Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

Remunerating private psychiatrists for participating in case conferences

Remunerating private psychiatrists for participating in case conferences Background: On 1 November 2000, a series of new item numbers was added to the Medicare Benefits Schedule, which allowed for case conferences between physicians (including psychiatrists) and other multidisciplinary providers. On 1 November 2002, an additional set of numbers was added, designed especially for use by psychiatrists. This paper reports the findings of an evaluation of these item numbers. Results: The uptake of the item numbers in the three years post their introduction was low to moderate at best. Eighty nine psychiatrists rendered 479 case conferences at a cost to the Health Insurance Commission of $70,584. Psychiatrists who have used the item numbers are generally positive about them, as are consumers. Psychiatrists who have not used them have generally not done so because of a lack of knowledge, rather than direct opposition. The use of the item numbers is increasing over time, perhaps as psychiatrists become more aware of their existence and of their utility in maximising quality of care. Conclusion: The case conferencing item numbers have potential, but as yet this potential is not being realised. Some small changes to the conditions associated with the use of the item numbers could assist their uptake. Background other multidisciplinary providers. These item numbers In Australia, there has been growing concern that sub- were introduced in recognition of the fact that improved optimal collaboration between different providers may co-ordination in community settings has the potential to impede the quality and outcomes of care, both in the lead to improvements in consumer impacts/outcomes physical and mental health arenas. In order to facilitate through a more flexible, efficient and responsive match greater collaboration between providers, a series of new between consumers' needs and services [1]. The item item numbers was added to the Medicare Benefits Sched- numbers enabled physicians to take part in discharge or ule (MBS) on 1 November 2000, which provided remu- community case conferences of varying lengths with other neration for case conferences between physicians and providers. As a sub-group of physicians, psychiatrists were Page 1 of 12 (page number not for citation purposes) Table 1: Summary of criteria for individual case conferencing item numbers Provider No. of other Role Type Duration in minutes attendees Item Physician Psychiatrist 3 2 Organise and Participate Community Discharge 15–29 30–44 45+ Fee* Benefit Benefit No. (including only co-ordinate (75%)* (85%)* Psychiatrist) 820 Y Y Y Y Y $115.55 $86.70 $98.25 822 Y Y Y Y Y $173.40 $130.05 $147.40 823 Y Y Y Y Y $231.15 $173.40 $196.50 825 Y Y Y Y Y $83.05 $62.30 $70.60 826 Y Y Y Y Y $132.40 $99.30 $112.55 828 Y Y Y Y Y $181.80 $136.35 $154.55 830 Y Y Y Y Y $115.55 $86.70 $98.25 832 Y Y Y Y Y $173.40 $130.05 $147.40 834 Y Y Y Y Y $231.15 $173.40 $196.50 835 Y Y Y Y Y $83.05 $62.30 $70.60 837 Y Y Y Y Y $132.40 $99.30 $112.55 838 Y Y Y Y Y $181.80 $136.35 $154.55 855 Y Y Y Y Y $115.55 $86.70 $98.25 857 Y Y Y Y Y $173.40 $130.05 $147.40 858 Y Y Y Y Y $231.15 $173.40 $196.50 861 Y Y Y Y Y $115.55 $86.70 $98.25 864 Y Y Y Y Y $173.40 $130.05 $147.40 866 Y Y Y Y Y $231.15 $173.40 $196.50 * At July 2004 Source: Department of Health and Ageing [1] Australia and New Zealand Health Policy 2005, 2:33 http://www.anzhealthpolicy.com/content/2/1/33 Page 2 of 12 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:33 http://www.anzhealthpolicy.com/content/2/1/33 200 $30,000 $25,000 $20,000 Services 100 $15,000 Benefits paid $10,000 $5,000 0 $0 1/11/00 to 30/4/01 1/5/01 to 31/10/01 1/11/01 to 30/4/02 1/5/02 to 31/10/02 1/11/02 to 30/4/03 1/5/03 to 31/10/03 Note: All benefits paid expressed as constant 2002/03 prices, using deflators from the Australian Bureau of Statistics (Implicit Price Deflators – Gross Non-Farm Product) Ca Figure 1 se conferences rendered and benefits paid, by six-monthly period, 1 November 2000 to 31 October 2003 (n = 479) Case conferences rendered and benefits paid, by six-monthly period, 1 November 2000 to 31 October 2003 (n = 479). eligible to use these item numbers to improve their collab- The current paper reports on an evaluation of the intro- oration with other mental health care providers, including duction of these item numbers which aimed to: (a) exam- staff of state/territory funded inpatient and community ine the processes/operation of the case conferencing item mental health services, other private mental health care numbers, from the perspective of psychiatrists and con- specialists like psychologists, and GPs and other primary sumers; and (b) consider the