Bills Digest No. 71, 2016–17
PDF version [680KB]
Amanda Biggs
Social Policy Section
Paula Pyburne
Law and Bills Digest Section
8 March 2017
Contents
Purpose of the Bill
Structure of the Bill
Committee consideration
Selection of Bills Committee
Senate Standing Committee for the
Scrutiny of Bills
Statement of Compatibility with Human
Rights
Parliamentary Joint Committee on
Human Rights
Background—Schedules 1 and 2
Rural health
Medical workforce shortages in rural
areas
Background
Provider number restrictions
Rural workforce audit (2008)
Current workforce situation
An overview of rural health policies
Overseas trained doctors (OTDs)
Rural workforce programs
Rural Generalist model
Policy position of non-government
parties/independents
Position of major interest groups
Financial implications
Key issues and provisions
Establishing the role
Functions of the Commissioner
Reporting requirements
Terms and conditions of appointment
Background—Schedule 3
Medicare Provider Number legislation
and the Medical Training Review Panel (MTRP)
History of the provisions
Policy position of non-government
parties/independents
Position of major interest groups
Financial implications
Key issues and provisions
Key provisions
Concluding comments
Date introduced:
9 February 2017
House: House of
Representatives
Portfolio:
Health
Commencement: Sections
1–3 on Royal Assent; Schedule 2 on 1 July 2020; Schedules 1 and 3 on the
earlier of a day to be fixed by Proclamation or six months after Royal
Assent.
Links: The links to the Bill,
its Explanatory Memorandum and second reading speech can be found on the
Bill’s home page, or through the Australian
Parliament website.
When Bills have been passed and have received Royal Assent,
they become Acts, which can be found at the Federal Register of Legislation
website.
All hyperlinks in this Bills Digest are correct as
at March 2017.
Purpose of
the Bill
The purpose of the Health Insurance Amendment (National
Rural Health Commissioner) Bill 2017 (the Bill) is to amend the Health Insurance
Act 1973 to establish a National Rural Health Commissioner. The Rural
Health Commissioner is to provide advice to the relevant Minister on the role
of the rural generalist and develop a National Rural Generalist Pathway, and to
provide advice on rural health reform as requested. The Rural Health
Commissioner will cease operations on 1 July 2020.
The Bill also repeals sections 3GC and 19AD of the Health
Insurance Act. Section 3GC established the Medical Training Review Panel,
which is no longer required as its functions are being performed by the
National Medical Training Advisory Network (NMTAN), a non-statutory authority.
Section 19AD requires that regular reports be made to the Minister regarding
the operation of Medicare Provider Number legislation. The repeal is intended
to reduce the regulatory burden on stakeholders and rural workforce agencies.
Structure
of the Bill
The Bill contains three Schedules:
- Schedule
1 inserts proposed Part VA into the Health Insurance Act to
establish the National Rural Health Commissioner, set out the functions of that
office, and provide reporting requirements
- Schedule
2 repeals Part VA on 1 July 2020
- Schedule
3 amends the Health Insurance Act to abolish the
Medical Training Review Panel and to remove the requirement to carry out a
review of the operation of the Medicare provider number legislation every five
years.
As the provisions in Schedules 1 and
2 of the Bill are unrelated to those in Schedule 3, this Bills Digest deals
with the relevant background, policy positions, financial implications and key
provisions in Schedules 1 and 2 separately from Schedule 3.
Committee
consideration
Selection
of Bills Committee
At its meeting of 16 February 2017 the Selection of Bills
Committee deferred consideration of the Bill to its next meeting.[1]
Senate
Standing Committee for the Scrutiny of Bills
The Standing Committee for the Scrutiny of Bills had no
comment on the Bill.[2]
Statement
of Compatibility with Human Rights
As required under Part 3 of the Human Rights
(Parliamentary Scrutiny) Act 2011 (Cth), the Government has assessed
the Bill’s compatibility with the human rights and freedoms recognised or
declared in the international instruments listed in section 3 of that Act. The
Government considers that the Bill is compatible.[3]
Parliamentary
Joint Committee on Human Rights
The Parliamentary Joint Committee on Human Rights considers
that the Bill does not raise human rights concerns.[4]
Background—Schedules
1 and 2
Rural
health
Rural Australians experience poorer health outcomes across
a range of health indicators.
According to the Australian Institute of Health and
Welfare (AIHW), ‘health outcomes, as exemplified by higher rates of death, tend
to be poorer outside major cities’. The main contributors to higher death rates
are ‘coronary heart disease, other circulatory diseases, motor vehicle
accidents and chronic obstructive pulmonary disease (e.g. emphysema)’. These
higher death rates ‘may relate to differences in access to services, risk
factors and the regional/remote environment’.[5]
According to the AIHW:
- Australians
in remote and very remote areas have mortality rates 1.4 times higher than
those living in major cities. Mortality rates for coronary heart disease were
between 1.2 and 1.5 times higher in rural and remote areas compared to major
cities; and death rates due to diabetes were between 2.5 and four times as high[6]
- the
prevalence of many chronic diseases is higher in regional and rural areas,
compared to major cities. Rates of chronic obstructive pulmonary disease (COPD),
asthma, diabetes, cardiovascular disease (CVD), cancer and mental health
problems are all higher[7]
- people
in rural and remote Australia have higher rates of risk factors including smoking,
overweight and obesity, physical inactivity, alcohol consumption and blood
pressure, compared to those in major cities[8]
- people
in remote and very remote areas often experience poorer access to health
services compared to those living in cities and they may have to travel
considerable distances to access services. In particular, the number of
employed medical practitioners (including specialists) was lower (253 per
100,000 people) in remote and very remote areas compared to the number in cities
(409 per 100,000)[9]
- the
number of GPs per 100,000 population was higher in remote and very remote areas
(137 per 100,000) compared to the number in cities (109), but the number of
services they provide per person is about half that of major cities[10]
and
- the
rate of emergency hospital admissions for surgery is highest for people in very
remote areas (22 per 1,000 admissions) and lowest for those in major cities (12
per 1,000).[11]
People in rural and regional areas also tend to have lower
use of Medicare funded services and access fewer medicines subsidised under the
Pharmaceutical Benefits Scheme (PBS).[12]
Socio-economic factors can compound these disparities. In
this National Health Performance Authority report, Healthy
Communities: Avoidable deaths and life expectancies in 2009–2011, it
was found that across regional areas, the age-standardised rate of potentially
avoidable deaths was nine per cent higher in lower income Regional 2 group
areas compared to wealthier Regional 1 group areas.[13]
But rates of potentially avoidable deaths in rural lower-income communities
(Rural 2 group) were more than twice as high as wealthier inner-city suburbs
(Metro 1 group).[14]
The association between poorer health status of people in
rural areas and lack of access to health services has been broadly
acknowledged.
