adequate IT and patient recall systems good teamwork across the health service good ﬁnancial management both the CEO and the leader of the medical team need to be ‘on board’ and well informed.

The point was made that it is those services which are best resourced and operating most efficiently that are most likely to be able to tackle the challenges of Medicare and reap the financial rewards available. In this sense ATSIHS access to Medicare tended to exacerbate existing inequalities (‘the rich get richer and the poor get poorer’). It was suggested that Medicare Australia should conduct a study specifically designed to review and document best practice in the use of Section 19(2).

Some stakeholders noted that the ‘throughput’ of patients was in general considerably less at an ATSIHS than in a general practice, which meant that the potential Medicare income for an ATSIHS was low relative to mainstream experience.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 111 A number of people expressed interest in the ‘cashing out’ of Medicare entitlements, saying that this was particularly appropriate in remote or isolated areas where the population served could be accurately deﬁned.

It was seen as desirable for Divisions of General Practice to play an active part in supporting the roll-out of EPC items and other innovations, but it was also emphasised that the relationships between some ATSIHSs and their local Divisions remain very weak. For this and other reasons, it was suggested, NACCHO afﬁliates also need to play a role in promoting new learnings and capacity for organisational change.

The WA Aboriginal Health Council has applied to OATSIH for funding for a Medicare Enhancement worker, whose task it would be to provide further education for AMS staff in WA and to assist in improving systems. (It was noted that VACCHO has a project ofﬁcer with responsibilities of this kind.)

4 Mainstream Services

There were varying estimates of the proportion of the Indigenous population who use the services of Derbarl Yerrigan. However, there was agreement that there are ‘large slabs of Perth’ (for example the Midland area and the southern coastal suburbs) that are not readily served by the three Derbarl Yerrigan clinics.

Among people consulted in Perth there were frequent references to the fact that few mainstream medical practices now bulk-bill, and that for many Indigenous Australians this represents a signiﬁcant barrier to Medicare access. (This was said to be even truer in other parts of Western Australia.)

The study team spoke with the manager of a large bulk-billing practice, located in a suburban area of relatively high Aboriginal population. While she was unable to give a ﬁrm estimate of the number of Indigenous patients using the practice51, she noted that in the context of accreditation the RACGP these days encourages practices to establish whether or not patients are Indigenous. (There was a relevant box to be ticked on this practice’s intake form.) It was also noted that the RACGP has made funds available to the WA Aboriginal Health Council (a NACCHO afﬁliate organisation) to conduct a cultural awareness training program for doctors.

It was this practice manager’s observation that Indigenous Australians were generally ‘not keen’ on going to see the doctor and tended to postpone a visit as long as possible. In some cases the result was that the patient became acutely ill and went straight to the hospital. ‘They don’t routinely look after their health’, she felt, and problems often arose in relation to continuity of care. Some Aboriginal people were possibly put off by the need to make an appointment, she thought.

The practice sometimes had Indigenous patients present without their Medicare Card. However it was generally a relatively simple matter to obtain the necessary information by telephoning the 1800 information line, which provided ‘a very good service’.

Consultations with Indigenous patients were said to take longer than average because they often presented with relatively complex needs, and also because the doctors felt it important to take the opportunity to ‘cover as much ground as possible’. Again the GPs would, if appropriate, try to make referrals on the spot. The practice manager said that there had never been an issue about claiming for the actual length of consultations. The practice also aimed to claim any additional rebates to which it was entitled, for example in relation to children and holders of health care cards.

51 Her guess was ‘around 5%’.

112 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 This practice had not yet undertaken any Adult Health Checks. The practice manager said that these were time- consuming and required special arrangements to be made; they were ‘not easy to implement’. However, older Indigenous Australians tended to be an easier group to work with, and the practice had conducted some 55+ health assessments with regular patients.

Another former practice manager who spoke with the study team referred to what she regarded as a common lack of engagement by GPs with Indigenous patients. She believed that there was a tendency only to treat the presenting problems without making the further enquiries or suggestions (eg follow-up pathology tests) that would be common with a non-Indigenous patient. ‘They treat each incident as a one-off’ – possibly reﬂecting an assumption that the patient is unlikely to follow an issue through.

Pilot program involving Aboriginal Health Workers

The Canning Division of General Practice, in suburban Perth, has obtained funding for two pilot programs that are designed to improve Indigenous Australians’ access to mainstream GP services.

The ﬁrst of these is the GP Links program, which originated in 2003 and is funded through the WA Department of Health. It involves the identiﬁcation of local Indigenous patients who are being discharged from Royal Perth Hospital and who are not recorded either as having a GP or as being clients of Derbarl Yerrigan. With the aim of improving access to appropriate care and reducing hospital re-admissions, an Aboriginal worker seeks to link such people with a general practice or other suitable services.

The pilot has involved working with a network of about 90 GPs within the Division, who have generally responded positively to the initiative. Nearly 300 patients have been involved to date, and there appears to have been a fall in rates of readmission to hospital.

The second program, which began in August 2005, involves an experienced Aboriginal Health Worker assisting a number of general practices in offering Adult Health Checks to Indigenous patients. Working in practices with relatively high numbers of Aboriginal patients, the AHW aims to identify people who will beneﬁt from the Health Check and to initiate the process, which is then completed by the GP52. In part the aim is to overcome initial GP resistance to new procedures such as the Adult Health Check, by making it as simple as possible for them to start providing these. This program has been funded by OATSIH, initially on a 12-months basis. A cultural awareness component for GPs has recently been introduced.

At the time of the study team’s visit the AHW was working with two practices in particular, devoting two days a week to one of these and a day a week to the other. (In one of these practices, which has some 400 Aboriginal patients on its books, the principal GP formerly worked with Derbarl Yerrigan.) The AHW either visits patients suggested by the practice (in which case the Health Check may begin in the home), or approaches people directly at the surgery (where the Check can sometimes be conducted on the spot). It was noted that practices vary in their capacity to identify patients who are Indigenous. The AHW also assists in ensuring that the patient receives any follow-up services that the Health Check may show are necessary – for example additional pathology tests, mammograms and so on.

The GP claims the appropriate Medicare rebate for providing the Adult Health Check, and the Division bills the practice $55 for the AHW’s work.

This second project is to be expanded to cover the new Health Check item for children aged up to 15 years; extension of the scheme to cover care plans is also under consideration.

52 As quoted in the Port Augusta case study, a similar pilot scheme has recently been set up through the Division of General Practice in that town.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 113 Specialist services

Some Perth stakeholders noted that the current S19(2) exemption applies only to non-referred services, and argued that changes need to be made to facilitate ATSIHS provision of specialist services.

WA Health Department representatives noted that the community controlled health service at Geraldton pays a number of specialists directly to provide services; it is unable to claim any Medicare rebates relating to their work.

5. Medications

Derbarl Yerrigan formerly paid PBS co-payments on behalf of all patients, but reached the conclusion that it could not afford to keep doing so. It still spends a substantial sum each year on co-payments, but has clear criteria as to the situations where it will do so (for example, only those with health care cards are normally eligible). Derbarl Yerrigan also covers the cost of medications required by people visiting from other parts of WA where they would normally be entitled to free medicines under the S100 arrangements. Derbarl Yerrigan also pays the cost of certain over-the-counter medications for some patients.

Derbarl Yerrigan maintains an in-house supply of certain drugs that its GPs dispense, eg to elderly people involved in the Home and Community Care (HACC) program. It still makes some use of drug samples, also.

A community pharmacy located on the edge of the city has an arrangement to dispense medications for which Derbarl Yerrigan covers the co-payments. Many of these are regular prescriptions for patients with chronic disease. The pharmacy also has a contract to ﬁll blister packs for Derbarl Yerrigan patients.

This pharmacy reported encountering some problems with Indigenous ‘walk-in’ customers who do not have a correct or current Medicare card or health care card. Initially the pharmacy will contact Derbarl Yerrigan for information; if necessary the pharmacy will then ring ‘Medicare enquiries’ (the 1300 line), who can sometimes help and sometimes not. If necessary and appropriate, a prescription can be dispensed using the emergency Medicare number.

The pharmacy maintains records that enable Derbarl Yerrigan to claim Safety Net entitlements in respect of regular patients for whom it makes the PBS co-payments. The pharmacy knew of only one or two individual Indigenous customers who beneﬁted directly from reaching the Safety Net threshold (Use of the Safety Net was said to be relatively rare among the pharmacy’s customers generally, Indigenous or otherwise.)

Compliance was described as a major problem, particularly for people with multiple complaints and a complex medication regimen; blister packs were a valuable aid in such cases.53

At this community pharmacy there was reference to ‘the new 20-day rule’ which means that a prescription does not count towards the Safety Net Threshold if it is dispensed within 20 days of the last prescription. It was noted that, depending on individual dosages, there were numbers of medications for chronically ill patients which might need to be dispensed at less than 20-day intervals. This meant additional cost for Derbarl Yerrigan or, alternatively, extra work to seek exemptions from the effect of the new rule.

53 Ad admission to hospital, it was noted, often proved disruptive or confusing in relation to ongoing medication.

114 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 Numbers of the people who took part in consultations in Perth emphasised that cost was a major barrier to Indigenous Australians accessing the PBS. For example, people associated with the Canning Division of General Practice (see section 4 of these notes) emphasised the difﬁculty that non-card-holders experienced in affording the PBS co-payment. They also commented that it is rare for an Indigenous family to claim entitlements under the Safety Net. Social work staff consulted at Royal Perth Hospital likewise stressed the difﬁculty that employed people have in paying the full PBS co-payment for every prescription, and again said that the PBS Safety Net appeared to be much under-used.

The manager of a suburban general practice commented that even the concessional PBS co-payment of $4.70 was a barrier ‘when you’ve got three sick children’, while ‘nearly $60 for two scripts, just like that’, was a major expense for someone not entitled to a health care card.

Staff at Derbarl Yerrigan likewise noted that the cost of purchasing medications can be a significant problem, even at concessional levels. There are many people (for example students on traineeships or on AbStudy) who do not qualify for a health care card but have great difficulty affording the cost of PBS prescriptions. As a result they may get delay in getting scripts filled, have them dispensed only one at a time, or try to ‘eke them out’ by using them less often than instructed.

6. Community Perspectives

Participants in the community discussion conducted at Derbarl Yerrigan were well satisﬁed with the services they received there – for example they were happy to be able to obtain their medications in blister packs which were easy to use. They reported no problems relating to the use of Medicare cards or health care cards, whether at Derbarl Yerrigan itself, at a pharmacy or at a hospital. They expressed no reservations about use of the VII. One woman commented that renewing her Medicare card had been straightforward, but that it had taken time to receive the new card.

Community members in this group indicated that Derbarl Yerrigan was where they mostly came for health care. On occasion, however, they would visit a bulk-billing GP if this was closer or more convenient. Beneﬁts of using Derbarl Yerrigan included transportation and medications provided free of charge. One woman recalled that when using a community pharmacy in the past she had chosen a chemist who allowed you to ‘book things up’ (ie who offered credit).

As in a number of the groups conducted elsewhere, there was uneven awareness or understanding of various entitlements (including, for example, the circumstances in which spectacles could be obtained free of charge, which forms of dental treatment did or did not have to be paid for at Derbarl Yerrigan, Safety Net provisions and the like).

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 115 Issues that were raised by other community members included the following:

Some people prefer to use private GPs rather than Indigenous-speciﬁc services because they feel the former offer them greater privacy. GP services are also closer at hand for most people, and it may be ‘easier to get in’. There is a clear preference for bulk-billing practices.

General practices may be able to use samples etc to provide some patients with free medications.

There can be communication problems and doubt about quality of service with some overseas-trained GPs.

There is always a temptation to put off going to the doctor, hoping that the problem will ﬁx itself (‘I don’t go unless I’m desperate’).

There are somewhat mixed reactions to the need to make an appointment to see the doctor.

There is a lot of undiagnosed or untreated illness among Perth’s Indigenous population.

Families tend to treat child immunisation as the mother’s responsibility.

Many people, including employed people on modest wages, have difﬁculty affording PBS co-payments. Some doctors, knowing this, try to ﬁnd ways of not prescribing PBS medications; for example they may tell a child’s parent, ‘Give ‘em Panadol and see how they go’.

One participant acknowledged that he sometimes failed to get prescriptions for his children ﬁlled because money was tight.

Only one participant had ever qualiﬁed for the PBA Safety Net concessions. Several had not heard of the Safety Net.

116 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 Echuca, Victoria - Rural

1. Background

Echuca is a town situated on the border between NSW and Victoria. It lies on the Murray River, approximately 205 km north of Melbourne. It is accessible by the Hume and Northern Highways.

Echuca belongs administratively to the Shire of Campaspe.

According to the 2001 Census, there were 10,717 people living in Echuca, of whom 317 (3%) identiﬁed as Indigenous Australians.

The main local industries are agriculture, forestry and ﬁshing, manufacturing and tourism.

2. Njernda Health House

While it is reported that the Aboriginal population numbers just over 300 people, the local AMS – Njernda Health House – has 1500 people on its books. Some patients are reported to be from Moama, which is ‘over the river’ in NSW.

Management at Njernda Health House have considered how to respond to the needs of ‘the battlers round town’ who are non-Aboriginal and seek the bulk billing service available at Health House. However, the decision was taken that the service be limited to Aboriginal people and their non-Aboriginal partners.

Health House reported frequent meetings with the previous Melbourne-based MLO who was described as having provided a great deal of support in terms of information sharing and problem solving, as well as handy tools such as a ‘ready reckoner’ of frequently used Medicare item numbers. The frequency of visits and the skills of the MLO had clearly been signiﬁcant factors in Health House’s conﬁdence in managing their Medicare systems. At the time of the study team’s visit a new MLO had recently been appointed.

Njernda Health House (Health House) provides eight GP clinics each week, across four days. About 15 appointments are provided each day, of about 30 minutes duration each, plus a walk-in clinic.

At this stage all Medicare income goes to support the doctors’ salaries. Health House formerly used a roster of GPs from private practices in Echuca, who took their Medicare income with them. Health House was concerned that those consultations were too short, and concluded that continuity of care would beneﬁt from a different arrangement.

The approach to quality improvement and service development described by staff at Health House was proactive and constant. For example, an increase in Hepatitis C had been picked up, so they sourced funds to have a research project look into reasons and responses. When concerns were rising about the number of young people using drugs, the approach was to ring around other services to see what was working or being tried elsewhere.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 117 EPC items

Health House sees EPC Care Plans as particularly positive; staff reported that they have included strategies in their Action Plan for this year to implement Care Plans. The Practice Nurse currently does part of the assessment, but could spend a couple of months chasing up information and following up issues and questions needing to be addressed.

PIP

Health House is due to be re-accredited in late 2006. The original accreditation was achieved with the (paid) assistance of the Division of General Practice, which provided a worker to attend to the technical requirements. The Division will assist with this year’s process as well.

Immunisation

Immunisations are offered on a walk-in basis, which allows nurses to provide them as the opportunity arises. Online access to the recalls on the Immunisation Register was reported to be important in achieving better immunisation rates. For example, the Health Worker can be asked to bring a vulnerable person in if there is a concern that his/her immunisations are falling behind.