costs associated with the case care practitioners. conferencing item numbers, and their impacts/outcomes for consumers. The original item numbers distinguished between organ- ising and co-ordinating a case conference (where three Method other providers had to be present), and participating in Design one (where two other providers had to be). The nature of The evaluation was approved by the University of Mel- mental health care meant that the more stringent attend- bourne's Human Research Ethics Committee, and com- ance requirements associated with organising and co- prised three stages. Stage 1 examined the uptake of the ordinating a case conference could not always be met, so, case conferencing item numbers. The then Health Insur- on 1 November 2002, an additional set of item numbers ance Commission (HIC), the Australian Government was added, designed especially for use by psychiatrists. agency responsible for rebates for private medical care, These new item numbers relaxed the attendance require- provided the study team with de-identified, aggregated ment for organising and co-ordinating a case conference, data on the nature and extent of use of the item numbers reducing the mandatory number of other providers to by private psychiatrists in the three years since their intro- two. Table 1 provides a breakdown of the item numbers, duction. The analysis considered uptake over time, but detailing the rebate associated with the different combina- did not separately examine the first two years (in which tions of psychiatrists' roles, number of other attendees, the 'physician' item numbers were introduced) and the consumers' settings, and case conference duration. third year (in which the 'psychiatrist-specific' item num- Page 3 of 12 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:33 http://www.anzhealthpolicy.com/content/2/1/33 Table 2: Nature of case conferences rendered, 1 November 2000 use them, and whether they thought they would be likely to 31 October 2003 (n = 479) to use them in future. Demographic details were also col- lected from both groups. Provider Psychiatrist only 37% Physician (including psychiatrist) 63% Other attendees Two 65% In Stage 3c, the psychiatrists who participated in Stage 3a Three 35% were asked to act as intermediaries. Those who agreed Role Organise and co-ordinate 72% were each sent additional information that explained Participate 28% Stage 3c, and asked to approach the two most recent con- Type Community 80% sumers for whom they had arranged a case conference, Discharge 20% and invite them to participate in a 30-minute phone inter- Duration 15–29 minutes 25% view. Consenting consumers were asked whether they 30–44 minutes 23% 45+ minutes 51% thought that case conferencing improved the quality of care they received, and whether case conferencing had any impact on outcomes for them. Demographic details were also collected. bers were introduced), on the grounds that the evaluation was concerned with the overall availability of an initiative Analysis that allowed psychiatrists to be remunerated for taking Analysis of the quantitative data in Stages 1 and 2 part in case conferences, and that the numbers available involved the generation of simple descriptive statistics. for sub-analyses would have been too small to allow Analysis of the qualitative data in Stage 3 employed tem- meaningful conclusions to be drawn. plate analysis, which involves identifying a key set of themes which relate to specific codes, and then producing Stage 2 examined the impact of the item numbers on a template to organise these codes [2]. other types of services provided by private psychiatrists. The HIC identified the consumer for whom each case con- Results ference had been arranged by his/her Medicare number Stage 1: Uptake of the case conferencing item numbers The uptake of the case conferencing item numbers in the and, using the Medicare number, extracted information on all services provided by private psychiatrists (both three years post- their introduction was low to moderate those who had participated in case conferences and those at best, although it did increase over time (see Figure 1). who had not) for these consumers (case conferences and Eighty nine private psychiatrists (less than 5% of all psy- direct consultations). These consumers acted as their own chiatrists) elected to use the item numbers. They rendered historical controls, and their consultations in equivalent a total of 479 case conferences, for which the HIC paid periods pre- and post- their first case conference were con- $70,584 (around 0.01% of all services provided by and sidered. De-identified, aggregated data were provided to benefits paid to private psychiatrists during the period). the study team. Table 2 shows that psychiatrists favoured the item num- Stage 3 