In 2012, evidence provided to the Senate Community Affairs
Committee inquiry on The
factors affecting the supply of health services and medical professionals in
rural areas, linked the distribution of the rural health workforce with
poorer health outcomes. The Rural Doctors Association noted:
Australians living in rural and remote areas have much poorer
access to local health services, significantly worse health outcomes and a
significantly shorter life expectancy than Australians living in metropolitan
areas.
Many people living in rural and remote areas are unable to access
even the most basic primary care medical services in their local communities,
and have to travel significant distances just to see a GP for a basic
consultation, or have to wait many weeks to be seen close to where they live.[15]
Furthermore, the Royal Australian College of Physicians
argued that the maldistribution of the rural medical workforce carried
significant, potentially unsustainable, fiscal costs for both individuals and
the medical system:
Rural patients with complex illnesses may need to see
multiple specialists, entailing multiple trips to distant urban facilities. The
associated cost is tremendous and not sustainable. NSW Health Isolated
Patient's Travel and Accommodation Assistance Scheme (IPTAAS), for example,
reports the need for an additional $28 million in supplementary funding, over
four years. In 2011/12 forecast expenditure is $18 million, a $7 million
increase on the previous year.[16]
Medical
workforce shortages in rural areas
Background
Until the mid-1990s, government policies on the medical
workforce were largely based on a belief that this workforce was in adequate
supply. Indeed, a cap was announced in 1995, to restrict medical school intakes,
with the intention of avoiding an oversupply of doctors in the future.[17]
In September 1996, an Australian Medical Workforce Advisory Council (AMWAC)
report indicated that this thinking may have been incorrect. AMWAC concluded
that rather than there being an adequate supply of general practitioners (GPs)
the GP workforce was in considerable oversupply in the capital cities and other
major urban areas of Australia, but in significant undersupply in rural and
remote areas.[18]
This became known as a maldistribution of the medical workforce.
AMWAC concluded that general practitioner shortages could
be alleviated by increasing the number of medical practitioners by a
combination of the following:
- additional
Australian general practice trainees
- use
of overseas-trained doctors
- maximising
the workforce participation of existing general practitioners and
- the
introduction of new models of care.[19]
In the early 2000s, the Australian Institute of Health and
Welfare (AIHW) health workforce figures seemed to confirm a maldistribution was
still occurring. AIHW found that between 2000 and 2004, total medical practitioner
supply rose in metropolitan regions, fell in non-metropolitan regions and GP
supply had also decreased.[20]
Provider
number restrictions
In 1996, the Howard Government introduced legislation and
initiatives intended to address the perceived maldistribution of medical
practitioners. These initiatives involved:
- restricting
the ability of medical practitioners to provide services eligible for Medicare
benefits. Whereas previously the attainment of medical registration alone had
enabled medical practitioners to bill Medicare as general practitioners, the
Government introduced a policy of restricting new Medicare provider numbers to
people who had achieved specialist, (including general practitioner)
recognition and
- placing
provider number restrictions on overseas trained doctors (OTDs) to prevent them
from accessing Medicare payments unless they gain exemptions from these
restrictions. Two sections of the Health Insurance Act impose these
restrictions—sections 19AB and 19AA. These were imposed to encourage OTDs to
practice in rural and remote areas identified as suffering from medical
workforce shortages (described as Districts of Workforce Shortage).[21]
Rural
workforce audit (2008)
In 2008, the Department of Health conducted a workforce
audit into the supply of doctors, nurses and other health professionals in
rural and regional Australia.
The audit found workforce shortages persisting in rural
areas. Although the number of full time equivalent (FTE) GPs had increased by
10.9 per cent during the decade from 1996–97 to 2006–07, there was a net decrease
in the supply of medical practitioners as the population grew by 13 per cent
over the same time.
The audit found that while there had been gains in workforce
distribution in rural and remote areas over recent years, due at least in part,
to alternative mixes of services and models of service delivery, ‘these have
been in a large part due to the increased numbers of overseas trained doctors
working in these areas’. It forecast that the supply of medical practitioners ‘will
continue to rely upon overseas trained professionals in the immediate and
medium term future’.[22]
Current
workforce situation
More recent data from the AIHW continues to show
maldistribution between rural and urban areas, although there have been
improvements in some areas:
- In
2015, the supply of employed medical practitioners in major cities was 442
fulltime equivalent (FTE) medical practitioners per 100,000 population, compared
to 417.2 FTE medical practitioners in 2012, a growth of around six per cent. In
2015 there were 263 FTE medical practitioners in remote/very remote areas,
compared to 256.3 in 2012, a growth of around 2.6 per cent.[23]
- The
supply of GPs in remote/very remote areas was 135.5 FTE per 100,000 population
in 2015, higher than the rate for major cities of 111.6. However, the supply of
specialists in major cities was 162.1 FTE, compared to just 34.2 in remote/very
remote areas.[24]
An overview
of rural health policies
As rural health workforce shortages have gained prominence
a number of measures and policies have been implemented to address these
shortages. Many aim to encourage medical practitioners to relocate to regional
and rural areas, or support training placements in rural communities.
Overseas
trained doctors (OTDs)
Current incentives for overseas trained doctors (OTDs)
mainly involve refinements to the Howard Government’s 1996 legislation and
initiatives intended to address the maldistribution of medical practitioners in
Australia.
Australia has become increasingly reliant on the services
of OTDs to fill hospital vacancies and to deliver primary care services,
particularly in rural and remote areas. While a policy of increasing the
numbers of Australian trained doctors is also in place, the effects of this
policy on workforce supply will not be felt for several years. More
importantly, in the case of medical practitioners, there is no certainty that
the required numbers of new graduates will choose to practise in rural and
remote areas. This is because there is a constitutional restraint on
governments which prevents them from introducing legislation to ‘conscript’ the
services of unrestricted Australian medical practitioners to work in certain
areas.[25]
In 2008, the Rural Doctors Association of Australia
estimated that some 40 per cent of doctors working in rural Australia were OTDs.[26]
The number of OTDs, compared with Australian trained doctors, increases with
remoteness.