Workforce problems

The major workforce issue that was raised at Health House pertained to EPC items, and the lack of staff available to provide them. One GP commented on the particular challenges of working in an AMS, particularly in terms of availability of administrative support. While the commitment was there to make the service as effective as possible, it was a challenge to get the most out of Medicare with the equivalent of one doctor and business systems that were less than streamlined.

Medicare training

It was said that training is only useful if it is tailored to the learning needs of each person and the particular context of each AMS. In late 2004 Health House set up HIC Online, and staff are very pleased with the resulting improvement in their management of Medicare claims. One and a half days of training was provided through the (then) HIC. Greater familiarity with the relevant item numbers has led to higher rebates.

118 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 3. Other Health Services

Echuca Regional Community Centre has a hospital which serves the Echuca/Moama area and also a large portion of South Western NSW. It consists of an acute hospital complex, residential aged care facility and a primary care centre.

The Hospital Accident and Emergency Manager reported that the majority of people now present with their Medicare card, and certainly that most are registered even if they are not carrying their card on presentation. In these situations the Medicare number may be available from records of a previous admission, or else a relative may bring the card to the Hospital.

The Hospital’s Aboriginal Health Worker reported that it was a frequent task to remind Maternity Unit nursing staff of the importance of the Medicare registration forms provided to women who have given birth.

4. Use of mainstream GP services

Staff at the Hospital reported that it was older people who tended to use private GPs rather than Health House. The reasons for this included the existence of a long-standing relationship with the GP established prior to Health House being set up, and the continuity of care which older people valued.

Generally, however, Aboriginal people were thought to prefer to use Heath House because it is community-controlled and within their ‘comfort zone’, whereas there may be some fears held about other practices. The availability of bulk billing is of course a central draw card, but the quality of the service also matters to people. Health House staff reported that they are constantly reviewing practices, identifying training needs and addressing ‘all the little things that add up to a quality service’.

5. Allied health services

A podiatrist from Bendigo attends Health House one day each month, and a counsellor and a psychiatric nurse one day each week. A local optometrist attends one day each fortnight. An acupuncturist, masseuse and a physiotherapist also hold weekly day-long clinics which are consistently booked out. Problems were reported in accessing services in relation to mental health and alcohol and other drug issues.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 119 6. Medications

Affordability remains the major problem with use of medications. A number of community members, for example, described the ﬁnancial burden of their poor health. One person said that she spent $140 every three weeks, yet when her GP looked into her eligibility for the PBS Safety Net, she was just short of the level of expenditure required. The Hospital has a general policy of not dispensing medication, but in particular circumstances discretion is used.

The role of the community pharmacist was highly valued by Health House; it was thought essential that people get the correct information about the medication they will be taking. This view is likely to be informed by the extremely good relationship that Health House enjoys with a very dedicated community pharmacist in Echuca, and the close walking distance between Health House and this pharmacy. If concerns are held that the patient will not get a script ﬁlled, a Health Worker can take the patient to the chemist, wait and then transport them home.

Health House have allocated approximately $17,500 this ﬁnancial year to cover co-payments through their account with the local pharmacy.

Compliance

Re-presentation was reported to be a common outcome of people not taking their medication properly. This was said to be an issue amongst both Aboriginal and non-Aboriginal people in the area. Community members agreed that it was common practice not to complete courses of medication. One community member put it this way :‘Take it til you feel good, put it in the fridge til you feel crook again’. Some said it is a choice people make and that self responsibility is key, whereas others thought Health Workers should be checking in on vulnerable people to ensure medications are taken.

Clear labelling and instructions were important, including the size of the writing and alternative forms of instructions for people unable to read well. Doses were also reported to be confusing at times, for example a 50mg dose being given in a 100mg tablet.

Suggestions were made for an education campaign which could include photos of what can happen if conditions do not clear up and or become contagious as a result of not ﬁnishing antibiotics. It was strongly felt that this should be an interactive campaign, not limited to TV advertisements but rather including a role for the community.

7. Community awareness and understanding

The community discussions conducted in Echuca revealed a high level of satisfaction with Health House in terms of the efforts made to ensure people are registered for Medicare and the ease with which Health House achieves this. There was, however, a low level of understanding about many aspects of Medicare, including the Safety Net and claiming of rebates for specialist services.

Community members who were consulted included a number of young men, all of whom either had a Medicare card or were still on their mothers’ cards. A couple of the young men did not know they could get their own card, while others said it was useful for contributing to 100 points of ID, with a Medicare card being worth 20 points.

120 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 Western Sydney, New South Wales - Urban

1. Background

The suburb of Mt Druitt is part of the area covered by Blacktown City Council. The Council’s Social Plan 2001 indicates that Mt Druitt has a population of 11,390 people, and also shows that it is a suburb with quite a mobile population, with only 49% of residents living at the same address over the past five years. Nearly half of the population was born overseas, including a significant number of people born in Asia, the Pacific Islands, Iran, Greece and the former Yugoslavia. Some 25% of residents come from non-English speaking countries (predominantly the Philippines). Mt Druitt is socio-economically disadvantaged, with a high proportion of people on low incomes, high unemployment levels (12%), relatively low post-school qualifications and limited access to private vehicles.

The Blacktown City Council area has the largest Aboriginal and Torres Strait Islander population in NSW, with a total population of 5,240 persons (2.5%). A large portion of the population, both Aboriginal and non-Aboriginal, are former inner city and rural residents who have been resettled under the State Government’s public housing programs. Many Aboriginal families are originally from the west and south of the State, from towns such as Brewarrina and Cowra.

The Aboriginal population includes people who permanently reside in the area and also a signiﬁcant number of people who are visiting relatives or are transient.

2. Range of services

Daruk Aboriginal Medical Service

Daruk Aboriginal Medical Service was established in 1988 to provide health care to the people within an area originally deﬁned by Mount Victoria to the west, Colo Heights to the north, Silverwater Road to the east and Elizabeth Drive to the south – an area of some 4,000 square kilometres. While Daruk’s charter deﬁnes the region it is responsible for, the service is used by many people who live well beyond those borders and the ‘expansion’ of its catchment area continues.

At the time of the earlier Keys Young study, the service was housed in a small, cramped building. Since then, a much larger, purpose-built facility has been constructed including administrative ofﬁces, clinical/doctors’ rooms, a staff break-out room, a spacious waiting room etc. Nevertheless, it was stated by several staff that Daruk has already outgrown this facility, that careful scheduling is required to accommodate the doctors working there, and that clinics and group programs are constrained by a lack of suitable space.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 121 Daruk holds 14,000 patient ﬁles (at the time of the previous study they held some 6,000 ﬁles), although the estimated number of new patients seen is equivalent – about 40 a month. The growth derives both from newborns of current patients, and also from country people continuing to move to the city. It was stated that ‘There is no good medical care available in most country towns – whether you’re white or black’. ‘Lots of older people come down – ‘cause their kids live here – and once here the old people don’t have a reason to go back’. As well, there are transient people who are actually drawn to Mt Druitt to obtain medical services at Daruk where they are assured of getting care in a sympathetic environment. A very small percentage of patients are non-Indigenous, often being spouses/partners. Certain services (eg dental care) continue to be available only to Indigenous patients and their immediate families, because of the high cost and demand for these services. Staff determine patients’ eligibility (ie Aboriginality) to use the dental program by checking family linkages and through informal networks.

Currently Daruk has a complement of 50 staff, including doctors, nurses, administrators, health workers, program/ project ofﬁcers and transport drivers. There is a total of 12 doctors on staff – all work part-time, anywhere from one to three days a week. A comprehensive range of medical specialists see patients at Daruk, conducting clinics there. These include one or more psychologists, psychiatrists, paediatricians, ENT specialists, chiropodist, dentists, midwives and other specialised nurses, obstetricians, and a rheumatologist. In most instances, the specialists are salaried by NSW Health, working in various hospitals in Western Sydney. Generally they attend Daruk weekly, and some have been doing so for many years (in the case of one obstetrician, for 15 years). A number of specialist nurses or health workers work full-time at Daruk. Numerous programs, such as a Social and Emotional Well-Being program, operate out of Daruk, utilising staff such as child and family workers, nurses and Aboriginal Health Workers. A hearing (otitis media) program targeting all primary school children is seen as a particularly critical service.

Daruk provides transport to and from the centre (and sometimes to other health facilities) to needy patients – older people, mothers with young babies and people with a disability. Transport is also provided to take the body of a deceased person back to the country if necessary.

Registrars from Daruk service four Western Sydney prisons – Emu Plains, Lithgow, Parklea and John Morony; each prison is visited one day a month. These are Daruk’s only outreach programs.

Daruk is relatively unusual in that is reported to have little problem recruiting GPs and has a very stable workforce. As one person said, ‘We are very lucky – we attract great GPs who want to work here and stay for many years’. Undoubtedly it is the urban location that contributes to the ease of recruiting doctors, as well as the ability to offer part-time work and the provision of a very rich array of local supporting and ancillary health services. Nonetheless, the GPs consulted at Daruk indicated that it is an interest in social medicine that remains the prime motivator in their working at Daruk. The ability to better deliver considered, holistic care to a high need group is professionally satisfying.

Public hospitals

Mount Druitt, Hawkesbury, Blacktown, Nepean and Westmead Hospitals are the main public hospitals in the area. However, given Mt Druitt’s proximity to Sydney city (direct train link), patients may also be referred to other major city hospitals. Western Sydney Area Health Service employs Aboriginal Liaison Ofﬁcers who act as go-betweens for Indigenous patients and medical staff, and operate out of the local hospitals.

122 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 Medical Practitioners and Allied Health Services

In the Mount Druitt area there are a large number of general practitioners, and the Aboriginal community members who were consulted indicated that most have a family doctor (GP) whom they use in conjunction with Daruk and other health services (these GPs may be located in nearby suburbs such as Tregear, Bidwell, Lethbridge Park).

For some, the relationship with their GP spans many years, and one of the attractions of sustaining the relationship is the fact that their doctor has a quite complete ﬁle covering their medical and medications history: ‘My doctor knows what drugs I’m allergic to, and I’ve had to be on drugs a lot. I need to be conﬁdent about what I’m taking’. The decision to go to their GP, to Daruk or another health professional is often determined by practicalities – the GP might or might not be able to see patients when they want, or they may be in the vicinity of Daruk on a particular day. People judged the standard of care of their GPs and Daruk as being comparable, and they clearly felt comfortable with their private GPs. Some Daruk patients indicated that occasionally they would even go to Redfern AMS, ‘if Daruk is busy’.

In addition, a full range of allied health services is provided in this area by private organisations (eg Douglas Hanly Moir Pathology, Castlereagh Radiology) or through the public hospitals.

Community Pharmacies

There are a number of chemists located in the Mount Druitt shopping centre and one pharmacy is located very near Daruk. Daruk has an account with the nearby chemist and occasionally sends a patient with a script there with Daruk meeting the co-payment.

The community members consulted all said they regularly used one or more community pharmacists and, again, reported generally positive relationships with them.

3. Issues relating to Medicare

Enrolment

Daruk early on began using Ferret, a computerised health management system which has enabled staff (among other things) to keep accurate records of patients’ Medicare status. Daruk continues to use this system, with staff observing that ‘Ferret is pretty good – it lets us keep track of our patients’.

It is believed that enrolment in Medicare is at a very high level – ‘Once a week or so, someone comes in without a Medicare number. We let them have an occasional freebee – but we insist they ﬁll out the [enrolment] form if they don’t have a card. Often this involves a baby or child in the family’. Some mothers report that they have lost the ‘blue book’ – the State-health issued immunisation record – and Daruk tries to replace as much of the child’s record as possible.

It was felt that the Medicare enrolment process was well in hand at Daruk and that the support of the MLO was not really needed now for enrolment purposes. At the same time it was noted that the Mt Druitt Medicare ofﬁce has closed and that people now have to go to Blacktown or Penrith if they need to visit Medicare.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 123 Adult non-enrolment was largely accounted for by transient and rural/remote patients. Sometimes the Medicare number or card given by a patient has expired, but the Enrolment and Amendment form is said to easily filled in and copies are always kept at Daruk. (While the researchers were visiting, one young woman who was without a Medicare Card was given the form. She opened it and, obviously dismayed, asked ‘Do I have to fill all of this in?’ She was instructed to fill in just the relevant sections, suggesting that the service found the form very accessible whereas individuals might not.)

Locating Medicare numbers

Relatively few patients fail to bring their Medicare cards with them when they come to Daruk – the system was described as being ‘pretty good’. If the Medicare number is on ﬁle and is correct, there is no problem. When Daruk needs to ﬁnd out someone’s Medicare number, they usually ring the Help Line. If a regular staff person was not on the line the service might not be as satisfactory – especially if their English isn’t good – then it might result in a ‘can’t do’.

There were some criticisms to the effect that ‘it takes six to eight weeks to get new cards’ and that ‘you only get ﬁve lines on a card. A couple with eight kids needs two cards’.

Medicare claiming (including EPC items and PIP)

At the time of the earlier Keys Young study, Daruk was making Medicare claims in a fairly hit-and-miss fashion. The very patchy Medicare enrolment amongst Daruk’s clients meant that the difﬁculties of administering the Medicare system inevitably resulted in equally patchy claiming practices. Daruk is certainly attempting to maximise claiming now. This is facilitated by use of a ‘cheat sheet’ as shown below, with the most common MBS items listed.

The ‘cheat sheet’ is sent into a consultation with the patient and passed to one of the administrative staff at the end of the consultation. Both administration and doctors are conﬁdent that they are generally claiming at an appropriate level. This familiarity with the system is facilitated by the stability of the workforce – some staff (both medical and non-medical) having worked at Daruk since it opened. One doctor, however, noted that medical staff do not receive training in regard to Medicare claiming, and so are in the hands of the administrative staff to pick up under-claiming. The bulk of consultations are said to be ‘36s’ (long consults) as ‘we have enough doctors so they can take their time’. One of the GPs suggested that he was occasionally concerned about the possibility of coming under Medicare scrutiny over the length of consultations, but added that ‘Aboriginal health requires longer consults – what would be “long” by usual standards is the norm when working with Aboriginal patients – so you probably underestimate the length of the consult’. As a consequence of these two factors he reckoned that he probably under-claims general consultation items.

There was agreement at Daruk that Adult Health Checks were ‘not really up and running – we need to ﬁnd a system for doing them’. Often patients do not want to wait around after presenting with another health problem, and the notion of holding ‘Health Check’ days was being examined. It was also said to be difﬁcult to achieve a 90% ‘immunisation rate in a practice as large as Daruk’s, and one with a marked degree of patient transiency’.