examined the experiences of key informants with bers with the following characteristics: designed for use by the item numbers. Specifically, it involved interviews with all physicians; requiring only two other attendees to be private psychiatrists who had and had not used the item present; requiring them to take an organisational role; numbers (Stage 3a and 3b, respectively), and consumers facilitating community case conferences; and reimbursing for whom case conferences had been arranged (Stage 3c). for longer case conferences. In Stages 3a and 3b, the HIC acted as an intermediary, Stage 2: Impact of the case conferencing item numbers on approaching all private psychiatrists who had made use of the case conferencing item numbers as well as a random other types of services provided by private psychiatrists sample of 100 who had not. The HIC sought consent from Table 3 summarises the face-to-face services provided by these psychiatrists for the study team to approach them private psychiatrists for consumers for whom case confer- for a 15-minute phone interview. Those who had used the ences had been arranged, pre- and post- their first case item numbers were asked about the processes involved, conference. It shows that the total number of psychiatrists the perceived impacts for themselves and their consumers involved in the consumers' care in the post- period was regarding improvements in co-ordination of care, and greater than the 89 who took part in case conferences con- whether the opportunity for case conferencing had flow- cerning these consumers (at 163), but that this was fewer on effects in terms of better mental health outcomes for than the number involved in consumers' care in the pre- their consumers. Those who had not used the item num- period (at 184). Despite the decrease in the total number bers were asked about their knowledge of and attitudes of psychiatrists providing care from the pre- period to the towards the item numbers, why they had chosen not to post- period, the total and average number of services Page 4 of 12 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:33 http://www.anzhealthpolicy.com/content/2/1/33 Table 3: Services provided by private psychiatrists for consumers increased, as did the total and average benefits paid. To for whom case conferences had been arranged, pre- and post- ensure that the latter increase was not accounted for by their first case conference inflation alone, a best-case/worst-case sensitivity analysis was performed, where all of the pre- benefits paid were Pre- Post- assumed to have been in 1997/98 dollars and converted No. of providers 184 163 to 2002/03 dollars, and all of the post- benefits paid were Total services 4,861 5,499 assumed to have been in 2002/03 dollars. Even under Average services 26.42 33.74 these circumstances, the post- benefits paid were higher Total benefit paid – actual $455,743 $549,673 than the pre- benefits paid. Total benefit paid – adjusted ($511,891) ($549,673) Average benefit paid – actual $2,477 $3,372 Stage 3: Key informants' experiences with the case Average benefit paid – adjusted ($2,782) ($3,372) conferencing item numbers Response rates In total, 47 key informants were interviewed. Twenty you are really getting paid for ... But if you are not getting any- seven (30%) of the 89 psychiatrists who had used the case thing for it, then there is a great deterrent to doing it.' conferencing item numbers agreed to be interviewed, as did 16 (16%) of the 100 who had not. Three consumers Logistical issues associated with the item numbers and one proxy (the mother of an adolescent boy) also Respondents indicated that there were a number of logis- agreed to be interviewed. These four were drawn from a tical issues associated with the case conferencing item potential pool of 23 (17%), since nine psychiatrists had numbers. A number of psychiatrists noted that arranging each agreed to recruit two consumers and a further four times to meet with other care providers was 'really too had agreed to recruit one. much' and should attract 'double or triple the current rate.' This was exacerbated in circumstances where psychiatrists Table 4 profiles the interview respondents, and, where were using the item numbers that entailed their 'organis- possible, compares them with the sample from which ing and co-ordinating' the case conference, rather than they were drawn. Interviewed psychiatrists who had used just 'participating' in it, because many psychiatrists the item numbers were reasonably representative of their assumed that the former required them to take responsi- broader group in terms of their age profile and the bility for setting it up. In fact, 'organising and co-ordinat- number of years they had been qualified as psychiatrists, ing' refers to recording what took place during the