In summary, OTDs have been able to gain exemptions from
certain restrictions if they agreed to work in designated districts of
workforce shortage (DWS) for a minimum of ten years (referred to as the ‘ten ten-year
moratorium’).[27]
If they agreed to this condition they were then able to access Medicare
benefits.
In July 2010, ‘scaling’ of the ten ten-year moratorium was introduced.
This provides time reduction incentives to reduce the moratorium restriction
period.[28]
Rural
workforce programs
Over the years, a range of rural workforce programs have
been introduced to help address workforce shortages. These include among
others, the General Practice Rural Incentives Program, Rural Relocation
Incentive Grants, Rural Procedural Grants Program, the Remote Vocational
Training Scheme, the National Rural Locum program, Bonded Medical Placements,
the Rural Australia Medical Undergraduate Scholarship (RAMUS) Scheme, the John Flynn Placement Program, and rural clinical schools,
of which there are now 17.[29]
In December 2015, the Coalition Government announced an overhaul of clinical training through the development of an Integrated
Rural Training Pipeline intended to ‘develop an integrated prevocational,
postgraduate medical training pathway in rural and regional areas’.[30]
This includes the establishment of:
- a Rural Junior Doctor Training Innovation Fund to ‘be targeted
at rural-based interns to enable them to spend some of their training year in
rural general practice, building on the rural training networks for junior
doctors that are funded by the states and territories’
- up to 30 regional training hubs in locations with existing rural
training sites, to ‘enable students to continue rural training past university
into postgraduate medical training’ and
- 100 new rural training places in the Specialist Training Programme.[31]
Telehealth services, whereby consultations
with specialists can take place remotely, have been subsidised under Medicare
since July 2011.[32]
Patients in eligible areas are able to access specialist video consultations.[33]
Despite these programs and initiatives,
people in rural areas continue to experience poorer health outcomes.
Rural
Generalist model
Unlike most other medical specialties, there is no nationally
endorsed professional definition of a rural generalist. At the World Summit on
Rural Generalist Medicine in Cairns in 2014, the following definition was adopted:
We define Rural Generalist Medicine as the provision of a
broad scope of medical care by a doctor in the rural context that encompasses
the following:
-
Comprehensive primary care for
individuals, families and communities
-
Hospital in-patient care and/or
related secondary medical care in the institutional, home or ambulatory setting
-
Emergency care
- Extended and evolving service in
one or more areas of focused cognitive and/or procedural practice as required
to sustain needed health services locally among a network of colleagues
- A population health approach that
is relevant to the community
-
Working as part of a
multi-professional and multi-disciplinary team of colleagues, both local and
distant, to provide services within a ‘system of care’ that is aligned and
responsive to community needs. [34]
Broadly then, a rural generalist is usually a GP who works
in both community-based primary care and acute care settings and who has
specialist skills typically in obstetrics, anaesthetics and/or surgery.[35]
Although specialised services such as obstetrics and anaesthetics were once routinely
delivered by rural GPs, these have become less common in the face of increasing
medical specialisation and the preference to deliver more specialised services
in larger centres.[36]
The rural generalist model was extensively analysed in a
systematic review conducted in 2007.[37]
The review outlined the origins of the rural generalist in Australia prior to
the introduction of Medicare:
Prior to the emergence of differential rebates and the growth
of the federal funding through Medibank and Medicare it was not uncommon for
general surgeons, obstetricians and physicians in rural areas to serve as
community primary carers in partnership, or in some cases competition, with
general practitioners. Similarly, rural general practitioners often worked as
anaesthetists, colleagues and assistants to rural specialists. Thus, rural
communities produced medical alliances and a scope of practice that was unique
to the environment and driven by the community need and the skills,
competencies and interests of their practitioners rather than their collegiate
or professional affiliations.[38]
The review noted that out of necessity, ‘primary care
practitioners in rural areas of Australia, Canada and the United States of
America (USA) perform a greater range of procedures, provide more medically
complex care, undertake work in the hospital as well as the community setting,
and are able to practice obstetrics’.[39]
The review noted the Rural Generalist model developed by
Queensland Health which had the following characteristics:
1. Hospital-based and
community-based primary medical practice
2. Hospital-based secondary
medical practice
a. In at least one
specialist medical discipline (usually but not necessarily limited to
obstetrics, anaesthetics and surgery)
b. Without
supervision by a specialist medical practitioner in the relevant discipline
3. And
possibly, hospital and community-based public health practice –— particularly in remote and Indigenous
communities.[40]
While safety and quality issues were cited in the review as
partly explaining the reduction in procedural practice by rural generalists the
review notes ‘there are other structural barriers to the delivery of generalist
services including the growth of ‘fly-in, fly-out’ specialist services,
improved retrieval services, role delineation of hospitals, rising medical
indemnity costs and litigious populations.’[41]
Overall, the 2007 review concluded that ‘[t]he generalist
model is a practical and cost effective means of meeting the comprehensive
health needs of rural and remote communities which have lower population
densities’. Furthermore, that ‘[a]rticulated “generalist” pathways in training
within hospital and community sectors, provides a solution to the skills
shortages in rural and remote communities’.[42]
In 2012, the Senate Community Affairs Committee inquiry
into issues affecting the supply of medical professionals in rural and regional
areas discussed the potential role of rural generalists as a means of
addressing gaps in specialist services in rural areas.
A number of submitters to the Senate inquiry supported increasing
the number of rural generalists to address the maldistribution of the medical
workforce. The Rural Doctors Association of Australia (RDAA) observed:
... we have lost the concept of generalism in medicine as
being a vital thing ... We
simply cannot afford to have an ever-increasing superspecialisation, because it
is going to cost the government and it is going to cost the taxpayer too much.