124 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 DOCTORS INITIALS PLEASE:

NAME:

Adult Health Adult Health Short Standard Long Prolonged Check Assess 3 23 36 44 710 (Under 55) 704 (Over 55)

Antenatal Attendance AnteNatal Cardiotography 16500 16514 (10990)

Home Visits

Brief Standard Long Prolonged 58 59 60 65 Not more More than More than More than than 5 min 5 min 25 min 45 min

Tests:

Hb (AIC) PTest ECG Tympanometry 73,40 73806 11700 11330 (74990) (74990) (74990)

Audiometry Urinalysis Spirometry 11306 73805 11506 (10990) (74990) (74990)

Nurse Immunisation Item Nurse Wound Management 10993 10996 (10990) (10990)

Items for Health Care cards and children under 16

Medical Service Unreferred pathology service 10990 74990 always put what pathology eg Urinalysis or Preg Test

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 125 The NSW Medicare Liaison Officer indicated that there is at present insufficient training of MLOs, for example around communicating to health services how to claim various MBS items. It was said that MLOs lacked a clear understanding of the clinical nature of many items, hence were unable to confidently explain what constituted appropriate claims. The MLO added that ‘cheat sheets’ were useful but ran the risk of emerging, frequently used item numbers not being added or else, if in an electronic form, being skewed to the first items on the list because the whole field was not in view on the computer screen.

It was noted that the AMSs tend to be the primary focus of the MLOs’ training and education activities, leaving little time for outreach work amongst those in the community not necessarily linked up with an AMS (eg youth, homeless people, drug addicts, those in refuges etc).

Daruk is not eligible to receive any PIP payments, since it is not an accredited practice. There is a degree of interest in/concern about lost PIP revenue; the Daruk doctors have not yet been able to address this issue, but feel they should.

Currently the administrative staff share the job of processing Medicare claims and they are currently introducing online claiming. OATSIH personnel indicated that Daruk has, in recent years, greatly expanded its clinical services but that its ﬁnancial management has not kept pace. They are actively working with Daruk administrative staff to help develop management systems and to train staff up, but issues like cash ﬂow remain a problem.

Specialist services

As noted earlier, there is a very broad range of specialists – both medical and allied health services – who conduct clinics at Daruk. In addition Daruk has a group of external medical specialists whom they use frequently (‘They bulk bill’). If a particular specialist doesn’t bulk bill, Daruk simply refers on to one who does or, alternatively, they work through specialists at the various local hospitals. One doctor indicated that in this location the availability of a specialist is not always the main barrier to use of specialists: ‘Getting someone to see a cardiologist if they don’t see the need can be a problem. We have to make the appointment and provide transport if we want to make sure they go’.

A number of the community members consulted for this study spoke of ways they managed accessing (and paying for) specialist care and/or various tests. Often, in the ﬁrst instance, they would use Daruk or be referred to a specialist in hospital. When faced with the need to have, say, an MRI or brain scan carried out, they generally have to save up for such a procedure. One man consulted said that he has, in the past, put the cost of expensive tests on his credit card and had the test done sooner rather than later. He indicated he would then need to save up the money to pay off the credit card. (Few of the other people consulted had credit cards.)

Dental services were identiﬁed as the area of greatest need and, of course, dentistry is not claimable on the MBS. For a lower income community such as the Indigenous population in Mt Druitt and surrounds, dental care at standard fees is simply not an option. The point was made that dental care is an essential element in a person’s overall health and well-being and that services like Daruk can’t meet the demand. As noted elsewhere, some community members will ‘shop’ between AMSs in an attempt to get free or affordable dental care.

126 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 Links between primary care (Daruk) and hospital care are facilitated by the existence of Indigenous Liaison Officers in the nearby hospitals. One such long-serving officer sees 35-40 Aboriginal patients a month at the hospital where he is based; he acknowledged that he was burning out in the job. ‘This is a welfare suburb and too many people have a welfare mentality. We need to try to make people more self-sufficient instead of always expecting everything will be given to them’. He described the common occurrence of an ambulance being called when someone was severely alcohol or drug-affected, being brought to hospital and having the affected person abuse hospital staff, only then to shortly sign themselves out of hospital. ‘One of the rules is, that if you want to leave, they have to find their own way home’.

Preventative programs

Numerous health workers pointed to the need for a greater emphasis on preventative measures and programs – like smoking cessation, parenting courses, drug and alcohol programs.

The need for a greater focus on parents and young babies/children was particularly supported by a NSW Health worker in the area. The Health Department has initiated a Home Visit program for all new mothers and from this has developed a longer-term, more intensive care program for families with high needs. The health worker suggested that antenatal care and a focus on young children 0-12 years were the areas of care most needed. She acknowledged that chronic care (eg diabetes) and interventions around family violence were also greatly needed, but could not see these needs being addressed in any signiﬁcant way in the short term.

Some GPs at Daruk also spoke of the need for a greater emphasis on outreach work (eg immunisation, men’s groups, links with refuges), as well as more preventative programs (eg healthy eating, diabetes management, exercise classes). In summary, what was needed was a ‘pro-active, health’ approach rather than a ‘preventive, illness focus’.

Daruk spokespeople suggested that one of the constraints to running more group programs was, as already noted, a shortage of space in the existing building. For example, there appears to be a need for a problem gambling counselling service, which would be run by an external agency at Daruk – space permitting. (Daruk seems to have quite a close and effective relationship with NSW Health, partnering on a number of initiatives. However it was clear that Daruk maintained control over the direction that these initiatives took.)

PBS and Pharmaceutical Usage

Daruk maintains a small supply of medicines on site – mostly samples, starter packs etc. In the view of one of the longer-serving GPs at Daruk, ‘compliance is pretty poor. I’d say 30% either don’t get their scripts ﬁlled at all, or else delay until they can afford it’. Many (or even most) community members are unemployed or are on low- incomes, hence would hold concession health cards. The group consulted, all of whom were on CDEP, held health cards although not all knew the card by this name (some referring to it by reference to its colour, for example). The ‘compliance’ picture they presented was somewhat more optimistic than that described by the GP. All said that they used community pharmacies and indicated that they sought, and received, good service from them.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 127 For example, a number of people said their pharmacist would check to make sure they knew how to take their medication, or might ask if they wanted a generic substitute for the brand prescribed. Many in this group of consumers seemed to be fairly sophisticated in their use of medicines – being cautious about their usage of medication and indicating they actively sought advice and/or were open to advise on the proper use of medicines. One person said ‘I’m allergic to certain antibiotics so I have to be very careful what I take. My GP knows this but I still always check my medicine’.

Nevertheless people indicated that the co-payment sometimes or often proved a hardship – especially for those on multiple medications or those with larger families.

Community members reported that they are frequently asked to show their health/pension cards and Medicare cards, even at pharmacists they use often. Rarely is this a problem and they say that the chemists keep records and look up their numbers if, by chance, they don’t have their card on them. Only one person indicated she had had a problem in this regard – when she took a nephew to her pharmacy and he didn’t have proper identiﬁcation.

When Section 100 was discussed, both local OATSIH personnel and Daruk GPs suggested that expanding Section 100 to an area like Mt Druitt would make sense and would almost certainly improve access of local Aboriginal people to needed medicines. There was an understanding that extending Section 100 to Daruk would not be without certain problems – administrative and political. However, it was judged not to be particularly expensive and likely to bring significant benefits to patients – given the perception that cost is a continuing barrier to getting scripts filled (or at least filled in a timely manner). As one health professional said, ‘They often don’t even have money for bus fare, let alone medicines’.

128 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 Riverina, New South Wales - Rural

1. Background

The City of Wagga Wagga is the regional centre of the rich agricultural district of the Riverina. Before settlement it was populated by the Wiradjuri people. At the time of the 2001 Census the population of Wagga Wagga was approximately 55 000, of whom 1765 (4%) identiﬁed as Indigenous Australians.

2. Nature of Services

Wagga Wagga has a regional hospital with 222 beds, specialists in most of the major health areas and an Emergency Department. There is also a private hospital with 100 beds (Calvary Hospital) which provides acute surgical, medical and obstetric services. Other health-related services in Wagga Wagga include ﬁve pathology laboratories, seven nursing homes, four retirement villages and four early childhood centres.

Riverina Medical and Dental Health Service (the AMS) was incorporated in 1988, and has received funding as such since 1998. At present the Service has the equivalent of 2.5 General Practitioners (shared across four positions), a Practice Nurse, one fulltime and one part time Aboriginal Health Worker, a 0.8 Maternity Nurse and fulltime maternity assistant, and a fulltime receptionist. It has also committed to two enrolled nurse trainee positions, and is an accredited training site with the Nurses Registration Board. As a result of this program three Aboriginal Enrolled Nurses have graduated in the past two years.

The Service has approximately 4000 patients on its books, all Aboriginal except for spouses/family members. The point was made that in the last few months more homeless people were presenting, and were likely to have chronic conditions as well as mental health problems.

3. AMS Use of Medicare

Medicare was described by one specialist as having ‘lessened the ﬁnancial burden and improved outcomes for Aboriginal people’. The income generated through Medicare claims was reported to have enabled the AMS to better attract sessional GPs and to retain them over time. AMS staff estimated that they were claiming around 80% of what they might be entitled to claim, but pointed out that there is no straightforward way of knowing whether they are achieving all they could.

High levels of Medicare enrolment were reported amongst the local community; it was said that a person who is not enrolled presents to the AMS only about once or twice a year. The group which continues to be slow to be enrolled is infants; however it was said that with online Medicare access and dedicated forms this was being addressed when women presented with their babies for AMS medical appointments. About three times each month a newborn was brought to the service who had not been registered, and this was remedied through use of the Indigenous-speciﬁc enrolment form and the 1800 number.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 129 The 1800 telephone information service was described as ‘excellent’; this particular AMS was in contact with the service 10 to 15 times each week. The matters on which they contacted the service included expired cards, changes of address, new enrolments, and queries about item numbers. Staff were not very familiar with the Medicare Liaison Ofﬁcer role, saying that they had ‘tried to get a Medicare visit’ without success so far54.

Communicare was installed about 12 months ago, and was identiﬁed as a signiﬁcant plus. Prior to the online system, AMS staff reported they had not claimed for many of their services and that a great deal of potential income had been lost. The cost involved in getting the system in place was reported as approximately $70,000, which had been covered by a grant from OATSIH, with some Medicare funds. The service currently occupies one staff member one day a week, whose role is to maintain the systems and knowledge needed to maximise income from Medicare, and to make sure other people in the service have the appropriate information they need.

The suggestion was made that telephone calls should be claimable under Medicare. The example given was the WorkCover arrangement where telephone calls are paid at a rate of ﬁve-minute units. This was seen to be particularly relevant in regional and rural settings where the absence of the full range of specialists and allied health workers leads to time-consuming practices of seeking referrals outside the local system. It was said that ‘the longer you spend with someone the less you get paid’, which was seen as a disincentive to providing a thorough and holistic service.

Another item that practitioners would like to see on the Medicare schedule is injections, which are currently limited to immunisations.

EPC items

A number of problems were identified in using the EPC items. The amount of time involved in undertaking the Adult Health Check (at least an hour) was seen as problematic given the pressure of other work. It was reported that it is difficult to get patients back for appointments, and there was also some propensity for patients to say ‘yes’ to every question, and to be unable to respond in detail to questions about previous health treatments. In terms of transporting patients back into the clinic to undertake the Health Check, the point was made that if health workers are doing the transporting they are not then available for the clinical tasks they are qualified to perform. Another issue was the physical space required by Health Checks; with the drop-in clinics, regular GP clinics, and specialists providing clinics out of the AMS, it was said that there is simply no physical space available for assessments to be done.

Care Plans were seen as highly desirable, but staff referred to ‘getting back to the reality of the four waiting rooms’. It was reported that health workers were in fact doing many things relevant to care plans, but without having the time to do the paperwork necessary to claim the rebate. Recruitment plans are under way to employ a full-time Registered Nurse and a full-time Health Worker, which will support Adult Health Checks being undertaken. Without these dedicated positions it was felt that there was no real capacity to provide EPC services.

54 As noted in the body of the report, the NSW MLO reported that he was ‘stretched thin’ and had difﬁculty in providing services Statewide.

130 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 PIP

With the support of the Murray Plains Division of General Practice, accreditation was gained some three years ago. Income from PIP primarily supports staff positions, and will contribute to two new nursing positions. It is expected that the new positions will increase the ‘triage’ capacity of the walk-in clinic.

Immunisation

Immunisation rates were reported to be at 93%, primarily due to methods used by the nurses which involve approaching families to have their babies immunised at any opportunity. The link to the online immunisation register (Australian Childhood Immunisation Register) was reported to have improved the management of the immunisation program; it automatically alerts nurses to people who are due to be recalled for the next set of immunisations. The Division of General Practice had assisted with getting the online immunisation register access organised.

4. AMS Workforce issues

Recruitment and retention of staff was reported to be an issue for the AMS; however, staff also reported that their training plan was under way and that they were committed to constantly improving the skills of their people. This was seen as a way to address retention problems.

5. Medicare training

Training of AMS staff was identiﬁed as critical to success in the use of Medicare. The staff member speciﬁcally responsible for Medicare claims had received training, and was expected to pass on new and emerging information to other staff members. The suggestion was made that core competencies for the role of Medicare Clerk within an AMS would formalise the required knowledge and skills base, and assist services to understand the level their worker was operating at. This was seen as directly linked to the maximising of income through Medicare claims.

It was reported that ‘everyone struggles with reading the Medicare book’; an example was given of an item number which had been ‘found just today’ and which differentiated between a dressing and a wrist plaster. The suggestion was made that the manual should be in ‘plain English’, and that a web based research capacity would improve full and accurate use of the item numbers.

Medical terminology training had been provided for front-line staff, but was reported to have made little difference to the claims. The AMS was particularly conscious of ensuring patient conﬁdentiality at the front desk, and did not see it as part of the receptionist’s/Medicare Clerk’s role to review the item numbers indicated by the GP. Item numbers for hearing services were also described as complicated, and it was said that some kind of ‘ready reckoner’ for this purpose would be useful.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 131 6. Mainstream GP services

It was estimated that mainstream GPs were accessed by around 10% of people in the local Indigenous community. One practice reported that it bulk bills Aboriginal patients, however some patients preferred to pay and this was of course respected. A GP practice which had traditionally been accessed by a fair number of the local community had recently closed down, and the doctors who had worked in that practice were now involved in other work, including working in or supporting the AMS in other ways.

The importance of Aboriginal Health Workers in mainstream practice was identiﬁed by people outside the AMS. It was seen to be particularly important that people who do not attend the AMS should have similar access to Aboriginal allied health workers as people who do use the AMS.

7. Specialists

The AMS reported that Aboriginal community access to specialists has improved over time, with several specialists now working to provide access either through clinics at the AMS or through dedicated session times in their own practices. Examples of improved access included a paediatrician in private practice who provides a clinic for up to a day a month within the AMS. This specialist reported that prior to offering the in-house clinic perhaps only one in four patients referred to him would attend their appointment. He identiﬁed distance and cost as two major barriers, with a $200 upfront payment required (providing a rebate of $111). This specialist has a provider number for the AMS location, and he is paid an hourly rate by the AMS. In terms of the needs of patients, he identiﬁed that 70% of the issues he is addressing with patients aged between 2-16 years are behavioural:

Nutrition, sleep and behavioural advice is appalling – we don’t see them until pre school age when it is more difﬁcult to intervene.

As well as the paediatrician, a Sydney based paediatric haematologist visits the Service on an annual basis to review approximately six young people with haemophilia. Access to two Ear Nose and Throat specialists was described, including one from Sydney, as well as a local specialist who was dedicating a morning clinic each month to patients referred from the AMS. The correctional services dentist provides a half day each week; children under 16 can be referred for this service.