case but were more likely to be female and to have attained conference, distributing a summary of this to the treat- their general medical qualifications earlier. Interviewed ment team, and ensuring that the consumer is informed psychiatrists who had not used the item numbers were about the outcomes of the case conference [1]. reasonably representative of their broader group in terms of their age and sex profile, but tended to be more recently Several respondents commented on difficulties meeting qualified (both as medical practitioners and as psychia- the requirement that at least two other providers be trists). No comparative data were available on the total present at the case conference. Sometimes, particularly in sample of potential consumer interviewees. rural areas, a second party was available (e.g., a GP), but not a third. On other occasions, potential participants in Stage 3a: Experiences of private psychiatrists who had the case conference did not qualify as 'formal care provid- made use of the case conferencing item numbers ers' [1] (e.g., a number of child and adolescent psychia- Financial incentives associated with the item numbers trists noted that teachers were integral to the team sharing Interview respondents were asked to consider their satis- responsibility for their consumer group, but did not faction, and often discussed this in terms of the remuner- 'count' towards the complement of other attendees). ation levels offered by the case conferencing item numbers. Many commented that the item numbers pro- Another observed difficulty was the fact that some provid- vided them 'with the opportunity to be part of a decision-mak- ers arrived late, left early or did not attend at all. GPs were ing forum that is not typically feasible in private practice', commonly cited, but there were others as well (e.g., com- because of the fee-for-service environment. munity mental health team members). Respondents understood that these providers have hectic, unpredicta- Having said this, the majority view was that the remuner- ble schedules, but were frustrated that their partial or non- ation provided 'helpful compensation', rather than covering attendance had financial implications, as indicated by the their full costs in terms of time spent arranging or partici- following quotation: 'There is a requirement that the special- pating in case conferences. This view was exemplified in ist or GP has to be there the whole time, which is ludicrous. If statements like: '... I mean, you put in much more work than someone says, "Thanks, that was good, but I've got to go now", they can't be paid for that.' This impacted on how likely psy- Page 5 of 12 (page number not for citation purposes) Table 4: Profile of interview respondents Psychiatrists who had used the case Psychiatrists who had not used the Consumers for whom case conferencing item numbers case conferencing item numbers conferences had been arranged Interviewed Eligible for Interviewed Eligible for Interviewed Eligible for (n = 27) interview (n = 16) interview (n = 4) interview (n = 89) (n = 100) (n = 23) Age group <18 bbbb 25% c 18–25 bbbb 0% c 25–34 0% 0%0%0% 50% c 35–44 19% 20% 25% 20% 25% c 45–54 48% 44% 31% 34% 0% c 55–64 30% 27% 25% 28% 0% c 65+ 4% 6% 19% 15% 0% c Missing 0% 3%0%2%0% c Sex Males 52% 67% 75% 74% 25% c Females 48% 29% 25% 24% 75% c Missing 0% 3%0%2%0% c Year qualified as doctor pre 1960 4% 20% 13% 35% b b 1960 – 1969 15% * 25% * b b 1970 – 1979 41% 16% 19% 16% b b 1980 – 1989 33% 49% 44% 33% b b 1990 – 1999 7% 9% 0% 13% b b 2000 – 2004 0% * 0% * b b Missing 0% 3%0%2% b b Year qualified as psychiatrist pre 1960 0% 4% 0% 18% b b 1960 – 1969 4% * 13% * b b 1970 – 1979 11% * 25% 13% b b 1980 – 1989 26% 27% 13% 21% b b 1990 – 1999 41% 45% 50% 34% b b 2000 – 2004 19% 16% 0% 12% b b Missing 0% 3%0%2% b b a. Mother of respondent interviewed b. Not applicable c. Data unavailable Australia and New Zealand Health Policy 2005, 2:33 http://www.anzhealthpolicy.com/content/2/1/33 Page 6 of 12 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:33 http://www.anzhealthpolicy.com/content/2/1/33 chiatrists were to be involved in further case conferences ing for 'speedy communication and the understanding of all unless the requirements changed: 'That only has to happen involved.' They felt that being able to sit down with other twice, and you begin to think it's just not worth it.' providers face-to-face enabled them to clarify the problem and develop an action plan which everybody agreed A number of psychiatrists cited travel time as a problem. upon. Psychiatrists reported that case conferencing had Even those who were positive about the item numbers clear advantages over trying to communicate with other noted that they often felt hesitant to attend case confer- providers either by phone or through