At the end of the day, we have to start putting some investment into people who
can do basic things very, very well in a comprehensive sense.[43]
Although several stakeholders pointed to the success of
the rural generalist pathway developed by Queensland Health, the Royal
Australian College of GPs (RACGP) warned:
State-based medical workforce initiatives (e.g. Queensland
Health Rural Generalist Program) are working as deterrents to the recruitment
and retention of rural general practitioners...with perceived success in
Queensland due to lucrative salaries which cannot be matched by private
practice. It should also be noted that the term 'rural generalist' represents a
state jurisdictional term and is not a recognised specialty by the Australian
Medical Council.[44]
The Australian College of Rural and Remote Medicine
(ACRMM) defended the Queensland rural generalist program:
I do not really want to comment on another college's approach
or what they have said but I can only talk about what we have seen and the fact
that the rural generalist program and generalist medicine is now very much on
the agenda within other states. We have a successful model now that addresses
what the real workforce needs are within rural and remote communities. Hence,
we would like to see that extended into general specialists within it. Those
are the skills that are missing out of the area, too, so we have a challenge
with that. The strength of it is that it is local training. As I said in my
opening, it is about a totally different approach to workforce, wherein there
is benefit to the community and the doctor providing the services out there.[45]
Overall, the Senate Committee report supported the rural
generalist pathway model adopted by Queensland, and rejected arguments it acted
as a deterrent to recruitment:
On evidence received, both in written submissions and orally,
the committee is not convinced by the argument from the RACGP that the
Queensland program is a long term deterrent to the retention and recruitment of
rural general practitioners. The program is now training an additional 50 new
graduates per year and is committed and funded to do so over the next five
years.[46]
The Committee went on to recommend:
... that the Commonwealth place on the agenda of the Council of
Australian Governments' Standing Council on Health an item involving
consideration of the expansion of rural generalist programs. It further
recommends that, as part of that agenda item, the Council consider an
evaluation of the Queensland Health Generalist Program and whether it should be
rolled out in other jurisdictions.[47]
Workforce issues were subsequently discussed at the
Standing Council on Health meeting in November 2012, and agreement was reached on
the use of more innovative approaches to dealing with workforce shortages.
However, no specific action on progressing a national rural generalist pathway
was reported.[48]
Instead, most jurisdictions have developed their own
training programs for rural generalists.[49]
For example, the NSW Rural Generalist Training Program (RGTP) requires GP
trainees to undertake a year of hospital practice or general practice, a year
of advanced skills training and two years of support to consolidate advanced
skills while training in community general practice or other approved training posts.
Advanced training in either obstetrics, anaesthetics, palliative care, mental
health or a combination of obstetrics and emergency medicine is offered.[50]
This variation in training pathway models has been raised
as an issue by the ACRRM:
The variation between state/territory pathway models
indicates an important role for national coordination. A major challenge for
implantation is the surge of medical graduates that will be seeking access to
training posts in the forthcoming years.[51]
To meet future challenges, the ACRRM has called for ‘[a]
nationally streamlined, rural training and educational pathway’ for rural
generalists. This would involve integrating existing programs. The ACRRM has
proposed ‘an officer of the Commonwealth Department of Health vested with
responsibility for national integration of the pathway. They would ensure
portability of qualifications, and alignment with overall workforce planning’.[52]
During the 2016 Federal election, the Coalition committed
to appointing a National Rural Health Commissioner who would develop a National
Rural Generalist pathway to address rural health workforce issues.[53]
Funding of $4.4 million for the Commissioner was committed at the Mid-Year
Economic and Fiscal Outlook (MYEFO) 2016 in December 2016.[54]
Policy position
of non-government parties/independents
The policy positions of the non-government parties in
relation to Schedule 1 and 2 of the Bill have yet to emerge. However, during
the 2016 Federal election the Greens indicated they would advocate for the
development and funding of a National Rural Generalist Framework, encompassing:
- mechanisms
to promote and sustain rural general practices
- strategies
for rural recruitment and retention, and other workforce development measures
- a
National Rural Generalist Training Program to ensure that the next generations
of rural doctors are equipped with the necessary education, training and skills
to prepare them for rural medical practice.[55]
The policy positions of cross bench members and Senators are
also unknown at the time of writing this Bills Digest.
Position of
major interest groups
As noted above, the proposal for a rural generalist
pathway as considered by the 2012 Senate inquiry was supported by a number of
stakeholders, including the Australian College of Rural and Remote Medicine
(ACRRM) and the Rural Doctors Association of Australia (RDAA). However, the
Royal Australian College of General Practitioners (RACGP) warned that the Rural
Generalist training pathway adopted by Queensland Health was deterring the
recruitment and retention of rural GPs.
Commentary in relation to this Bill has been generally
positive. For example, the RDAA said it ‘strongly welcomed’ the announcement of
legislation establishing the National Rural Health Commissioner particularly
citing the Minister’s statement that 'appropriate remuneration for Rural
Generalists, recognising their extra skills and longer working hours, will also
be under consideration’.[56]
Rather than the limited term proposed in this Bill, the RDAA has called for a
fixed term appointment of between four to six years. As the Bill repeals the
legislation relating to the National Rural Health Commissioner on 1 July 2020,
this would not be possible if the Bill is passed without amendment.
The ACRRM also welcomed the legislation, saying that ‘this
statutory office holder position under the Health Health Insurance Act offers
ongoing sustained attention to health and health services in rural and remote
communities’. They were also ‘pleased’ that the National Rural Generalist
Pathway which they had been advocating over a number of years ‘has been given a
high priority’.[57]
In a statement at the time the appointment of a National
Rural Health Commissioner was announced, the RACGP said it ‘warmly welcomed’
both the appointment of a National Rural Health Commissioner and the ‘commitment
to pursue a National Rural Generalist Training Pathway’. The RACGP called for ‘all
political parties to support the appointment of an Independent Rural Health
Commissioner.’ But perhaps reflecting its comments to the Senate inquiry, it stated
that ‘[d]efining the terms of reference and outcome measures are critical to
success of this proposal.’[58]
Financial
implications
The Explanatory Memorandum (EM) estimates the cost of
establishing the National Rural Health Commissioner at $4.4 million over four
years (to June 2020).[59]
Key issues
and provisions
Establishing
the role
Item 1 of the Bill inserts proposed
Part VA—National Rural Health Commissioner into the Health Insurance
Act 1973 to establish the National Rural Health Commissioner[60]
(the Commissioner) for the period from the commencement of the relevant
provisions of the Bill until 1 July 2020 when proposed
Part VA will be automatically abolished.[61]
Functions of the Commissioner
The primary function of the Commissioner is to give advice
to the Minister responsible for rural health including:
- defining
what it means to be a rural generalist
- developing
a National Rural Generalist Pathway and
- advising
on matters relating to rural health reform, as requested by the Minister.[62]
The Minister may, by notifiable instrument,[63]
give written directions to the Commissioner about the performance of his, or
her, functions. In that case the Commissioner must comply with the direction.[64]
In carrying out those functions the Commissioner must consult
with health professionals in regional, rural and remote areas, with the states
and territories, and with other rural health stakeholders who the Commissioner
considers appropriate.[65]
In addition, the Commissioner must consider appropriate remuneration, and ways
to improve access to training, for rural generalists.[66]
The Secretary of the Department may enter into an arrangement with the
Commissioner for the services of APS employees in the Department to be made
available to provide assistance to the Commissioner in carrying out his, or
her, functions.[67]
Reporting requirements
The Bill contains reporting requirements. The Commissioner
must prepare and give to the Minister:
- a draft report setting out the Commissioner’s draft advice and
recommendations in relation to his, or her functions, no later than six months
before the deadline for the final report or any earlier day specified by the
Minister and
- a final report setting out the Commissioner’s final advice and
recommendations, no later than 30 June 2020 or any earlier day specified
by the Minister.[68]
The Commissioner may request an extension of time in which
to deliver the draft report. In that case, the Minister may extend the deadline
by up to two weeks.[69]
However, there is no provision in the Bill for the Minister to extend the
deadline for the final report.