8. Medications

A range of issues were identiﬁed in relation to medications that are and are not available through the PBS. The point was made that ‘exemptions’ were needed from brand price premiums, and that a preferable approach would be for doctors to be able to prescribe ‘generically’ and/or for the pharmacist to substitute the most affordable brand. The current system of prescribing by brand name was ‘annoying and confusing’ and could lead to patients believing that different brands were more or less effective than others, thus contributing to non-compliance.

132 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 Another example of difﬁculties with the PBS was a medication called Aetilax, which was described as a ’sensible long-term treatment for chronic constipation’ but was only available on the PBS for patients with cancer. The removal from the PBS of a commonly prescribed topical antifungal medication had also been source of frustration. The point was made that drug companies no longer give away samples as they did some years ago. On occasion doctors ring the chemists and ask them to give three days’ medication to an individual patient, on account, to enable them to start their medication in a timely way. Another person interviewed made the point that when people delay or are unable to have the script ﬁlled, and this results in hospitalisation, the cost of meeting the co-payment for a script suddenly becomes a $500 a day cost for inpatient treatment.

In relation to the Section 100 arrangements, one GP suggested that these could negatively impact on the relationship with others in the community, in that ‘people get jealous - why can’t I get my medication free?’. Various suggestions were made for limiting the demand that eligibility for the S100 scheme could produce, including limiting access to people on health care cards, restricting the scheme to antibiotics, or eligibility being left to the doctor’s discretion.

Compliance

Compliance or ‘adherence’ was identiﬁed as an ongoing issue by all the health professionals who were interviewed in Wagga Wagga. A specialist made the point that where parents see an improvement in their child’s health or behaviour they are more likely to maintain the correct use; however, compliance with long term prevention strategies was reported to be poor.

Access to the S100 arrangements as part of a ‘one stop shop’ was seen by one specialist as a potentially important part of increasing compliance, suggesting that a ‘fact sheet’ could provide the necessary information to support proper use of medication. All of the doctors interviewed indicated that patients regularly choose which of their prescribed medications to purchase, based on their available cash. The impact of this is that patients are stopping and starting medication, which can worsen their condition and leave them open them to other health risks.

9. Community awareness and understanding

Community members interviewed in Wagga Wagga were not familiar with the Medicare Safety Net, and were unsure how to claim a rebate after seeing a specialist. Specialists who charged the patient only the ‘gap’ were seen as particularly sensible (billing Medicare the standard fee directly), and the question was raised why this is not standard practice. One matter that caused a lot of frustration was the NSW Health travel support system for isolated patients, where expenses have to be paid up front (60% can be claimed back). The out of pocket cost was raised as a direct barrier to accessing health services outside the City of Wagga Wagga.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 133 Moree, New South Wales - Rural

1. Background

Moree is situated on the North Western Plains of New South Wales, west of the Great Dividing Range and at the junction of the Newell and Gwydir Highways. It is the centre of the Moree Plains Shire. At the time of the 2001 Census there were approximately 10,250 people residing in Moree, of whom 2709 (18%) identiﬁed as being of Indigenous origin. Locations with high proportions of Indigenous Australians in the Shire include Mehi Crescent and Stanley Village. Stanley Village is situated one kilometre east of Moree township, while Mehi Crescent is three kilometres south-west.

Moree is a service centre for the outlying towns of Mungindi and Collarenebri which have sizeable Aboriginal communities. It is also the closest major NSW town to Toomelah, a large, disadvantaged Aboriginal community 70 minutes north of Moree near the Queensland border. However as Toomelah is signiﬁcantly closer to Goondiwindi in Queensland, Goondiwindi provides most health services to Toomelah.

Moree’s main industries are agriculture (cotton, grain, oilseeds) and manufacturing. The cotton industry has been a long-standing employer of Aboriginal people – both local and itinerant – as cotton pickers. Recent changes to farm practices were reported to have impacted negatively on this source of seasonal employment, reducing by up to 200 the number of people employed in the cotton picking season.

2. Nature of Health Services

Moree Hospital

The town has a hospital with 52 beds. The hospital is a part of the Moree Plains Health Service, which also provides a wide range of other services including community health, primary health, aged care, mental health and outreach services. Moree Hospital has a community catchment for general care and also operates as a district hospital for the surrounding area. The hospital has no resident doctors but is serviced by nine Visiting Medical Ofﬁcers on a roster system.

Aboriginal Health Service, NSW Health

Moree also has a small Aboriginal Health Service that is funded by the NSW Department of Health through the Hunter North East Area Health Service. This service employs a co-ordinator for Aboriginal Health Services, an Aboriginal Health Worker and two Aboriginal Health Education Ofﬁcers. An important part of its work is the Cardiovascular Project, aiming at early detection and management of cardiovascular disease. The program is supported by a visiting nephrologist (kidney) specialist from Tamworth Hospital, however the nearest cardiologist is in Toowoomba, Queensland.

134 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 Pius X Aboriginal Medical Corporation

Moree has an Aboriginal Medical Service (AMS) - Pius X Aboriginal Medical Corporation – which has been managed by a Board of Directors since it came into community control in 1987. This service is located three km south-west of Moree township, near Mehi Crescent Aboriginal Community.

Pius X employs two Registered Nurses, a Nurse Unit Manger, two Aboriginal Health Workers, a Sexual Health Worker, a dental therapist and dental assistant, a full time GP and a receptionist. Pius X is primarily funded through OATSIH, receiving just under $860,000 a year.

It was estimated that the service sees over 100 patients each week, with about 15 appointments within each clinic session, plus 10-15 people attending on a ‘walk in’ basis. The majority of patients are from Moree, with some seasonal demand around holiday times when other families are visiting the area. The clinic does not offer an outreach medical service, although the GP attends a small number of patients in the local Aged Care Facility. Outreach is, however, a core part of the Health Workers’ role.

While the majority of the patients seen are Aboriginal, it is not uncommon for non-Aboriginal partners of Aboriginal people, non-Aboriginal people of low socio-economic status and itinerant workers to make use of the service. An increase was reported in the numbers of non-Aboriginal people on low (or no) incomes seeking the bulk billing services that Pius X offers, and community members reported the perception that ‘a lot of poor whites use Pius’.

Aboriginal children may be referred to the Crippled Society (Tamworth), Stuart House or Far West (Sydney) for respite care or rehabilitation. Banksia House in Tamworth is the closest psychiatric facility and provides an after hours service and accommodation for those with alcohol and other drug dependencies or psychiatric illness.

3. AMS Use of Medicare

The previous Keys Young study reported that hospital staff, general practitioners and Medicare and AMS staff all advised that non-enrolment in Medicare (particularly of babies) was a signiﬁcant problem in the community. The chief reason for this was thought to be that it was a low priority for new mothers and wasn’t attended to until their baby became ill.

Positive progress on this issue was reported by the AMS and other stakeholders in the current study. The AMS advised that the vast majority of Aboriginal people in this community are now registered with Medicare. A Hospital Health Worker supported this view, indicating that people who are not registered with Medicare present for treatment at the Hospital only about three or four times a year. When people do present without their card, they generally have left it at home and a relative is asked to bring their Medicare card in when visiting.

The AMS saw the introduction of the online Communicare system as a significant factor in the improvement in registrations, since people presenting to the AMS can be signed up ‘on the spot’. The Indigenous-specific Medicare form is also an important part of this shift, particularly in terms of proof of identity. The form allows the Medicare worker to vouch for the unregistered person on the basis of ‘medical records’ or ‘period known the person’. If this was not possible, the option to attend the Centrelink Office to obtain a letter confirming identity was reported to be straightforward. Prior to Communicare being installed it was also common for Medicare claims to be rejected by the HIC due to out-of-date cards. The online system now alerts the provider to the status of the card, and action can immediately be taken to order a new card.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 135 One issue that has continued to arise in the AMS is patients’ use of more than one surname, which is problematic if the name being used by the presenting person does not align with their Medicare details. The AMS generally resolves this by contacting the 1800 help line and determining, with the patient’s permission, the correct details.

The Medicare Ofﬁce in Moree was described as well-located, adjacent to one of the main supermarkets and therefore convenient to access. No problems were reported in using the Medicare Ofﬁce or in relation to the staff.

The GP at Pius X made the point that, as a relatively new GP in the AMS system (12 months duration), he would have beneﬁted from a ‘buddy system’ with another AMS GP, particularly to gain a better and more rapid understanding of the item numbers most relevant to Aboriginal patients. This was perhaps particularly the case with an overseas trained GP.

EPC items

Pius X staff advised that undertaking check-ups under the EPC would not be feasible without a further two Aboriginal Health Workers. With extra staff it was felt the basics could be attended to, but without extra resources they are simply too time consuming.

PIP

The Division of General Practice and Pius X undertook a joint project to achieve accreditation. The Division and Pius X also have a Memorandum of Understanding in place to foster a positive working relationship. Pius X now has access to the Division’s Quality Use of Medications program, which offers a one on one education session with each GP, provided by a clinical pharmacist.

Immunisation

The AMS offers immunisations on an ad hoc basis, rather than at set clinic times. Compliance with immunisation remains a challenge in this community; currently compliance is at about 80%. The problem was identiﬁed as resulting from a lack of education on what immunisation is about, and a fear of the unknown. Similar issues were reported to impact on take up of other public health programs, such as Pap smears, with a ﬁgure of some 1700 women Aboriginal women in the area who had never had a Pap smear.

Medicare training

The staff with key Medicare roles at Pius X were provided with on-site training when the Communicare system was installed. The trainers were from the 1800 Helpline, and the opportunity to build a direct relationship with these individuals was identified as very useful to the people in the Medicare clerk roles. Senior staff reported that people managing the Medicare claims system require ongoing training. Two points were made - firstly that the 1800 Helpline assumes that the relevant question is being asked correctly and is limited to responding to that query; and secondly that it would be helpful to have a visit from a suitably qualified person who could advise on the extent to which Pius X is using the system correctly and fully.

136 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 4. Use of mainstream GP services

The AMS reported that the vast majority of Aboriginal people in the community utilise the AMS, with a small number attending the town’s private GP practices. Familiarity with the AMS environment, trust of the staff there and the bulk billing arrangements were all reasons put forward for this. Town practices require an upfront payment which was clearly identiﬁed as a disincentive for most Aboriginal people. Those who did attend the town practices did so because they were comfortable paying the fee, and or were comfortable with the doctors, whom they may have been seeing prior to the AMS opening.

5. Specialists

At the time of the previous study the only specialist visiting the AMS was a psychiatrist, one afternoon every two months. Several specialists now hold clinics at the AMS. These include: a gynaecologist who comes two days each month; a dentist who comes each six weeks and stays two weeks and is completely booked out for this period; a women’s health nurse and a gynaecologist who visit one day each month; and an Ear, Nose and Throat specialist from Sydney who comes one day each month. At any one time Pius X can have four or ﬁve clinics running on the one day. While this is a great achievement in terms of ensuring specialists are available to the community, it does impose a strain on the AMS in terms of space.

The uptake of appointments with specialists who do visit the clinic is considered to be very high, with a low incidence of ‘no-shows’. It was noted that some specialists visit Moree on a Saturday when the AMS cannot offer a clinic room as it is closed. This reduces the accessibility of these specialists, as community members are far less likely to attend appointments in other settings.

Oncology remains a signiﬁcant gap in terms of a specialist but also in terms of treatment. There is a strong community perception that cancer incidence is high amongst the Aboriginal community as a result of years of crop dusters spraying while pickers worked the ﬁelds. At present people needing chemotherapy travel to Tamworth, Brisbane or Sydney.

6. Medications

The Pius X clinic maintains a small dispensary of commonly prescribed medications such as basic antibiotics, analgesics, antifungals, steroid creams, anti-psychotics, diabetic medication, asthmatic medication, and hypertensive medication. A clinic staff member reported it is a ‘ﬁght each year to have this money allocated to the purchase of drugs’; in 2004-05 $25 000 from the OATSIH grant was expended on the supply of medications. The rationale for this approach was quite clear: ‘when people come to this, their ﬁrst point of care, we should be able to provide the medication the person needs.’

The S100 arrangements were particularly appealing to this AMS as a way of increasing the likelihood of medications being taken. Other factors which were seen to contribute to non-adherence to medication regimes included the considerable walking distance from the AMS to the town pharmacies; the very difﬁcult ﬁnancial circumstances in which most people live; and the lack of priority placed on proactively maintaining health.

The Registered Nurse who manages the dispensary exercises some discretion in the provision of free medication – for example, to people known to be in particularly difﬁcult ﬁnancial circumstances, those with several children in their care, with chronic conditions and so on.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 137 There were two items the AMS would particularly like to see on the PBS: an anti-hypertensive which currently costs many patients about $27 per month, and in particular the lancets used by diabetics to prick their ﬁnger each day, which cost $4.50 each.

Moree used to have two pharmacies in the main street, but one has closed since the previous study. The remaining pharmacy was viewed by the people interviewed as friendly and accessible.

Compliance

Pharmacy staff and AMS staff reported that it was not uncommon for Aboriginal clients to fail to have a prescription filled because they did not have sufficient spare cash even for the co-payment. This was reported to be of particular concern when parents/guardians failed to fill a prescription for a child in their care owing to a lack of money. One Moree doctor believed that ‘if a body such as ATSIC [sic]could cover the … co-payment, this would significantly increase the proportion of Aboriginal patients who filled their prescriptions’.

A main beneﬁt for Aboriginal clients who attended Pius X AMS was reported to be the opportunity to receive free basic medications, without the need for a co-payment. This was reported to ensure that this population at least started on a particular medication when necessary. .

Education

A number of those consulted in Moree believed that an education program is needed in relation to the importance of medications and of using them correctly. Common problems that were mentioned included people not getting scripts ﬁlled in a timely way, taking only half the medication and keeping the rest to use next time they are sick, and sharing medication with others – including heart and blood pressure medication.

One key message for an education campaign would be the importance of finishing courses of antibiotics to prevent conditions worsening. Another suggestion was to educate people in better understanding medication instructions: one Aboriginal Health Worker gave an example of a patient who read the label which said ‘take one tablet twice a day’ to mean they should cut one tablet in half, and take half on two occasions each day. Another message was needed to address the reported tendency of Aboriginal people to get a prescription filled only if they felt sick. Both AMS staff and doctors in town reported that they spent time trying to impress upon patients the importance of taking their medication and completing the whole course. This was less of an issue amongst people on regular medications who would budget to afford their scripts, but it was also reported that people were in a financial position from time to time where they had to choose which script to fill. This was reported by AMS medical staff to be a potentially dangerous pattern of medication use.

7. Community awareness and understanding

Community leaders acknowledged the efforts Pius X made to achieve higher rates of Medicare registration, and identified the Indigenous-specific registration form as an effective strategy. The demands for identification were seen as a particularly difficult barrier which the form has addressed. Some community members also recalled a television campaign about Medicare, and a pamphlet in the Koori Mail.

138 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 Townsville, Queensland - Regional

1. Background

Townsville is a regional city on the north-eastern coast of Queensland, approximately 1,300 km north of Brisbane and 350 km south of Cairns. Townsville and its immediate region lie within two separate Local Government Areas, Townsville and Thuringowa.