letters, and often ences because of the time involved in getting to the meet- constituted the first opportunity for all relevant providers ing: 'I see a lot of people from a long way away. I could travel to meet. Some went as far as to say, 'There really wouldn't up to one hour one way to be involved in it. That is a disincen- be any other way of communicating with everyone if we hadn't tive for me doing this kind of thing.' done a case conference.' Several psychiatrists expressed frustration at having 'claims Respondents noted that case conferences clarified the rejected' by the HIC. In their eyes, these rejections often roles and responsibilities of each provider, and helped occurred for minor reasons, and had a major impact on them to perform these roles optimally. They cited exam- the likelihood that they and their colleagues would take ples such as, '... in one case, the social worker had skill in the part in future case conferences. treatment of trauma and once I realised this I was able to hand over this aspect of management to the social worker.' Some psychiatrists indicated that they and their col- leagues had experienced confusion over some of the con- Respondents observed that the case conferencing item ditions associated with the item numbers. For example, numbers had a direct impact on the quality of assessment there was a lack of clarity regarding the term 'formal care and treatment. With regard to assessment, respondents providers of a different discipline', creating confusion reported that communicating with other providers at a about whether other physicians (e.g., paediatricians) case conference enhanced their understanding of the con- could be included in the total number. sumer. Consumers with complex needs often have prob- lems in multiple domains of life, and several psychiatrists Impact of case conferences on psychiatrists' roles described how case conferences aided their assessment According to respondents, case conferencing allowed capacity because other attending providers could give them to take on a consultant role, permitting them to them better insight into consumers' strengths and weak- offer specialist advice. They indicated that both parties nesses. With regard to treatment, many respondents com- benefited from this role. They enjoyed the break from mented that treatment planning was improved by direct care delivery, and appreciated meeting with col- including 'different views from different people', although leagues working in the field, making statements like, 'Just some added the caveat that they had to be careful to weigh to have more contact with GPs and other mental health profes- up the relative merits of suggestions offered by different sionals is really rewarding.' They also felt that other provid- participants. ers (particularly GPs) were better equipped to deliver optimal care, suggesting that 'It educates the GP and helps Impact of case conferences on consumer outcomes the management of other patients ... the GP is going to use the The majority of respondents indicated that case confer- ences impacted positively on consumer outcomes. Some knowledge gained in a case conference to help manage patients for the foreseeable future.' had difficulty in 'pinning down' exactly how this occurred, remarking that the case conference helped them Impact of case conferences on co-ordination of care to gain a more comprehensive understanding of different Overwhelmingly, respondents indicated that case confer- facets of the consumer's life, which translated into ences improved co-ordination of care, particularly to con- improved treatment and greater consumer satisfaction. sumers with complex needs and/or problems in multiple One psychiatrist summarised this in the following way, areas of life – e.g., those with a dual diagnosis of mental 'Whatever helps me understand the person, and their treatment illness and intellectual disability, those with chronic men- network, helps the patient. The patient is often not going to tal health problems and/or problems that were not know how it's helped, but it gives me a broader understanding responsive to routine drug treatments, and children and and I can use that in different ways. That is psychiatry!' adolescents. As one provider put it, '... with these multiple problems, there is often a need for ... lots of other providers case Others were more specific, citing tangible outcomes that conferencing is most useful in this situation.' they believed to be a direct result of case conferencing. For example, several psychiatrists reported that a case confer- A number of psychiatrists noted that case conferencing ence had enabled the treatment team to improve manage- facilitated information transfer between providers, allow- ment when the consumer was in crisis and/or required Page 7 of 12 