In addition to preparing the draft
report and final report which are described above, the Commissioner must,
within three months after the end of each calendar year, prepare and give to
the Minister, for presentation to the Parliament, a report about the
Commissioner’s activities during the previous calendar year.[70]
The Minister may, by notifiable instrument, give written directions to the
Commissioner about the matters to be included in the annual report. The
Commissioner must comply with such a direction.[71]
Importantly, whilst the Commissioner’s annual report
is to be presented to the Parliament, there is no equivalent requirement that
either the draft report or the final report be presented to the Parliament.
Terms
and conditions of appointment
The terms and conditions of appointment for the Commissioner
may be summarised as follows:
- the
Minister appoints the Commissioner, by written instrument, on a full‑time
basis or a part‑time basis for a maximum period of two years (with the
possibility of reappointment)[72]
- the
Commissioner must be a person with experience in rural health[73]
- the
Commissioner’s remuneration is to be determined by the Remuneration Tribunal[74]—or,
in the absence of such determination, in accordance with a legislative
instrument made by the Minister prescribing the relevant remuneration and
allowances.[75]
The Minister may terminate the appointment of the
Commissioner for a range of reasons including:
- for
misbehaviour or if the Commissioner is unable to perform the duties of his, or
her, office because of physical or mental incapacity[76]
- if
the Commissioner becomes bankrupt or takes certain specified actions in
relation to his or her creditors[77]
- if
the Commissioner is appointed on a full-time basis—the Commissioner is absent,
except on leave of absence, for 14 consecutive days or for 28 days in any 12
months; or if the Commissioner engages, except with the Minister’s approval, in
paid work outside the duties of his or her office[78]
- if
the Commissioner is appointed on a part‑time basis—the
Commissioner engages in paid work that, in the Minister’s opinion, conflicts or
could conflict with the proper performance of his or her duties[79]
- the
Commissioner fails, without reasonable excuse, to disclose to the Minister
details of any direct or indirect pecuniary interests that the Commissioner has,
or acquires, which conflict or could conflict with the proper performance of
the Commissioner’s functions.[80]
Background—Schedule
3
Medicare
Provider Number legislation and the Medical Training Review Panel (MTRP)
In 1996 changes were made to the Health Insurance Act
that affected training arrangements for newly graduated doctors, through the insertion
of sections 19AA, 3GA and 3GC.[81]
These provisions have become collectively known as the ‘Medicare provider
number legislation’, and were designed to address a number of medical workforce
issues: firstly, to ensure the quality of newly graduated doctors; secondly to
deal with medical workforce distribution problems (and a perceived oversupply);
and thirdly to reduce growth pressures on Medicare.[82]
To address concerns and secure passage of the legislation
the government inserted a sunset clause (subsequently repealed in 2001), and the
establishment of the Medical Training Review Panel (MTRP) to collect data on
postgraduate training and report annually, and under section 19AD the biennial
tabling of a review of the Medicare provider number legislation. This requires
the Minister to table in Parliament a report detailing the operation of the
Medicare provider number legislation every two years. Within three months of
the tabling of this report the MTRP is required to convene a meeting to discuss
the report.
In 2007, the interval between these biennial reviews was
extended to five years. Four reviews have been conducted: 1999 (mid-term
review), 2003, 2005, and 2010. The review scheduled for 2015 was not conducted because
legislation repealing the requirement to conduct the review was before the
Parliament and was expected to pass. However, Parliament was prorogued before
passage was secured.[83]
Of the reviews that have been completed under section
19AD, stakeholder engagement has been high.[84]
The Explanatory Memorandum to the Bill justifies the
repeal of section 19AD in part by claiming that previous reviews ‘have not
identified any anomalies, unintended consequences or points of contention with
the quality standards governing access to the Medicare Benefits Schedule’.[85]
Nevertheless, the 2010 review made some 25 recommendations across a range of
areas, with four of these relating to amending legislation and a number of
others revising regulations. Significantly, the 2010 review found that a number
of recommendations from the previous review conducted in 2005 had not been
implemented, ‘and there is little information to explain why the
recommendations were not actioned’.[86]
The 2010 review received 37 electronic submissions, six
formal submissions, and two stakeholder forums were held, demonstrating
significant stakeholder engagement.[87]
Notably, the review included a recommendation that the Department of Health
‘establish a mechanism that allows regular industry input into operational
issues in order to identify and address any problems in delivering services
under the programs, rather than wait for the five five-year review of the Medicare
Provider Number legislation’.[88]
This recommendation was subsequently discussed at the Special Meeting of the
Medical Training Review Panel which was held on 20 April 2011.[89]
Representatives from the Australian Medical Association (AMA) supported the
recommendation in principle, but also expressed concern that it might lead to
the discontinuation of the five five-yearly reviews. Dr Michael
Bonning of the AMA commented:
We agree with and support this recommendation in-principle
but we want this group to be conscious of the fact that this could provide a
rationale for discontinuing of any further reviews and that given this body's
strong support for the role of both itself, the MTRP and the five yearly
reviews that is noted in the proceedings here and that this review process
remains the peak process for providing updates and scrutiny for ongoing
workforce programs.[90]
The MTRP was established in 1997 to monitor and report on
medical education and training in Australia. In 2009 a review was undertaken,
which ‘re-affirmed the important role that the MTRP plays, both as a forum
bringing together key stakeholders in medical education and training and also
as an advisory group informing work in relation to medical education and
training in Australia’.[91]
Members, which are appointed by Ministerial Determination, include the Medical
Deans of Australia and New Zealand, specialist medical colleges, the Australian
Medical Students Association, the Confederation of Postgraduate Medical
Education Councils, the Australian Medical Association Council of