The population of the greater urban area of Townsville (including Thuringowa) was approximately 155,500 at the 201 census; approximately 5% identiﬁed as Indigenous Australians.

Tourism has helped in the city’s expansion, though its traditional role as an industrial port for exporting minerals from Mount Isa and Cloncurry continues to be of importance. Townsville also has manufacturing and processing industries relating to sugar cane and timber in particular. The city is serviced daily by rail, road and air transport.

The James Cook University is located in Townsville; it is the only university in Far North Queensland.

2. Main Health Services

2.1 Townsville Hospital

The Townsville Hospital is the largest hospital in North Queensland. It provides comprehensive medical care for the local community, as well as populations north to Thursday Island and west to Mount Isa. It has a capacity of over 450 beds and employs nearly 75 full-time staff, with some 50 visiting specialists. The proportion of Aboriginal and Torres Strait Islander inpatients ﬂuctuates between 10-20% over the year. Indigenous inpatients come from all over northern Queensland – Townsville itself, Palm Island, McKay, Bowen, the Queensland/NT border, Thursday Island, the Gulf and Cape York. The most common inpatient conditions are renal illness, cardiovascular disease, cancer and diabetes.

The Aboriginal Hospital Liaison Unit (AHLU) employs four full time staff and works closely with the Torres Strait Islander Medical Service (see 2.2 below).

The hospital provides a service to everyone who attends. If an Indigenous person seeking admission does not have his or her Medicare card or number, the admissions desk or the Liaison Officer may phone the Townsville Aboriginal and Islander Health Service, which will then follow up with the Medicare office in Brisbane. However, the AHLU reports still having some difficulty obtaining phone numbers, addresses and other details from Indigenous patients and their families when they are admitted to the hospital. ‘More needs to be done to ensure everyone is enrolled on Medicare. Sometimes we only find out if Indigenous Australians attending the hospital didn’t have their Medicare cards or numbers when they are discharged.’

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 139 Transport

Transport is an issue for the Liaison Ofﬁcer when Indigenous patients are discharged from hospital or need to attend specialist appointments, as many evidently come to the hospital with little or no money to get back home (or to purchase medications). Bus and taxi vouchers can be provided, but these are used up quickly (sometimes a year’s allocation within two months); the hospital then needs to wait until the following year to replace their stock of vouchers.

Some time ago the Indigenous community in Townsville and the Aboriginal Hospital Liaison Unit successfully lobbied the hospital for an Indigenous-speciﬁc bus. However the hospital eventually took control over it when the bus was not being utilised on a full time basis:

‘We got the bus and then one day we didn’t need to use it. The other units in the hospital asked to borrow it for the day and we haven’t been able to use it since. We are told we now have to book it and it is for the full use of the entire hospital. One of the reasons we asked for a bus was so we could use it at a minute’s notice. We are now lobbying for another bus’.

Other community comments about transport to and from the hospital included the following:

‘The mainstream bus service is always late and I miss my appointments at the Hospital and then I am blamed and I am looked in that horrible blaming way and I know it’s because I am black’.

‘The Rotary and other community services should be providing transport to people in need of hospital appointments’.

2.2 Townsville Aboriginal and Islander Health Service

The Townsville Aboriginal and Islander Health Service (TAIHS) employs some 45 staff, including the equivalent of ﬁve full-time GPs. It is open on weekdays and Saturday mornings, and serves up to 10,000 Indigenous patients a year. Staff reported that there was a need for additional doctors to meet the needs of a large and diverse client base.

TAIHS provides primary health care mainly within the Townsville, area; it also sees some patients visiting from Palm Island. Outreach services are provided to places such as Richmond, Palm Island, Ingham and Mount Isa. Special outreach services also provide dental services for Charters Towers and Ayr.

TAIHS provides GP services, dental care, a social health unit, an eye health team, a podiatrist, dietician, and a psychotherapist. Wherever possible it works on the basis of patient appointments; ’We will provide a service to ‘walk ins’ but they need to wait longer. But we are generally able to make room’.

TAIHS does not provide point of care diabetes testing, explaining that this would be difﬁcult and very time consuming with 700 or so patients who are diabetic; it would require a large storage system as well as additional staff.

TAIHS staff believed that they saw ‘the great majority’ of Aboriginal and Torres Strait Islander people from the local area. There continued to be some use of GPs by Indigenous patients (especially, it was thought, for minor or one-off problems such as the ﬂu), but this had decreased with the decline in the number of bulk billing practices. (One effect was that TAIHS now tended to see more people with minor ailments for which they might previously have gone to a GP.) It was also clear that Indigenous Australians living in one area of Townsville normally used the mainstream Kirwin Health Clinic.

140 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 We mainly go to the Health Clinic in Kirwin because it is much closer and you can walk there or catch one bus which comes by quite often. The staff are great at Kirwin and they see many Indigenous clients. There are no long waiting periods, and they bulk bill.

Community members consulted at TAIHS stated that they preferred to come to the Service (rather than the hospital, for example) as they usually do not have to wait long to be seen, and can get assistance with transport to specialist appointments and to the community pharmacy:

‘I go to the health service because I always have to wait for hours to see anyone at the Hospital. The new bus service used to take us from the TAIHS to the Hospital and then to other appointments and then to home. The other Hospital areas have taken this away from us’.

As indicated above, however, community members who lived some distance away reported difﬁculty in getting to TAIHS itself; some also disliked the appointments system55.

Transport problems were frequently mentioned in the course of the Townsville consultations. TAIHS health workers are ‘inundated’ with demands to transport regular Indigenous clients to and from their medical appointments, so they are unable to allocate the time required to transport a small number of people from outlying areas when they can transport a greater number of Indigenous clients who live closer to the TAIHS. People from outer areas may therefore choose to seek services elsewhere.

TAIHS provides a bus service for Indigenous clients who live in the Upper Ross area and Garbutt. However, ‘If you are not on time you don’t get picked up – even if you are only ﬁve minutes late’.

Medicare Enrolment

Observers consulted in Townsville reported that knowledge and understanding of Medicare has greatly improved both in the Indigenous health sector and among Indigenous Australians in the general community. Since the employment of the MCO at TAIHS, more community members are enrolled and have Medicare cards. According to the MCO, nearly 100% of patients have Medicare cards.

The MCO establishes a client’s eligibility for Medicare enrolment through the use of the referee system on the back of the proof of identity forms, and occasionally asks to see a driver’s licence. The MCO will ﬁll in enrolment forms on a client’s behalf where there are literacy problems.

Such enrolment problems as arise tend to relate to new enrolments of clients from out of town (particularly rural and remote areas of Queensland) and to the registration of newborns.

The MCO visits the mothers of newborns in the hospital to explain the importance of both themselves and their babies being enrolled in Medicare: however, ‘sometimes the hospital doesn’t ﬁll in the baby red book which is a requirement before they are discharged from the hospital’. The usual principle was said to be that a baby should be registered for Medicare at the location where it was born. If the baby is not enrolled before the mother leaves hospital, ‘there is some chasing up to do’.

55 Getting to TAIHS continues to be an issue for patients, including older people and homeless people who have no phone and little money for transport. As a result there is pressure on health workers to pick up clients and to take them back home from the Health Service.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 141 Use of Medicare

TAIHS has in recent years had a strong focus on generating income from Medicare rebates, as a way of increasing its budget and thus improving the health care that it provides. Its income from Medicare has run at around $700,000- $800,000 a year, and the level continues to increase; as at May 2006 TAIHS claims for the current ﬁnancial year already totalled some $1.2 million.

TAIHS has a Medicare Claims Officer (MCO) with particular responsibility for overseeing the claims process, and this is clearly important in maximising Medicare income. The Service attributes its success in generating Medicare income primarily to effective ongoing communications with medical staff about the importance of this income stream – for example providing clear information on Medicare issues, feedback on levels of rebates claimed, and regular reinforcement of the Medicare ‘message’. Such communication is underpinned, however, by direct financial incentives. For some years TAIHS has offered its GPs a bonus, on top of salary, of 10% of the value of the rebates they claim; this incentive has recently been increased to 25% which, it was said, ‘has a real impact’ on the level and consistency of claims. In order to provide a specific incentive for AHWs in relation to EPC services, TAIHS also pays each AHW a fixed sum for every EPC item that he or she contributes to.

The TAIHS Practice Manager and Senior Medical Ofﬁcer normally take responsibility for keeping abreast of changes to Medicare, the introduction of new items and the like, and for ensuring that relevant information is communicated to other staff.

TAIHS has welcomed the introduction of Indigenous-speciﬁc EPC items such as care plans and adult health checks, because ‘by and large they represent the way we were managing cases anyway; thus these items have been relatively easy to ﬁt into ‘the sort of practice we were running’. TAIHS has prepared hundreds of health care plans, and believes that most of its chronically ill patients now have such a plan. It reports that during 2005 it completed 150 of the (then relatively new) Adult Health Checks.

In some cases – especially where staff are not sure that a patient will return – a care plan or health check may be provided on-the-spot (‘opportunistically’). For a regular patient, however, an appointment will normally be made to provide this service.

TAIHS has prepared a ‘tick-and-ﬂick’ form for its AHWs to assist them in carrying out their roles in relation to EPC items. While the paperwork associated with EPC claims takes time, the ﬁnancial reward was said to be well worth the trouble.

Although TAIHS is an accredited practice, income from PIP is considerably less than income derived through delivery of EPC services; PIP is ‘not that big for us’. TAIHS claims PIP payments in relation to teaching, the practice nurse incentive and immunisation, for example, but does not qualify on other points such as after-hours services. TAIHS no longer seeks to use the Asthma 3+ program because it has found it too difﬁcult to achieve the repeat patient visits that this requires. Use of the Mental Health Care 3-Step Process Plans has stopped for similar reasons: ‘We focus on the best return for our effort’, it was said – in both health care and ﬁnancial terms.

Immunisation

TAIHS receives ﬁnancial incentives for completed immunisations, but does not reach the 90% target that would entitle it to additional outcome payments.

142 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 Hearing services

Many Indigenous patients under the age of 50 are not eligible for hearing services even under the new eligibility criteria, and TAIHS would like to see the criteria further broadened.

Specialist services

A small number of specialists visit TAIHS to provide regular monthly clinics. These include an endocrinologist based at the Townsville Hospital, a local physician in private practice, and an ophthalmologist whom TAIHS ﬂies in from Brisbane. In each case the specialist does his or her own bulk billing and retains the Medicare income; the beneﬁt from TAIHS’ perspective is the improved access to specialist services that its patients receive. Similar arrangements apply to certain allied health workers (eg a podiatrist) who are involved in providing services relating to care plans.

There is generally a high attendance of Indigenous clients when specialists visit the TAIHS. However, the effort needed to coordinate specialist appointments is considerable and, as noted above, TAIHS incurs costs to ensure that these services are available.

For other specialist services TAIHS doctors will normally refer patients to the Townsville Hospital; it is frequently asked to assist such patients with transport.

3. Medications

TAIHS GPs write prescriptions which patients present at a community pharmacy; there is a particular local pharmacy which is much used by TAIHS patients, and where they will usually be taken if they require transport. In the past TAIHS has made prescription co-payments on behalf of its patients; as the cost of doing so approached $100,000 a year, however, it decided it could no longer afford this. Where patients are in particular ﬁnancial need TAIHS may be able to provide some medication samples; some very limited ﬁnancial assistance is available from emergency relief funds accessed through the TAIHS Social Health Unit.

Ideally TAIHS would like to be funded for a pharmacy on site. Apart from the quality of service this could offer patients, it would save a large amount of AHW time that is currently spent transporting patients to get their medications.

When Indigenous Australians are discharged from the Townsville Hospital they are provided with a small supply of medications (up to three days) and then are sent a bill a few weeks later – which, it was said, is rarely paid.

Community members consulted at the Bindal Sharks CDEP stated that during long stays in hospital the patient has to pay for medications (including Panadol, for example) and that they are regularly charged for medications received on discharge.

On the other hand, community members who were interviewed generally seemed to have little idea of just why they needed to know about Medicare and the use of the Medicare card.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 143 4. Satisfaction with Medicare Australia

The Townsville Aboriginal Liaison Unit at the Hospital and the MCO at TAIHS were pleased with the service provided by the Indigenous Liaison Unit at the Brisbane Medicare ofﬁce. The MCO makes frequent use of the 1800 number. There is also regular email contact, and all issues are promptly followed up by the Unit. Staff from the Brisbane Medicare Ofﬁce also provide relevant training when requested.

The community pharmacists interviewed in Townsville telephoned the Medicare Brisbane ofﬁce regularly, for example to check Medicare numbers, expiry dates and the like.

5. Community Perspectives

Community members were consulted at TAIHS and at the Bindal Sharks CDEP in Townsville. All those who took part in these discussions reported having Medicare and health care cards.

Issues which arose in the community discussions included the following:

Indigenous Australians in certain areas of Townsville prefer to use nearby mainstream services rather than have to travel to TAIHS.

Participants reported getting advice about alternative (and cheaper) generic medications from their local pharmacy.

Younger Indigenous Australians were seen as more at risk of not knowing their rights about health and Medicare issues. ‘More promotion needs to be provided to Elders about having their kids taken off their cards when they turn 15’.

Some people believed that TAIHS need to do more outreach work on dental health checks, men’s health promotional sessions and sexual health. It was said that more preventative work was needed in the secondary schools in Townsville, as well as after-care for AIDS and cancer patients.

CDEP participants said they would like TAIHS to consider providing an outreach service to the CDEP once a fortnight.

CDEP participants were not aware that they are now eligible for Government Hearing Services assistance, and were also unaware of the PBS Safety Net. (‘I have never heard of a Safety Net and it isn’t promoted by TAIHS or the Hospital’.)

Palm Island residents believed that the Townsville Hospital needed to employ an Indigenous Liaison Ofﬁcer part- time, who could provide assistance to Palm Island people – especially at the weekend when TAIHS is closed.

There could be a tension between spending money on medications and providing for basic family needs. ‘We get told off if we spend our money on medications to improve our health. That is seen as disrespectful to our families if they need food’.

144 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 6. Culturally speciﬁc information materials

TAIHS staff stated that they would like to see Medicare Australia fund culturally appropriate information materials produced locally, providing employment as well as ensuring that such material is appropriately written and presented. It was suggested that information materials and videos should aim to cover topics such as the following: importance of carrying a Medicare and concession card importance of enrolling children changes to Medicare – ie child on and off a Medicare card the importance of having Health Care Plans effects of drugs and alcohol smoking prevention general good health and dental care.

Education materials and information sessions for Indigenous parents in rural and remote areas should encourage parents to take their kids for health checks, follow up consultations and to see speciﬁc specialists.

We need more health workers employed to promote health education to our young people in the high schools.