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:33 http://www.anzhealthpolicy.com/content/2/1/33 hospitalisation, providing examples like the following: Some respondents indicated that they had taken part in 'We had a case conference and it worked very well ... in fact case conferences but had not billed for them, because it that was one and half years ago, and the patient has not had had not occurred to them to do so. One psychiatrist who an admission since, or a crisis contact with the GP. So it has had attended case conferences but not charged for them saved money' was asked why and replied, 'Laziness! They are simply not in the forefront of my mind. I have done them, but I have not Respondents were also asked to consider whether case charged for them. It is the secretaries that have to do the billing. conferences had the potential to lead to negative out- I simply have not mentioned it to them, and if you don't talk to comes, and the majority did not believe this to be the case. them they can't charge for them.' Most reported that they engaged in several practices to minimise the likelihood of this occurring, such as explain- Others felt that organising a case conference in a manner ing the nature of the case conference beforehand, inviting that satisfied the HIC's criteria was time consuming and the consumer to attend, and reviewing the process with difficult, and that the remuneration offered was incom- him or her afterwards. Several noted that some consumers mensurate with this effort. This view is summarised by felt intimidated by their treatment providers meeting to one psychiatrist who said, 'It's just too hard to arrange a time discuss them, especially if they were not present at the case to meet with people, then plan it and run it. The payment you conference, but that this was usually resolved by offering get for that does not compensate for the time you spend arrang- reassurance. ing it.' Stage 3b: Experiences of private psychiatrists who had not Several respondents reported that they used alternatives to made use of the case conferencing item numbers case conferencing to communicate with other providers. Reasons for non-use of the item numbers Often this involved contacting other professionals 'bit by The reasons for respondents' non-use of the item numbers bit', either by telephone or via letter, or using a single serv- were explored. As a first step, respondents were asked ice provider as a conduit for communicating with the rest whether they were aware of the case conferencing item of the team. numbers before they were contacted by the study team, Likelihood of future use of the item numbers and, if so, whether they knew how they operated. Six respondents (37%) were unaware of the item numbers, Respondents were asked about the likelihood that they and a further six (37%) were unsure about how they would use the case conferencing item numbers in future. worked. In total, then, 12 respondents (75%) had insuffi- Five (31%) indicated that the item numbers were not rel- cient knowledge of the item numbers to make use of evant to their practice and were therefore unlikely to use them. them in the future. Even some of those with a basic understanding of the Respondents for whom the item numbers were relevant existence and operation of the item numbers were not fell into three camps concerning the issue of future use. In fully cognizant of the conditions associated with them, the first group were three psychiatrists (19%) who per- and this had contributed to their non-use of the item ceived that the remuneration provided by through the numbers. To illustrate, one psychiatrist believed that all item numbers did not outweigh the logistical difficulties providers had to be physically present at the case confer- involved in case conferencing. They preferred to continue ence. He wanted to link up with the other providers by tel- to use their current 'bit by bit' model of contact with other econferencing, but he did not believe this was acceptable providers. under the conditions of the item numbers and had conse- quently not used them. In fact, teleconferencing is permis- A second group of six psychiatrists (33%) indicated that sible [1]. they would use the item numbers subject to checking the conditions associated with their use. For example, one Those respondents who were aware of the existence and psychiatrist in a rural area commented, 'Yes, I'm likely to operation of the item numbers had elected not to use use it provided the payment structure reflects the extra difficul- them for a variety of reasons. For some, the item numbers ties of meeting in person for rural health professionals. I'm talk- were not seen as relevant, either because their private prac- ing about travel time, long distances etc.' tice was so small that involvement in