Doctors-in-Training, the Australian General Practice Network, the Rural Doctors
Association of Australia, the Australian Salaried Medical Officers federation,
the Australian General Practice Training, state and territory health
departments and the Commonwealth government.[92]
In 2012, Health
Workforce 2025: Doctors, nurses and midwives was published by Health
Workforce Australia (HWA).[93]
This report contained detailed modelling on workforce supply, demand and
training. In response, the National Medical Training Advisory Network (NMTAN)
was established within HWA to improve the coordination of medical education and
training nationally. When HWA was closed in 2014, its health workforce
activities including the NMTAN moved to the Department of Health. An overlap
between the work of the MTRP and NMTAN was identified in October 2014, and it
was jointly agreed by members of both MTRP and the NMTAN that the MTRP could
cease and the NMTAN would take on the production of its annual report on
medical education and training.[94]
The MRTP’s 19th report on medical training in Australia
was released in May 2016, and was prepared with oversight from the NMTAN.[95]
History of
the provisions
In 2015, legislation to repeal sections 3GC and 19AD
passed the House of Representatives, but failed to pass the Senate before
Parliament was prorogued.[96]
The schedules repealing these two sections were contained in the Omnibus Repeal
Day (Spring 2015) Bill 2015. This Bill was subsequently referred to the Senate
Finance and Public Administration Legislation Committee on 26 November 2015,
which reported on 3 February 2016.[97]
The report did not include any specific discussion on the repeal of sections
3GC and 19AD, nor did stakeholders make submissions.
Policy
position of non-government parties/independents
The policy positions of non-government parties and cross
bench members and Senators in relation to the provisions in Schedule 3, are not
known at the time of writing.
Position of
major interest groups
At this stage, no commentary in relation to the repeal of
sections 3GC and 19AD has been identified. However, given the high stakeholder
engagement in past reviews of the Medicare Provider Number legislation, which
included support for the review process, it is anticipated that as
Parliamentary debate progresses, stakeholder comment on the repeal of section
19AD is likely to emerge.
Financial
implications
According to the EM there are no costs or savings
associated with the repeal of section 3GC, but small unspecified regulatory
savings are forecast from the repeal of section 19AD. Given the repeal of
section 19AD is partly justified in the EM on the grounds that it is ‘resource
intensive’, the lack of identified savings from its repeal is of interest. If
savings are to be realised, then it would be helpful to policy makers to have
this detail in advance of the Parliamentary debate. For example, savings from
no longer engaging an independent reviewer to conduct a review should be
quantifiable.[98]
Key issues
and provisions
The Medicare provider number legislation consists primarily
of sections 19AA, 3GA and 3GC of the Health Insurance Act. It was
inserted into the Health Insurance Act in 1996 by the Health Insurance
Amendment Act (No. 2) 1996 which introduced, amongst other things, the
requirement for medical graduates to complete postgraduate education in order
to gain access to Medicare benefits. This affects both overseas and Australian
trained doctors.
As explained above, when section 19AA was introduced in
1996 by the Howard Government, a number of groups in the medical workforce
perceived this to be a risk to the future employment opportunities of the then
doctors in training.[99]
A ‘sunset clause’, providing that the restricted access to Medicare benefits
only applied to services rendered before 1 January 2002, was included ‘as a
safeguard which ensured the legislation would be revoked automatically unless
it was demonstrated to Parliament that there were no significant adverse
impacts on affected doctors’.[100]
The mid-term review of the legislation conducted in 1999
found the legislation was working well, and the initial fears of affected
doctors had not eventuated.[101]
The review report recommended the sunset clause be repealed. In 2001, the Health
Insurance Act was amended by the Health Legislation
Amendment (Medical Practitioners’ Qualifications and Other Measures) Act 2001
which removed the sunset clause, and included a requirement under section 19AD
that the operations of the legislation be reviewed on a biennial basis.[102]
This was subsequently amended by the Health Insurance
Amendment (Provider Number Review) Act 2007 so that the review process
would be undertaken every five years.[103]
According to the Explanatory Memorandum to the originating
Bill:
The review process takes nine months to complete and requires
significant staffing resources from the Department of Health and Ageing. With
continuing wide acceptance of the legislation, the need to conduct a review
biennially is no longer critical.[104]
Related parts of the Health Insurance Act are
sections 3GA and 3GC. Section 3GA allowed for the creation of a Register of
Approved Placements which enables doctors subject to section 19AA to provide
professional services while undertaking training towards Fellowship. Section
3GC of the Health Insurance Act allowed for the creation of the Medical
Training Review Panel whose functions include preparing reports on the numbers
of practitioners enrolled in courses and programs, and the types and
availability of those courses and programs.[105]
Key
provisions
Items 1 and 2 in Schedule 3 to the Bill repeal
sections 3GC and 19AD respectively.
Concluding comments
This Bill delivers on an election commitment to establish
a National Rural Health Commissioner who would be tasked with consulting with
relevant stakeholders to improve rural health and to develop a National Rural
Generalist training pathway. The function of the Commissioner is advisory and
time-limited to 1 July 2020. The provisions in the Bill around the
establishment of the Commissioner and his, or her, role are supported by a
number of rural stakeholder groups.
The Bill also repeals section 3GC of the Health
Insurance Act, which would abolish the Medical Training Review Panel
(MTRP), and section 19AD which would remove the requirement to conduct regular
reviews of the Medicare Provider Number legislation. These provisions are
unrelated to the establishment of the National Rural Health Commissioner.
Stakeholder views around these provisions have yet to emerge. However, the
abolition of the MTRP has been supported by members of the MTRP and the
National Medical Training Advisory Network (NMTAN) which will take on its
reporting functions.
Reviews of the Medicare Provider Number Legislation in the
past have attracted high levels of stakeholder engagement, so stakeholder
interest in this provision may yet emerge.