There should be a Medicare phone in all Health Centres and Hospitals for people to access so they can ring the 1800 number directly and have their queries addressed. This would save time of out staff on the follow up processes for Medicare.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 145 Torres Strait and Northern Peninsula Area, Queensland - Remote

1. Background

The Torres Strait Islands are a remote group of islands which lie in the Torres Strait separating the Cape York Peninsula from Papua New Guinea. They are governed by the State of Queensland. The islands are distributed across an area of approximately 48,000 km2. The distance across the Strait from Cape York to Papua New Guinea is approximately 150km. The outer islands are accessed by private boat or charter aircraft, there being no scheduled ferry or air service. The commercial, transport and communications centre and the island with the largest population is Thursday (or Waiben) Island, 20 kilometres from the mainland and a two hour ﬂight by regular service from Cairns. Thursday Island’s main industries are pearling, ﬁshing and tourism. There are regular ferry services to Thursday Island from Cape York, and between Thursday Island and the Northern Peninsula Area (NPA) on the mainland.

According to the 2001 Australian Census, the population of the Torres Strait Islands was 8,089, but this number varies greatly in holiday season with more than 20,000 tourists visiting the area every year. The Indigenous population estimate was 6,214 (80%).The population of Thursday Island is about 3,500, around 80% of whom are Aboriginal/Torres Strait Islander.

The NPA consists of five communities; Bamaga, with a population of around 1,700 (75% of whom are Aboriginal/ Torres Strait Islander) is the main town. Bamaga has a small shopping centre (with a supermarket, bakery, post office and milk bar etc), a council headquarters, a police station and a State school. Seisia (population 180 - largely Islander) is on the coast three kilometres from Bamaga, and is the site of the wharf. Injinoo (population 600) is six kilometres from Bamaga and has its own school campus. New Mapoon, an Aboriginal community of about 350 people, and Umagico, with a largely Islander population of about 350, are both about four kilometres from Bamaga. The roads between the communities frequently become flooded during the wet season, though they have been upgraded.

Torres Strait Islanders, the Indigenous peoples of the islands, are Melanesians – culturally akin to the coastal peoples of Papua New Guinea. They are regarded as being distinct from other Aboriginal peoples of Australia, and are generally referred to separately. The population also includes people from Papua New Guinea (PNG) and the Paciﬁc Islands (Fiji, Tonga).

Cairns

Cairns, along with Townsville, is a major centre for Torres Strait Islanders. Cairns offers the nearest post-secondary education facilities and many medical services which are not available in the Torres Strait. There is a relatively large resident Islander population in Cairns and relatives from the islands often visit during the year.

146 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 2. Range of Health Services

2.1 Structure of the Health Service

Health services in the Torres Strait and on Cape York are almost entirely the responsibility of the Queensland Health Department. The Torres Strait and NPA District Health Service is a district-based sector of Queensland Health and operates primarily with State health funds, supplemented now with direct MBS and PBS payments. Queensland Health provides funds for hospitals and primary health centres, paying the salaries of medical ofﬁcers, nurses and allied health professionals. It is estimated that around 80% of people in the Torres Strait and NPA have a concession entitlement card (Health Care Card).

Major illnesses include diabetes, obesity, trauma, parasites, skin infections, respiratory diseases, hypertension, alcohol and smoking-related illness/injury, and infectious disease epidemics (eg encephalitis, dengue fever).

At the time of the earlier Keys Young study changes were under way to allow salaried medical officers to bulk-bill. The Health Service had a number of reasons for wanting to participate in the Medicare Benefits Schedule. Most importantly, they took the view that they were not an Aboriginal and Torres Strait Islander-specific service, but rather a mainstream service whose primary, secondary and tertiary health care was designed specifically for Aboriginal and Torres Strait Islander health conditions and cultural needs – this being the dominant population. Extra funds, it was argued, were needed to expand program work and employ more medical staff – in part to serve the large numbers of domestic tourists (many of whom are eligible for Medicare services) who would otherwise receive free (ie State-funded) medical care and pharmaceuticals if medical benefits were not available.

There is also a burden placed on the health services arising from visitors from Papua New Guinea, and even illegal ﬁsherman from Indonesia (as was evidenced at the time of the current ﬁeld visit).

2.2 Thursday Island Hospital

The 38-bed hospital on Thursday Island opened in 1997 and is the major medical facility in the district, providing pathology, radiology, maternity, ante-natal, dentistry and a number of other services as well as having an accident and emergency department. There is a helicopter based at the hospital to carry out medical evacuations in the region. There are ﬁve doctors (three service the outer islands), two dentists, one pathologist, a radiologist, nursing staff and a number of technicians/ assistants. Practitioners service some 10,000 patients a year, and the hospital schedules visits to the outer islands on average once every three weeks. The current cost of servicing the outer islands is reported to be some $900,000 a year. Specialists - including a paediatrician, obstetrician, ophthalmologist, cardiologist, internal medicine specialist, diabetes specialist and a renal specialist - make regular visits from Cairns/ Townsville, up to eight times a year. Virtually all the specialists are public hospital-based and therefore provide non- fee services.

The hospital pharmacy now supplies medicines to inpatients, all patients on the outer islands as well as Bamaga (and through Bamaga, the rest of the NPA). This occurs under a Section 100 arrangement. Residents of Thursday Island who are not in hospital utilise the local pharmacy.

A primary/community health care centre is located in the grounds of the hospital and is staffed on rotation by hospital medical staff. There are no GPs in private practice in the Torres Strait and NPA area.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 147 2.3 Thursday Island Primary Health Care Centre

The Primary Health Care Centre (PHCC) is funded by Queensland Health. The PHCC has an Indigenous Management model in place, based on cultural traditions, and utilises a chronic health care approach. The PHCC employs 63 staff directly and 150 additional staff who service the immediate community and the outer islands.

PHCC staff and services include health workers, nurses, administration/ management, a hearing service, respiratory care, two Ear/Nose/Throat specialists, and an eye doctor. An environmental health ofﬁcer visits from Cairns.

The PHCC undertakes considerable work in the areas of oral health, dental hygiene, men’s and women’s health, post acute rehabilitation and aged care, ear grommets in children, maternal and child health, chronic disease, public health, health promotion, HACC, occupational therapy, nutrition, podiatry and diabetes care.

The PHCC health clinic services up to 50 clients a day – mainly residents of Thursday Island, with some from the outer islands. The Indigenous community does not tend to make ready use of this service: ‘Community people still only visit our service when they are really sick’.

Community people consulted stated they would go to the hospital if they had issues with the PHCC. ‘Sometimes it is just easier to go straight to the hospital as you get seen quicker and get out of there quicker. At the PHCC you have to wait a long time’.

‘I won’t go there because there are too much politics going on with my family and the PHCC. Everyone knows your business and everyone else’s business when you go there. I know who has what sickness and when someone is told they have a really bad illness others pick on you and make you feel guilty if you don’t change your diet and then they tell the Centre staff’.

The Australian Hearing Service currently makes three visits a year to the Torres Strait and services about 50 clients (largely children) on each visit. It costs about $200 per child and parent/carer to travel from Bamaga to Thursday Island to access hearing services. The outer islands are not targeted due to the high demand in other areas, although these islands should be targeted soon. The PHCC claims that nearly 98% of children have a severe hearing problem yet will now need to wait until July 2006 before the next scheduled specialist visit.

PHCC staff stated that more skilled workers were required to deliver specialist hearing services to the community and that health workers should be able to claim this under Medicare.

The Australian Hearing Service only sees adult clients who are on the pension or have a disability: ‘People that are employed have to pay ﬁrst for a hearing aid and they get seen by the centre hearing staff for check ups and follow ups. Can someone on $25,000 a year claim this service on Medicare?’

‘I am employed and educated but I can’t afford to see the hearing specialist or get a hearing aid. My son now has to have grommets in both ears. Even though this service is free I need the money to travel many times down the Queensland coast. My son will have to wait until I have saved the money for all the trips so I don’t disappoint him by only getting half a service’.

‘Many of our Indigenous kids suffer from glue ear and have to attend testing and check ups every few months (sometimes over three to six years depending on their condition and age). Many children have been identiﬁed as needing grommets placed in their ears which results in a lot of follow ups after the operation. This is costly, therefore follow up is not adhered to by the Health Clinic, Centre and the client’.

148 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 2.4 NPA Health Service

There is a 10-bed Hospital at Bamaga staffed by three full time Medical Ofﬁcers, Registered Nurses and Health Workers as well as administrative/ancillary staff. It is open 24 hours, seven days a week, with an after hours staff of two. There is no theatre at Bamaga Hospital, with patients being either seen at the Thursday Island Hospital or evacuated to Cairns.

Pharmaceuticals for all communities are distributed through the hospital dispensary and through the local community health centres.

There is a primary health care centre in each of the ﬁve NPA communities, staffed by health workers and administered by the Bamaga Primary Health Care Centre. Patients generally go to the local clinics for dressings, analgesics etc. The three doctors alternate between hospital consultations and community consultations. Each nearby clinic is visited once a week by one of the doctors, and the outer community clinics once a fortnight. All clinics are ‘drop-in’ with no appointments. Each clinic is centrally located in the community and is open Monday to Friday. After-hours patients have to present at the hospital for treatment, which can be difﬁcult for those without transport.

Cairns health services

Cairns Base Hospital services Cairns and surrounds (eg Atherton, Yarrabah) and provides services to the whole of far north Queensland and the Torres Strait Islands through outreach programs and visiting specialists programs. There is a private Catholic hospital nearby.

Wuchopperen ACCHS, located in the centre of Cairns, services a large proportion of Aboriginal and Torres Strait Islander people from Cairns and within a 50-60 kilometre radius. It also runs satellite clinics and remote clinics weekly. The centre is open long hours and most patients are from Cairns.

There is a 24-hour medical centre (accident & emergency, primary care, X-ray, pathology and pharmacy) which sees a signiﬁcant number of Indigenous patients.

3. General Issues

Recruitment

The Thursday Island Hospital continues to have signiﬁcant problems recruiting and maintaining staff. One doctor stated ‘Recruitment is our greatest problem – it takes a special kind of doctor to want to work here’. The Island is seen as being too remote, so that few practitioners want to stay for long periods of time, particularly if they have a young family.

In contrast, a spokesperson at Bamaga said ‘Recruitment is not a particular problem for us – our doctors stay here ﬁve years or more, on average. We kit them out well in their accommodation, they are provided with a vehicle and they have a say in decision-making. In short, they are looked after and are part of the community’.

It was emphasised that GPs in remote areas like the Torres Strait not only have a heavy workload, but also need skills and capabilities that are much broader than are generally required of GPs in urban areas. For this reason, the availability of professional development/training is an important incentive in attracting and keeping staff.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 149 The Thursday Island Hospital has just seen its ﬁrst three Torres Strait Islander Registered Nurses graduate. However, ‘the issue with sponsoring Indigenous students is that when they graduate they don’t operate in their communities. All three graduates have relocated to Cairns and Townsville’.

Community members consulted stated that more Indigenous people need to be employed in providing health services in the Torres Strait: ‘We need more of our own working in the medical ﬁeld. I don’t trust people I don’t know and if they are working in government I don’t want to talk to them because we don’t get anything for our time and they ﬂy in and out in a day and don’t make any real changes for our families’.

Transport

In the Torres Strait district transport remains a serious concern to the Health Service staff: ‘A number of patients have missed their specialist appointments because they couldn’t get to the wharf to catch the ferry to Thursday Island, which places more pressure on the communities on Horn Island and at Bamaga’.

The twice-daily ferry service between Thursday Island and Seisia (NPA) is quite expensive ($75 return). Bamaga Hospital pays the cost of an ambulance from the hospital/home to the airstrip, but not to the wharf at Seisia (to go to Thursday Island). Regular ferry services do not run to other islands, though boats and light aircraft may be chartered. Chartering is expensive and so people tend to wait until a few people can go and share the cost. People also travel between islands in small privately-owned boats or dinghies/tinnies. Community people usually have to wait an average of three weeks before they can visit a specialist on the mainland.

‘If I have to go to Cairns or Townsville for an urgent specialist appointment, I usually can’t afford the ferry, bus and plan fares return. My family will save up all their money over a couple of months to send me for one trip. I went a few months ago and when I got to Cairns they said my appointment had been moved to the next day. I didn’t have the money for another night’s stay so I slept on the beach’.

Culturally speciﬁc information and education

Since the previous Medicare study, a number of Health Service staff and some patients said that information in Creole was still required. The Health Council would like such materials to be produced locally (funded by Medicare). They thought that videos in Creole could be used by health workers throughout the islands. The PHCC still continues to prepare and photocopy its own materials.

Suggested topics were similar to those mentioned in section 7 of the Townsville case study.

There was said to be an ongoing need for education for community members on the importance of having Chronic Health Care Plans along with an explanation of what is required by an individual in developing a care plan.

Of the six staff interviewed at the Primary Health Care Centre, the Medicare Claims Ofﬁcer was the only staff member who was aware of the 1800 Indigenous access line – and even this person was not familiar with the Medicare Indigenous Tool Kit.

Promotion was said to be needed through radio, print and television media. (‘All of the community watch Imparja television and listen to the national radio network’.) There had been some media promotion on Adult Health Checks but evidently this was not a regular thing.

150 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 The pharmacy requested that as much information as possible be made available to workers to keep up to date on relevant changes to Medicare and Indigenous health policies. The IT section felt that the ‘purple book’ from the Northern Territory – ‘Medicines Book for Indigenous Health Workers’ – should be adapted and implemented for Torres Strait health workers.

‘Lifestyle’ and Chronic Disease

It was stated that the main source of income for Torres Strait Islanders (Thursday Islanders and NPA residents) was the CDEP. The fact that many people are on low incomes means that it is difﬁcult for community people to meet the high cost of groceries and other necessary produce in the district: ‘If there were more items subsidised under Medicare there would be more money to afford necessary living expenses’.

The Health Council is strongly advocating that the Queensland government introduce freight subsidies on the price of goods as the community continues to suffer. It is also advocating a more holistic approach to better health outcomes, increased employment and affordable access to food and stores. Food and other general supplies are delivered to Thursday Island and then trans-shipped to the outer islands. Each island has a supermarket or shop/ store operating under one supermarket chain (IBIS). It is perceived by locals that this gives the chain the ability to mark up its prices too readily but, in fact, the chain has been subsidised for over 20 years by the State government to ensure isolated areas have access to supermarkets.

One respondent said that ‘Torres Strait Islanders will buy a big bag of rice and ﬂour and then hunt for their main food – turtle and dugong. They still need to purchase fruit and vegetables and will usually not be able to afford these so they go without and ﬁll up on carbohydrates therefore increasing the risk of chronic disease’.

Another person indicated that traditional fishing (crayfish, beche de mer, croaker) has declined dramatically with ‘only a handful of Islander fisherman remaining’. This was attributed to depletion of the fishing stock and tighter fishing regulations as well as a decline of traditional cultural practices. A comment was made, at Bamaga, about increasingly poor dietary habits amongst the local community. ‘Instead of buying fresh fruits and vegetables when they are available, people rely on eating great quantities of rice. Also, on a weekend, they may buy a huge bucket of fried chicken – eat it on a Friday night and the leftovers the next day’.

Numerous professionals operating in the Torres Strait stressed that people were getting sicker – not better – and that chronic diseases and ‘lifestyle’ illnesses were increasing. One spokesperson went so far as to say ‘My own family members are killing themselves – they eat poorly (and too much), don’t exercise, smoke all the time. Life expectancy up here is dropping – not getting better!!’

