Issue number:
Date Issued:
24 Nov 2004
Issued to:
Regional Public Health Services, Public Hospitals and Multi-Purpose Services
To confirm previous advice about the 2003-2008 Australian Health Care Agreement (AHCA) and the requirement for public hospitals to comply with the Medicare Principles.

Victoria is committed to adhering to the principles outlined in clause 6 of the AHCA (the Medicare principles). Information about the requirement to comply with clause 6 was provided in circular 33/2003 of 11 December 2003. Clause 6 requires that eligible persons be given the choice to receive, free of charge as public patients, health and emergency services of a kind or kinds that are currently, or were historically, provided by hospitals. Access is on the basis of clinical need within a clinically appropriate period and is to be provided equitably, regardless of geographical location.

In addition to adhering to the Medicare Principles, public health services, public hospitals and MPSs are required to comply with the related sections of the AHCA. These cover issues including: compliance with national standards on patient election processes, not billing against the Medicare Benefits Schedule (the MBS) for services provided to public patients, and ensuring that public patients have access to the same clinical services as private patients.

The Commonwealth Minister for Health can impose significant financial penalties on Victoria if the AHCA is breached.

The purpose of this circular is to remind public health services, public hospitals and MPSs of the requirement to ensure compliance with the Medicare Principles and the AHCA and to make their staff and visiting medical officers aware of these requirements.

An area of particular importance for rural hospitals is that of emergency services. In this context it is important to note that the Medicare Principles acknowledge the entitlement of public patients to health and emergency services historically provided by hospitals. The AHCA also makes specific provision in clause 40 for the continuation of certain pre-existing arrangements in those hospitals that rely on general practitioners for the provision of medical services (normally smaller rural hospitals and MPSs which do not employ doctors).

It is recognised that these hospitals and all MPSs have never had full-scale emergency departments and do not have medical practitioners on staff. The type of care that is generally provided by these hospitals for an emergency presentation is either admission (if the hospital can provide appropriate clinical care) or stabilisation and transfer to another facility for admission where appropriate. Emergency services in the nature of primary care ordinarily given by general practitioners are not currently and have not historically been provided by these smaller rural hospitals.

As these hospitals do not have "medical out-patients" or "casualty departments", it is appropriate for a medical practitioner to utilise hospital facilities and provide treatment and care for his or her patients who have attended for treatment in the nature of primary care. The utilisation of hospital facilities in no way disentitles such a practitioner from billing the patient or claiming a payment from the HIC. This practice is recognised in the MBS where it provides that medical practitioners who have made arrangements with a local hospital to routinely use outpatient facilities to see their private patients should bill against surgery consultation items.

In such hospitals the emergency department service typically consists of a nurse triage service where, generally, nursing staff assess patients on arrival. Where there is a clinical need for patients to be admitted, they should receive care as public patients, free of charge, unless they elect to be a private patient.

It is not practicable to expect medical practitioners in rural communities to be on call all hours. Consequently, to meet the needs of people who attend at one of these hospitals seeking non-urgent, primary care type services, many hospitals have formal arrangements with visiting medical practitioners to attend patients who present at the hospital for primary care type services which would normally be provided in a doctor's surgery. These arrangements may be with one or more general practices and involve the provision of a doctor for an on-call roster for a designated time period each day. This arrangement may be for a 24-hour roster or for a combination of in-hours and out-of-hours arrangements. The arrangements should provide that the doctor on call is deputising for the patient's normal treating practitioner and procedures should be in place to ensure that the treating practitioner is aware of any treatment given. In accordance with the MBS, the appropriate surgery consultation should be charged. Notices should be posted at appropriate locations to help patients to understand the arrangements.

Hospitals must make it clear to patients whether or not they are being treated either as an admitted patient (where circular 30/2004 will apply), a non-admited patient or whether the visiting medical officer is seeing them privately (where circular 30/2004 will not apply).

Where the patient is admitted to the hospital, hospitals should note that all eligible persons have the choice to be treated as either public or private patients. Election to be treated as a public or private patient must be made by the patient or their legally authorised representative before, at the time of, or as soon as practicable after admission. The patient or their legally authorised representative should sign a statement acknowledging that they have been fully informed of the consequences of their election, that they understand these consequences and that they have not been directed by a hospital employee to a particular decision.

Public health services, public hospitals and MPSs must ensure that all relevant staff understand and comply with the Medicare Principles and the other requirements of the AHCA. They must ensure that any complaints relating to potential breaches of the Medicare Principles or the AHCA are managed at senior levels. Public health services, public hospitals and MPSs should consult with the Department of Human Services before taking action that might be construed as a breach of the Medicare Principles or the AHCA.

Chris Brook
Executive Director
Rural & Regional Health and Aged Care Services