[1]. Senate
Standing Committee for the Selection
of Bills, Report, 2, 2017, The Senate,
16 February 2017, p. 3. See also: Selection of Bills Committee, Report, 1, 2017, The Senate,
9 February 2017, p. 4.
[2]. Senate Standing Committee for the Scrutiny of Bills, Scrutiny digest, 2, 2017, The Senate,
Canberra, 15 February 2017, p. 18 18.
[3]. The
Statement of Compatibility with Human Rights can be found at page 4 of the Explanatory
Memorandum to the Bill.
[4]. Parliamentary
Joint Committee on Human Rights, Report,
1, 2017, The Senate, Canberra, 16 February 2017, p. 32.
[5]. Australian
Institute of Health and Welfare (AIHW), ‘Impact of
rurality on health status’
AIHW website.
[6]. AIHW,
Australia's
health 2016, AIHW, Canberra, 2016, p.248.
[7]. Ibid.,
p. 249.
[8]. Ibid.,
p. 250.
[9]. Ibid.
Based on weekly hours worked.
[10]. Ibid.
Applies to very remote areas.
[11]. Ibid.,
p. 251.
[12]. AIHW,
Australian
health expenditure by remoteness, AIHW, Canberra, January 2011, p. 5. The data reports
lower expenditure per person in rural and regional areas, reflecting lower
utilisation rates.
[13]. National
Health Performance Authority (NHPA), Healthy
communities: avoidable deaths and life expectancies in 2009–11,
NHPA, Canberra, December 2013, p. v.
[14]. Ibid.
See also Rural Doctors Association of Australia, Submission to Senate Community
Affairs Committee, Inquiry into the
factors affecting the supply of health services and medical professionals in
rural areas, submission no. 67, 22 December 2011, p. 5.
[15]. Senate Standing Committees on Community Affairs Committee, The
factors affecting the supply of health services and medical professions in
rural areas, The Senate, August 2012, pp. 16–17.
[16]. Ibid.,
p. 18.
[17]. B
Birrell, ‘Medical
manpower: the continuing crisis’, People and Place, vol. 4, no. 3, 1996. Full
text article available on request.
[18]. Australian
Medical Workforce Advisory Council (AMWAC), The medical workforce in rural
and remote Australia, 1996, Sydney.
[19]. Ibid.
[20]. AIHW,
Medical
labour force 2004, AIHW, Canberra, 20 December
2006, p. vi. The fall in GP supply was due to a fall in hours worked. Actual
numbers of GPs increased.
[21]. Health Insurance
Amendment Act (No. 2) 1996.
[22]. Department
of Health (DoH), ‘6.
Key findings’,
Report on the audit of health workforce in rural and regional AustraliaReport
on the audit of health workforce in rural and regional Australia,
DoHA, Canberra, 2008, Chapter ch. 6 (Key findings).
[23]. AIHW, ‘Table 23: employed
medical practitioners: FTE per 100,000 population by remoteness area, 2012 to
2015’, Medical practitioners overview 2015 tablesMedical workforce 2015: data tables: medical
practitioners overview, AIHW,
Canberra, Table 23, 2015.
[24]. Ibid.,
Table 24.
[25]. The Constitution
section 51(xxiiiA): Parliament shall, subject to this Constitution, have power
to make laws for the peace, order, and good government of the Commonwealth with
respect to: the provision of maternity allowances, widows' pensions, child
endowment, unemployment, pharmaceutical, sickness and hospital benefits, medical
and dental services (but not so as to authorize any form of civil
conscription), benefits to students and family allowances.
[26].
Rural Doctors Association of Australia, Overseas
doctors make valuable contribution to our medical workforce, media
release, 31 October 2008.
[27]. Districts of workforce
shortage are areas in which the general population’s need for healthcare has
not been met. DWS are determined by the Department of Health with reference to
the most recently available Medicare statistics. DWS only applies to medical
jobs that need to provide services that attract Medicare rebates.
[28]. Department of HealthDoH, ‘Medicare
provider number restrictions’, DoH webpagewebsite, 9 April
2014.
[29]. For
a list of current programs see Department
of Health (DoH),
‘Rural
and Regional Health Australia (RRHA) list of programs’, DoH webpagewebsite, 30 June 2016.
[30]. Australian GovernmentS Morrison
(Treasurer) and M Cormann (Minister for Finance), Mid-year
economic and fiscal outlook 2015–16 ,
December 2015, p. 184.
[31]. S
Ley (Minister for Health) and F Nash (Minister for Rural Health), Building
a health workforce for rural Australia, media release,
15 December 2015.
[32]. Department of Health (DoH), ‘Connecting
health services with the future: technology and technical issues for Telehealth’, DoH webpagewebsite, 5 June
2011.
[33]. Department of HealthDoH, ‘MBS
Online: Telehealth eligible areas’, DoH webpagewebsite, 20
December 2012.
[34]. Australian
College of Rural and Remote Medicine (ACRRM), ‘Rural
generalist medicine’,
ACRRM webpage, [2015].
[35]. Senate
Standing Committees on Community
Affairs Committee, The
factors affecting the supply of health services and medical professions in
rural areas, The Senate, Canberra, August 2012,
p. 32. This definition is based on the description provided by Queensland
Health.
[36]. Ibid.,
p. 30.
[37]. D
Pashen, R Murray, B Chater, V Sheedy, C White, L Eriksson, S De La Rue, M Du
Rietz, The
expanding role of the rural generalist in Australia—a systematic review,
Australian College of Rural and Remote Medicine, Brisbane, November
2007.
[38]. Ibid.,
p. 13.
[39]. Ibid.
[40]. Ibid.,
p. 16.
[41]. Ibid.,
p. 14.
[42]. D
Pashen, et al, The
expanding role of the rural generalist in Australia—a systematic review,
op. cit., pp. 58–59.
[43]. Senate Standing Committees on Community AffairsSenate Community Affairs Committee,
op. cit., p. 30.
[44]. Ibid.,
p. 33.
[45]. Ibid.,
pp. 34–35.
[46]. Ibid.,
p. 37.
[47]. Ibid.,
p. 38.
[48]. Standing
Council on Health (SCoH), Communique,
SCoH meeting, Perth, 9 November 2012.
[49]. All
jurisdictions except the ACT have developed rural generalist training pathways.
See ACCRM, op. cit.
[50]. Health
Education Training Institute (HETI), ‘NSW
Rural Generalist (Medical) Training Program’, HETI website; HETI, ‘Training
pathway’, HETI website website.