Public health issues continue to be a focus of health interventions. For example, outbreaks of dengue fever have occurred in recent years, leading to campaigns to eliminate mosquito breeding sites, to ensure that all dwellings are screened and to promote use of insect repellents and protective clothing. There were about 500 cases of dengue fever reported last year, with some 40-50 people requiring hospitalisation from the disease.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 151 EPC Items and Adult Health Checks

There appears to be relatively little use made of the Adult Health Checks, or any other comprehensive care planning. As one doctor on Thursday Island stated ‘People come to you really sick – and even then they often have to wait one or two hours to be seen. There’s no way they are going to stay on to do a health check and wait even longer. Besides, the doctor is too busy dealing with people in a critical state to step back and carry out a health check’.

Community members consulted suggested that community leaders, in particular family groups (as nominated by the families), could be given more information at regular health session/s that could be run by the PHCC. This might cover information about improving their health status and that of their families – ie implementing their chronic health plans and not just attending a health service when health conditions become critical. These leaders could then go back to their families and explain new changes and health requirements that individuals and families need to act upon to work toward improving health outcomes.

‘My family will not generally persist with having a full adult health check as we are told it will take around 30 minutes to do. We then might need to go to other health clinics and hospitals to have blood tests and x-rays. We don’t have the time to do this or the money to get to these places. Our children and grandchildren cannot be looked after during the time taken to undergo the outcomes of a Adult Health Check or the time we are away which is sometimes three days including travel’.

It was also said that the Adult Health Check item was not adequately understood by health professionals. Even where Health Checks were undertaken, often one component could be left incomplete (or else was not able to be ‘signed off’ by a health worker). Hence the rebate is not claimed from Medicare.

At the time of the ﬁeld visit, Bamaga health workers indicated that James Cook University was scheduled to be in the NPA shortly to carry out ‘mass’ adult health checks. This campaign-style approach was an element of a longitudinal study being conducted in Northern Queensland under an NHMRC funded grant.

Like many Indigenous health facilities, the Primary Health Care Centre on Thursday Island uses the Ferret system for its client consultation procedures; patients are then screened and referred to the appropriate doctor or specialist. This system produces basic care plans which make it easier for staff to ‘look up’ a patient to follow how each is progressing with their care plans.

Thursday Island community members are mainly presenting for dental care, diabetes (up to 25%), renal failure, hearing problems, heart disease, STDs and type 2 diabetes in children.

‘More Indigenous people are becoming more worried about their teeth than other health issues. We get them in to see the attending dentist and then have the dentist ask about other health issues which generally leads to the client coming to the other side of the Health Centre’.

‘The dentist will sometimes become a counsellor at times as most of the dental problems are experienced by female clients who have become victims of family violence’.

It was suggested that a public health study undertaken in Victoria should be replicated in the Torres Strait. This study involved Koories diagnosed with diabetes being placed on a Bush Tucker foods diet for three months: ‘All the Koories didn’t have diabetes any more. The problems re-occurred once the study ﬁnished and the Koories that participated ended up with diabetes again as no one was monitoring them’.

152 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 At Bamaga, the smaller and more residentially stable population means that health workers are better able to informally monitor people’s health – they know who is pregnant, who didn’t show up for a Pap smear, who is trying to quit smoking.

Specialists

A limited number of private specialists visit Thursday Island and Bamaga Hospitals and the community centres. Most specialists are from the public hospital system and therefore do not bulk-bill. It was reported that a private Ear/Nose/Throat doctor used to make visits, but had so many problems with Medicare claims that he did not return. One specialist commented that those outside the hospital system are unlikely to make the effort to visit the communities because there is not adequate remuneration: specialists in private practice still have to maintain their rooms and staff while they are away and unless all their travel, accommodation, equipment and on-the-ground staff costs are met, visits to remote communities will never be viable.

Another observer felt that public hospital specialists are the ones who would go to outlying areas, but they are often limited by inadequate resources and their inability to drop their hospital workload. Some specialists said if they could bulk-bill their consultations in remote communities they could get a replacement for the period they were away from the hospital. As one specialist stated:

The reality is that the Medicare system is not adequately paying for either primary or specialist care for remote Indigenous communities, and that the State health services are having to pick up the load without getting Commonwealth funds for it. I desperately need another staff member to properly provide outreach specialist care. How about Medicare funding it? Much cheaper than all the use of Medicare by metropolitan Caucasians.

Actually getting the services to remote community residents is not hindered simply by ﬁnancial factors. As one health administrator said, ‘We have specialists visit, and 35 people may be booked to come. When the day comes, maybe only seven will show up – for any number of reasons. It may then be weeks or months before the specialist visits again.’

4. Issues relating to Medicare

Medicare enrolment

The Thursday Island PHCC Medicare Claims Ofﬁcer stated that 95% of community people now have a Medicare card, although only about 75% carry their cards on them at the time of appointment. The PHCC does not hold client cards as they want the clients to be responsible for themselves.

Similarly in Bamaga the records show that, at most, only about 4% of the community was unlikely to be correctly enrolled in Medicare. The health service’s administrative system immediately ﬂags a patient whose enrolment has expired.

The Medicare Claims Ofﬁcer normally establishes a client’s eligibility for Medicare enrolment through the use of referee system on the back of the proof of identify forms.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 153 The Medicare Claims officer has updated all client records and strongly commends the use of the Medicare Proof of Identify – Verification forms as a positive process to making enrolment procedures easier ‘It also makes it easier for the Indigenous Liaison Officers in the HIC Brisbane office to process all client details and track client movements for some of the additional follow up that is required’. The Health Workers and Registered Nurses who visit the outer Torres Strait Islands also fill in these forms and provide them to the Medicare Claims Officer at the PHCC.

Indigenous people travel extensively between the islands on a regular basis. If someone moves from an island, relevant information is not automatically provided to the hospital or the PHCC. The administrative burden increases for the Registered Nurses, the health workers and the Medicare Claims Ofﬁcer to determine a current address.

Teenagers still need to be advised that they need to apply for a separate card of their own, particularly if they move away from their family. Leaving the area to go to boarding school is common, and this may result in the child not having a current Medicare card.

It was reported that a reasonably high portion of claims continues to be rejected where people tend to carry their old cards even when they have expired, and do not renew their cards as needed. ‘We are trying to have our clients renew their cards and throw away the old ones. We only check the handwritten cards. There is less of an issue with new Medicare numbers as the HIC Indigenous Liaison Unit regularly maintains these records. Most of the claims now rejected relate mainly to children who are not registered’.

No client is denied access to the PHCC. However the pharmacy no longer issues free medications to someone without a Medicare card unless a proof of residency on Thursday Island is provided. Problems still arise as many patients are known by different names (people have up to four names which are frequently used interchangeably, as well as an Island name). Several people in the one family may use the same name (eg Robert Senior, Robert Junior) and dates of birth are often not known or are incorrect.

Newborns are still less likely to be enrolled with an actual name on the mother’s Medicare card and may not be followed up, even months after leaving hospital as there are no additional resources for follow up and many Indigenous mothers may have moved from their previous registered address.

Forms and procedures

The staff consulted at the PHCC were of the view that the majority of patients they saw were unlikely to carry their concession card with them thus often didn’t have it at the time of an appointment.

There is no Centrelink ofﬁce on the outer islands, and when staff phone the Centrelink ofﬁce on the mainland they report being placed on hold or asked to speak to the client directly; and then they are placed on hold therefore clogging up the phone lines at the PHCC.

There is a perception among medical professionals in the Torres Strait that Indigenous community members, particularly on the outer islands, will ‘listen more to a doctor’ than to a health worker (or other staff) about the importance of bringing their Medicare or Health cards to appointments and specialist visits.

Community members suggested they did not have an issue with the voluntary identiﬁer. According to one person this was ‘more of an issue with identifying non-Indigenous people as they usually won’t state either way unless directly asked [if they are Indigenous], which causes issues if staff believe they are not and the client says they are with no proof provided’.

154 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 Medicare claiming

As a result of the continuing shortage of doctors in the region (particularly the outer islands) and the fact that a signiﬁcant proportion of primary health care is overseen by health workers and nurses, Medicare claiming still remains limited. The Health Service Executive thought that claiming some health workers’ and nurses’ work, particularly the hearing services work, would be appropriate because of the remoteness of the location, and suggested that if necessary any such arrangement could be quarantined to the Torres Strait area (particular if a visiting or resident doctor were to oversee the work provided by the health workers and nurses).

At Bamaga the administrative head of primary care was of the view that ‘probably we don’t claim nearly as much as we could claim’. However the manager responsible for Medicare claiming at Bamaga felt that staff were thorough and systematic with regard to the claiming process and, most likely, were claiming close to the maximum appropriate.

The PHCC understands that late lodgements of Medicare claims will be rejected. The issue the Centre would like resolved by Medicare is that when it re-submits a claim it might get rejected again, and that it takes six months to be notified by Medicare. The Medicare Claims Officer completes the forms, submits and/or re-submits forms and even follows up on non-resident GPs who have left the Centre to return overseas or to other parts of Australia. This is because the claims officer needs the GP’s signature on all claim forms (even resubmitted ones) that were incorrect in the first instance. If GPs are not available or cannot be contacted, the claim is destroyed. Needless to say, this process is very resource intensive.

There appears to be a minor issue regarding MBS claiming for services provided at Bamaga, in that the money claimed does not return directly to Bamaga but goes, instead, to consolidated district health monies at Thursday Island where a re-allocation of funds occurs. Here, and in other localities, the growing realisation that MBS claiming does or could have a direct effect on the ﬁnances of a particular service has been the primary motivation to embrace the Medicare systems. When the nexus between claiming and reaping the beneﬁts is in any way broken, then the incentive to claim is reduced.

5 Issues relating to PBS

Thursday Island Hospital pharmacy services 15 communities and ﬁlls 1,000 scripts a month. Residents of Thursday Island must get their medication by prescription directly from the pharmacy in town.

The PBS arrangements in the Torres Strait region are unique, and provide a particular variation on Section 100. This arises out of two distinctive conditions prevailing in the region – its extreme isolation and the rather remarkable existence of a viable community pharmacist on Thursday Island. A special approach to S100 has been developed that seems to satisfactorily address the requirements of the Commonwealth, Queensland Health, the community pharmacy and local consumers.

Bulk supply arrangements (as in conventional S100 situation) operate with regard to the supply of medications for Bamaga and other NPA communities and all the outer islands. The result is much enhanced access to, and management of, pharmaceuticals in these areas.

On Thursday Island itself the system is different. Any script written for patients by a GP at the local PHCC is taken to the community pharmacy to be dispensed, and the cost of the co-payment is picked up by Queensland Health through the District health service. Transients (eg Army personnel, Telstra workers) who would not be eligible for coverage of Section 100 pay their own co-payment.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 155 This system seems to work well, the only remaining issue being that Queensland Health absorbs the costs of the co-payments – moreover this is borne out of the budget of the District health service.

Thus the hospital/PHCC pays the Thursday Island pharmacy $350,000 a year and the recent increase in co-payments has resulted in more pressure on the budget and on resources available to the outer islands. The hospital and PHCC are currently negotiating the co-payment issue with the Commonwealth and Queensland Health.

Since the introduction of Section 100 there has been a signiﬁcant increase in the uptake of medication. There is a group of health workers and registered nurses who can dispense certain medications on the outer islands and at Bamaga.

Both Thursday Island and Bamaga indicate that dispensing has not been without some problems. The hospital pharmacist stated that there had been an increase in the risk of errors by staff working on the outer islands: ‘not writing the information down correctly and handwriting of labels for medications and staff not properly trained’.

The Hospital pharmacy has also had many problems with its medication stock control on outer lying islands as this responsibility has been given to the health workers there. Some medications expire very quickly and there has been a problem of an oversupply of one particular medication that is not being frequently used. The hospital is actively working with the Island’s pharmacy on minimising overall costs by ﬂying out medications and supplies to the outer islands.

The Hospital on Thursday Island has only recently received a computer labelling machine to ensure that all labels on medications dispensed have the correct information: ‘The national Health Line should be sourcing simple information about medications so that the NPA districts would all have a more streamlined process for medications’.

In Bamaga there is no pharmacist and dispensing is done by any number of nurses – said to result in some ‘mishaps’. Resources are not available to have a pharmacist, and attempts are being made to ensure that nurses are either trained to dispense medications and/or that this becomes a specialist task carried out by a very limited number of trained nurses.

Each of the islands and Bamaga has a stock medication room: ‘It would be great to have a couple of people assigned to work on stock control over all 25 sites’.

The Thursday Island Pharmacy is of the view that access to medicines has improved over the years due to the introduction of Section 100 and funding for training of medical staff at health clinics on the outer islands. Improvements have also been seen in stock ordering, dispensing medications and blister packs. Nonetheless the pharmacist reports having a lot of problems with entitlement numbers; about ﬁve or six are thrown in the bin each month because a number cannot be found for them.

156 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 Brisbane - Urban

1. Background

According to the 2001 Census, there were approximately 1.6 million people living in Brisbane, of whom approximately 26,972 (1.7%) identiﬁed as being of Indigenous origin.

Brisbane covers a very large geographical area. It also boasts Australia’s highest rate of capital city population growth, and has been the fastest growing city for almost 20 years. For example, the urban population reportedly grew by 11.5% between 1999 and 2004 (ABS).

2. Aboriginal and Islander Community Health Service

The Aboriginal and Islander Community Health Service Ltd (AICHS) is a community controlled service located in the inner Brisbane suburb of Woolloongabba. It also provides clinical services (part-time) at three other Brisbane locations: Inala, Acacia Ridge and Woodridge.

AICHS staff total approximately 60 all up. The medical service itself employs 5-6 GPs (with some additional sessional visitors), plus nurses and AHWs. Some specialist clinics are conducted at AICHS, eg in paediatrics, audiology and gynaecology.

AICHS has a Community and Dental Health Branch whose staff include two FTE dentists and four FTE dental assistants. It also has a Child, Youth and Family Branch, the staff of which includes youth health, outreach and sexual health workers together with nursing, psychology and drug and alcohol services.

AICHS reports problems in ﬁlling some positions as relevant Award rates fail to keep pace with the wage and salary levels available elsewhere56. The Senior Medical Ofﬁcer, however, has been with AICHS since 1997.

AICHS is primarily funded by DoHA (project and grant income totalling over $3 million in 2004-05), and also receives funding support from the Queensland Department of Health and Department of Communities. In 2004-05 the (then) Australian Government of Family and Community Services provided some $700,000, chieﬂy for Indigenous Families and Child Support Services. Income from Medicare rebates in 2004-05 amounted to some $343,000. Income from Medicare rebates has, among other things, enabled AICHS to employ a dental technician, to pay part of a GP salary and to purchase additional capital equipment.

The sheer complexity of funding arrangements was identiﬁed as an issue for the Service, which was said to have to deal with over 30 separate funding agreements.

AICHS recorded almost 23,000 ‘episodes of care’ in the ﬁnancial year 2004-05. The total number of patients seen each year was estimated at around 15,00057.

56 Other stakeholders identified staff recruitment and retention as a major challenge for Indigenous-specific health services, whether in Brisbane or elsewhere in the State. This difficulty was reflected in a significant degree of reliance on overseas-trained practitioners, whose understanding of the Australian health system and of the MBS in particular was inevitably limited. 57 There was much doubt about the reliability of the patient figures recorded for 2004-05 which, at some 6,000, were considerably less than were recorded the previous year.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 157 AICHS has the Ferret patient and information recall system, but ﬁnds that it does not meet all the Service’s diverse requirements. The GPs use Medical Director.

AICHS has operated in Woolloongabba for some 30 years, but now faces the need to relocate as a result of the current property being resumed for major roadworks. The aim will be to ﬁnd a suitable new site that is still well- served by public transport.

The medical service has in the past operated on a drop-in basis, but is moving towards an appointment-based system. (The dental service and various specialists already operate on the basis of appointments.) Among other things, this will enable more efﬁcient provision of transport services to patients.

AICHS has a dedicated Medicare worker (clerk) who has the main responsibility for ensuring that claims are completed and submitted. The Medicare clerk reported frequent contact and a very positive relationship with the Brisbane MLO and her staff. AICHS staff comments on the service provided by the MLO and her colleagues were very enthusiastic: ‘they do a great job; they are ‘absolutely wonderful’. Medicare claims are submitted manually at this stage.

In general it was seen as the responsibility of the Senior Medical Ofﬁcer and the Practice Manager to keep abreast of Medicare information and changes.

Staff at AICHS had welcomed the introduction of care plans for EPC chronically ill patients, and regarded this as the sort of service they had themselves sought to provide; now they could do it ‘formally’ while also generating income. At the time of the study team’s visit AICHS reported having conducted a number of Adult Health Checks, and indicated that it planned to provide these more systematically in the future. An appointment is always made for conduct of a Health Check, which typically takes around 45 minutes.

AICHS is an accredited practice, but its income from PIP is low – eg some $4,700 in the 2004-05 ﬁnancial year. Senior staff commented that the requirements of mainstream accreditation did not necessarily reﬂect the issues and priorities that were important for an AMS.

Management at AICHS reported having received assistance from the Division of General Practice in understanding and responding to various health system changes over recent years.

AICHS maintains a small stock of medications for distribution direct to patients. (For example, it was said, homeless young people would get no medication if AICHS did not provide it for them.) Staff observed that the level of PBS co-payment was a signiﬁcant problem for many patients who were not eligible for health care cards.

3. Inala Indigenous Health Service

The Inala Indigenous Health Service is co-located with the Inala Community Health Centre in outer suburban Brisbane. Its Clinical Director is an experienced Aboriginal doctor who is widely respected (‘a true visionary’). The Director is an employee of Queensland Health and receives a budget for operation of the Service from Queensland Health.

Staff include three nurses, two AHWs, an administrator and a nutritionist, with additional sessional services provided by external Medical Ofﬁcers (also employed by Queensland Health).

158 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 There are close links and co-operation between this service and AICHS (which also provides a service at Inala).

The Health Service has fairly recently been included in the S19(2) exemption, enabling it to claim Medicare rebates for services provided. It has been receiving Medicare income of around $20,000 to $22,000 a month, which has been ‘a huge help’ in improving and expanding services.

The Clinical Director expressed great enthusiasm for the Indigenous-speciﬁc EPC items, especially the Adult Health Check, which was ‘brilliant’ in terms of screening and early intervention.

The Service is not an accredited practice at this stage and is therefore not eligible for the Practice Incentives Program.

This Service, also, has regular contact with the MLO unit in Brisbane and is well pleased with the services it provides. At the time of the study team’s visit to Brisbane there were plans for the MLO to come to Inala to provide Medicare training for staff of the Service.

The Clinical Director spoke about problems with patient access to medications, saying that ‘the problems aren’t really all that different’ between urban and remote settings. At least a discretionary capacity to provide medication fee of charge would be very beneﬁcial, he believed. At present, free samples were the only medications that some of the Service’s patients were likely to get.

4. Access to Medicare under Section 19(2)

It was noted that in various ways the item-based Medicare system is not a good fit with the way Indigenous health services are delivered, and that there is scope for DoHA to consider development of new Medicare items which better reflect the ways in which such services are provided. A key issue was that, with Medicare, ‘everything’s triggered by the doctor’, this does not reflect the way that ATSIHSs operate, and is by definition inapplicable in those areas where there are no GPs). There was still further need for Medicare to better reflect the realities of remote area services in particular – where, for example, the nurse and/or AHW was likely to be providing most services without any GP involvement. The recognition of an AHW role in providing allied health services in support of care plans was welcomed by a number of stakeholders, but was also described as ‘very limited’.

Another perception of the MBS was that it was very much focused on ‘medical care’ rather than ‘health care’ – that is, it tended to place insufﬁcient emphasis on preventive services. Thus the Indigenous-speciﬁc EPC items were a particularly welcome addition to the schedule.

At the time of the study team’s visit to Brisbane, the Queensland Aboriginal and Islander Health Council (QAIHC, the Queensland NACCHO afﬁliate) was awaiting the results of a study conducted by Dr Katie Panaretto of the Townsville Aboriginal and Islander Health Service, examining billing patterns and the use of Medicare in a sample of community controlled services in Queensland. QAIHC subsequently made that report available to the study team, and some of its ﬁndings are discussed in the body of the present report. Dr Panaretto’s research makes it clear that claiming levels vary among health services in ways that are not fully explained by their GP numbers or patient numbers; it appears that some services have to date been able to respond better than others to the challenges and opportunities created by access to Medicare funds under S19(2).

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 159 Some of the Brisbane stakeholders emphasised that reliable patient record and recall systems were essential if health services were to be able to make effective use of Medicare; in fact all management and administrative systems needed to be working well if a health service was to be able to embrace Medicare effectively. QAIHC representatives stated that there had been no speciﬁc OATSIH strategy designed to tackle issues of this kind, and also argued that NACCHO and its afﬁliates could have been used more actively to assist health services to adapt to the use of Medicare.

As in Perth, for example, it was argued that smaller or less well resourced health services were at a disadvantage in accessing Medicare funds: ‘It works best where the AMS is a certain size and has a certain level of funding’. In the words of one senior bureaucrat, ‘The whole MBS/PBS system is too hard’ for small and unsophisticated health services to navigate.

Several of the stakeholders consulted in Brisbane expressed support for the notion of ‘cashing out’ Medicare funds for Indigenous health services. Here as in other places, numbers of people interviewed by the study team believed that pooled funding arrangements for the Katherine West health service had worked very successfully; the perceived advantages of such an arrangement included more predictable budgeting and forward planning and the encouragement of a more strategic approach.

5. Mainstream Services

GPs

According to the Brisbane Medicare Liaison Ofﬁcer (MLO), private GPs are much less likely than Indigenous- speciﬁc services to attempt to sort out problems relating to Medicare numbers and enrolment; she felt that there was relatively little GP use of either the general-purpose or the special Indigenous Medicare information line for this purpose.

The MLO identiﬁed the limited availability of bulk-billing in private practices as a signiﬁcant barrier to Indigenous access. Poor cultural awareness among many GPs (eg as to why a patient may have brought a relative to the surgery with her) was another barrier. Many practices ‘just don’t want to know’ about ways in which they could offer a more Indigenous-friendly environment and approach. Overt racism was reported as common in some country towns in particular, and could affect both general practices and community pharmacies.

Representatives of the Queensland Aboriginal and Islander Health Council (QAIHC) likewise identiﬁed cost and cultural respect/appropriateness as key issues needing to be addressed in the context of Aboriginal and Torres Strait Islander access to mainstream services. Outside major towns and cities there were also problems reﬂecting the very limited health services available.

Stakeholders interviewed in Brisbane welcomed introduction of Indigenous-speciﬁc EPC items in the context of general practice, but it was said that in itself this hardly represented any real incentive for mainstream GPs to try to attract Aboriginal or Islander patients. The point was made that mainstream GPs needed to invest time and effort into adapting their practices to provide Adult Health Checks or other similar services; obviously this took a degree of commitment that not all doctors were likely to have.

Some stakeholders thought that the provision of accessible information on Medicare issues and changes needed to be improved, both for mainstream and for Indigenous-speciﬁc service providers.

160 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 Specialists

The general lack of specialists in rural and remote areas was said to have signiﬁcant implications for Indigenous access to appropriate care. For example there were essentially no obstetric services available on Cape York. In response to this, it had become routine practice to ﬂy women who were about to give birth to a centre like Cairns. While there were clear medical advantages to this, it raised major social and community issues, including the fact that people were not born in their own country.

Hospitals

QAIHC representatives and others noted that there were long-standing negative images which deterred some Indigenous Australians from seeking health care at hospitals. (‘Hospitals are still seen as the place you go to die’, said one observer.) Hospitals can be frightening and forbidding places to many people, both Indigenous and non- Indigenous. There are also cultural gaps between the expectations of the hospital system and Indigenous families and individuals.

Hospitals are rarely set up, for example, to cope with the large numbers of family members who may come to visit an Aboriginal patient. Nursing staff may well react negatively to large groups of visitors.

Large public hospitals typically have Indigenous Liaison Ofﬁcers; their roles and the services they provide appear to vary somewhat from one hospital to another.

At one Brisbane hospital the Liaison Ofﬁcer stated that she saw many Indigenous Australians, especially from country areas, who were either not enrolled in Medicare or could not produce a Medicare card. This was a time- consuming issue for hospital staff to deal with, although the availability of the Indigenous information line had made things far easier. At the Accident and Emergency Department, it was said, patients with urgent needs were simply admitted to the hospital, leaving any paperwork problems to be sorted out later. There were various ‘horror stories’ of delays, charges etc that could arise from confusions about Medicare coverage – due, for example, to variations in the spelling of a name.

One hospital ILO noted that she and her colleagues received no support in the form of counselling or debrieﬁng to assist them in coping with the confronting situations and emotions that they frequently encounter.

It was said that, if they were to offer more adequate services to Aboriginal and Torres Strait Islander people, staff in Accident and Emergency Departments would need to be trained both in cultural awareness and also in Indigenous health care – for instance, what are they key risk factors for a 40-year-old Aboriginal male?

It was also noted, however, that there has been some progress made in developing partnerships between AMSs and hospitals in Queensland; a co-operative program around post-natal care in Townsville was a good example. As a general principle, it was said, Indigenous health services needed to be more clearly seen as playing a role in the broader health system.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 161 6. Medications

Numbers of Brisbane stakeholders raised the issue of access to medications in cities and towns. With the current S100 arrangements, some said, ‘you’re only fixing half the problem’; serious access issues remained to be addressed in metropolitan and regional areas. High cost and limited transport were identified as two key barriers to accessing the PBS in non-remote areas. Numbers of those consulted in Brisbane referred specifically to the PBS co-payment as a barrier for many Aboriginal or Torres Strait Islander people.

QAIHC has been reviewing issues relating to medications and access to the PBS in Queensland, with the aim of developing strategies to improve access across the State. Like a number of other stakeholders, QAIHC is interested in the feasibility of extending or adapting the S100 arrangements for use beyond remote areas. In the context of the current operation of the S100 arrangements it was noted that the Yarrabah community in Far North Queensland, for example, has a high need for pharmacy services but is ineligible for S100 because of its geographical proximity to Cairns. In practice, however, it is not at all easy for Yarrabah residents to access a community pharmacy.

The ideal arrangement, some stakeholders believed, would be for AMSs to be authorised to own and operate a pharmacy service. Short of that, co-location of pharmacies with health services would be very desirable.

There were some stakeholder comments to the effect that the PBS was still in the process of addressing access issues, while not much progress had so far been made on QUM issues.

Limited issue of drugs on discharge from hospital was raised as an issue, together with inadequate instructions on the use of drugs that might be unfamiliar to the patient.

Two community pharmacists who were consulted in Brisbane identiﬁed few issues relating to PBS access. One of them said that it was unusual for an Indigenous customer to be unable to produce his or her Medicare card and (if applicable) health care card. If this did happen, he would ask the customer’s consent to contact Medicare (‘the IME hotline’) rather than leave the individual to sort the matter out. The process was ‘quite straightforward’, although he was unaware of the availability of the special Indigenous information line.

This pharmacist noted that his pharmacy had experience in conducting Home Medicine Reviews (HMRs), but had never received an HMR request involving an Aboriginal or Torres Strait Islander customer.58 He also commented that the PBS co-payment could be a serious problems for customers on low incomes who did not have a health care card – especially if they needed two or three prescriptions at once. For regular customers the pharmacy was willing to provide some medications on credit.

Staff at AICHS made the comment that Indigenous Australians may not be ‘all that keen’ about going to a ‘glitzy’ pharmacy with exclusively white staff.

58 AICHS had not made many use of Home Medicines Reviews so far.

162 Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 7. Medicare Liaison Ofﬁcer and Indigenous Information Line

The MLO unit in Brisbane has four permanent positions (including the MLO), and one temporary position. There is a second, OATSIH-funded, MLO position based in Cairns. It was reported that over 20 other Medicare Australia staff, in various locations across Queensland, have received cultural awareness training to assist them in dealing with enquiries from Indigenous organisations and individuals.

The MLO stated that the calls most commonly made to the 1800 information line in Brisbane relate to Medicare eligibility and enrolments, plus questions about the claims process. Nearly 2,000 calls a month are handled in Brisbane.

The rate of new Medicare enrolments in Queensland, other than for newborns, was said to be now relatively low, suggesting that considerable progress had been made in enrolling most Aboriginal and Torres Strait Islander people.

At the time of this study, most Medicare claims from Queensland ATSIHSs were still being processed manually; the MLO saw some advantages in this, in that all such claims were checked by her staff and any defects or omissions addressed. She emphasised that it is common for ATSIHSs to underclaim, for example by failing to claim the additional rebates relating to children and concession card holders.

The MLO unit sends out a monthly report to ATSIHSs on claiming issues, this is designed to further educate staff and to improve the accuracy and completeness of future claims. The MLO reported that the number and accuracy of claims from ATSIHSs has been increasing over time, but also that high staff turnover within health services continues to affect the level of understanding of the MBS within health services. Queensland Health has created Medicare-designated positions in several locations (eg Mt Isa, Weipa, Cooktown), which has helped improve claiming by State-funded health services. However, the fact that most ATSIHS doctors have no direct incentive to claim rebates tends to reduce the levels of claiming (‘the doctors put up a wall’). According to the Brisbane MLO, relatively few community controlled services have a staff member speciﬁcally responsible for dealing with Medicare matters. Short-term funding to enable ATSIHSs to establish such positions was suggested as one possibility.

While Medicare enrolments have increased and the machinery for solving enrolment problems has greatly improved, the MLO noted that some difﬁculties are still experienced relating to such matters as name changes, variants in names, failure to register new babies, and the fact that children may from time to time be in the care of various extended family members.

The MLO saw a need for more active implementation of Medicare Australia’s Indigenous Recruitment and Retention Strategy, both to increase the numbers of Indigenous staff and also to provide better support for Indigenous workers. For example, there was said at the time to be no Indigenous worker in the Cairns Medicare ofﬁce.

Aboriginal and Torres Strait Islander Access to Major Health Programs - Urbis Keys Young - 2006 163