[51]. ACRRM,
The
rural way: implementation of a national rural generalist pathway, ACRRM,
Brisbane, May 2014, p. 2.
[52]. Ibid.,
p. 38.
[53]. F
Nash (Minister for Rural Health), ‘Election
2016: coalition to create rural health champion and pathway for rural medical
professionals’, media release, 24 June 2016.
[54]. S
Morrison (Treasurer) and M Cormann (Minister for Finance of the
Commonwealth of Australia), Mid-year
economic and fiscal outlook 2016–17, op. cit., p.
173.
[55]. The
Australian Greens, ‘Delivering
health in the bush: meeting rural health needs’, policy document, no publication date,
accessed by the Parliamentary Library 29 June 2016.
[56]. RDAA,
Rural
Health Commissioner a step closer to becoming reality, media release, 8
February 2017. See also D Gillespie (Assistant Minister for Health); D
Gillespie (Assistant Minister for Health), Australia's
first national rural health commissioner: the champion of regional and rural
health reform, media release, 8 February 2017.
[57]. ACRRM,
‘ACRRM
welcomes National Rural Health Commissioner bill introduction’, media release,
8 February 2017.
[58]. RACGP,
‘RACGP
strongly supports the appointment of a Rural Health Commissioner’, media release,
24 June 2016.
[59]. Explanatory
Memorandum, p. 3.
[60]. Health
Insurance Act, proposed section 79AB.
[61]. Item
1 in Schedule 2 to the Bill abolishes proposed
Part VA.
[62]. Health
Insurance Act, proposed subsection 79AC(1).
[63]. Generally,
unlike legislative instruments, notifiable instruments are not subject to
Parliamentary scrutiny, nor are they subject to automatic repeal 10 years after
registration: Legislation
Act 2003, section 7.
[64]. Health
Insurance Act, proposed section 79AN.
[65]. Health
Insurance Act, proposed paragraphs 79AC(2)(a) and (b).
[66]. Health
Insurance Act, proposed paragraph 79AC(2)(c).
[67]. Health
Insurance Act, proposed section 79AO.
[68]. Health
Insurance Act, proposed subsection 79AC(3).
[69]. Health
Insurance Act, proposed subsection 79AC(4).
[70]. Health
Insurance Act, proposed section 79AM.
[71]. Health
Insurance Act, proposed section 79AN.
[72]. Health
Insurance Act, proposed subsections 79AD(1) and (2).
[73]. Health
Insurance Act, proposed subsection 79AD(3).
[74]. Health
Insurance Act, proposed subsection 79AG(1).
[75]. Health
Insurance Act, proposed subsection 79AG(4).
[76]. Health
Insurance Act, proposed subsection 79AK(1).
[77]. Health
Insurance Act, proposed paragraph 79AK(2)(a).
[78]. Health
Insurance Act, proposed paragraphs 79AK(2)(b) and (c) and proposed
subsection 79AI(1).
[79]. Health
Insurance Act, proposed paragraph 79AK(2)(d) and proposed
subsection 79AI(2).
[80]. Health
Insurance Act, proposed paragraph 79AK(2)(e) and proposed section
79AL.
[81]. These
sections were inserted into the Health Insurance Act by the Health Insurance
Amendment Act (No. 2) 1996. For more information see: C Field,
Health
Insurance Amendment Bill (No. 2) 1996, Bills digest, 47, 1996–97,
Parliamentary Library, Canberra, 1996.
[82]. A
Biggs, Health
Insurance Amendment (Provider Number Review) Bill 2007, Bills digest,
113, 2006–07, Parliamentary Library, Canberra, 2007, p. 2.
[83]. Parliament
of Australia, Omnibus
Repeal Day (Spring 2015) Bill 2015 homepage, Australian Parliament website.
This information was confirmed through personal communication with the
Department of Health, 7 March 2017.
[84]. A
Biggs, op. cit., p. 3.
[85]. Explanatory
Memorandum, p. 2.
[86]. Department of HealthDepartment
of Health and Aging (DoHA), Report
on the 2010 review of the Medicare provider number legislation, DoHA,
Canberra, December December 2010, p. 5.
[87]. Ibid.,
p. vii.
[88]. Ibid.,
p. xii.
[89]. Subsection
19AA(2) of the Health Insurance Act specifies that the MTRP must convene
within three months a meeting to discuss the report on the review of the
Medicare provider number legislation.
[90]. Department of HealthDoH, ‘Special
meeting to discuss the Report on the 2010 Review of the Medicare Provider
Number Legislation’, DoH,
Canberra, November 2012, p. 17.
[91]. Department of HealthDoH, Medical
Training Review Panel 19th report, DoH,
Canberra, May 2016, p. 16.
[92]. Ibid.
[93]. Originally
published as Health Workforce Australia (HWA), Health
Workforce 2025 Volume 1 and 2: Doctors, nurses and midwives it was
revised and published as Australia's
future health workforce – —doctors, HWA, August 2014.
[94]. Department of HealthDoH, Medical
Training Review Panel 19th report, op.
cit., p. 17.
[95]. Ibid.
[96]. Parliament
of Australia, Omnibus
Repeal Day (Spring 2015) Bill 2015 homepage, Australian Parliament website.
[97]. Senate
Finance and Public Administration Legislation Committee, Report:
Omnibus Repeal Day (Spring 2015) Bill 2015 [Provisions], 3 February February 2016.
[98]. The
cost of engaging an independent reviewer for previous reviews was estimated at
$80,000. A Biggs, op. cit., p. 5.
[99]. For
information see C Field, Health Insurance
Amendment Bill (No. 2) 1996, Bills Digestdigest, 47, 1996–97, Department of the
Parliamentary Library, Canberra, 1996.
[100]. Explanatory
Memorandum, Health Insurance Amendment (Provider Number Review) Bill 2007,
pp. 1–2
[101]. Ibid.,
p. 2.
[102]. Parliament
of Australia, Health
Legislation Amendment (Medical Practitioners Qualifications and Other Measures)
Bill 2001 homepage, Australian Parliament website.
[103]. Parliament
of Australia, Health
Insurance Amendment (Provider Number Review) Bill 2007 homepage, Australian
Parliament website.
[104]. Explanatory
Memorandum, Health Insurance Amendment (Provider Number Review) Bill 2007,
p. 1.
[105]. Ibid.,
p. 2.
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