case conferences was not practical, or because they saw very few consumers Finally, two psychiatrists (13%) indicated that they would with complex needs for whom case conferences would definitely use the item numbers in the future, having been have been warranted. made aware of their existence and operation. One of these psychiatrists stated, 'Since this has been brought to my atten- Page 8 of 12 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:33 http://www.anzhealthpolicy.com/content/2/1/33 tion, and more importantly to my office manager's attention, Discussion we'll bill more for this. I'll do it in the future.' Study limitations Two study limitations should be borne in mind in inter- Stage 3c: Experiences of consumers for whom case preting the above findings. The first relates to the quanti- conferences had been arranged tative data provided by the HIC for Stages 1 and 2. The Attendance by consumers at case conferences HIC provided these data at an aggregated level, in order to Three respondents had been present at the case confer- protect the confidentiality of individual psychiatrists and ences convened to co-ordinate their care. Of these, two consumers. This was entirely appropriate, but it limited attended face-to-face, and one attended via video link. All the analyses that could be performed, particularly since were positive about their involvement, indicating that it the relatively low level of uptake of the item numbers 'allowed them to be heard.' One consumer did not attend, meant that the overall numbers were small. and was angry about this because she wanted to have input into the meeting. However, she was ultimately The second limitation relates the use of intermediaries to pleased with the outcome of the case conference. recruit interview participants. Again, this was considered proper practice, since it meant that the study team could Impact of case conferences on co-ordination of care not identify any psychiatrist or consumer unless they Three respondents reported that, in their experience, case expressly consented to be interviewed. However, it placed conferences enhanced co-ordination of care. In particular, constraints on the study team's control over the recruit- they noted that case conferences allowed providers to clar- ment process, which undoubtedly affected the response ify their treatment roles. Respondents reported that clear- rates. In spite of a second invitation letter being sent from ing up confusion at the 'provider end' improved clarity at the HIC to psychiatrists, and reminder calls being made to 'their end.' One respondent explained this in the following psychiatrists to encourage them to recruit consumers, the way: 'I suppose that the lines became clearer as to what every- response rates for Stage 3 were relatively low. one's job was.' Interpreting the findings Respondents also indicated that case conferences Patterns of uptake Despite the above caveats, the study provides useful eval- improved communication between all parties, helping providers to develop an appreciation of each other's uative information about the case conferencing item points of view and work as a team. As one respondent put numbers. The key finding – that although the uptake of it, 'I found them really valuable. Having all the professionals the item numbers has been slow, psychiatrists who have there gave an open forum for me to present my views to them ... used them have been extremely positive about them, cit- It meant that other professionals could also have input. Every- ing benefits for them and their consumers (particularly one was working together as a team.' those with complex needs and/or multiple providers) – is consistent with the small amount of related work that has Impact of case conferences on consumer outcomes been done in this area in Australia. Evaluations of initia- Respondents were asked whether they noted changes in tives designed to expand the activities in which psychia- their 'health and wellbeing' following the case conference, trists and GPs could be involved (the Partnership Project and gave mixed responses. Two expressed the view that and the Enhanced Primary Care MBS item numbers, although their coordination of care had improved, this respectively) found that although relatively few providers had not impacted on their day-to-day functioning. A took advantage of the opportunity to be involved in and third, the parent of the adolescent boy, said that the case remunerated for case conferences, those who did found conferences arranged for her son made a small but signif- them professionally satisfying and believed that they icant improvement to his welfare, describing them as 'a improved co-ordination of care for consumers with com- contributing factor.' The fourth respondent reported that plex needs [3-11]. she experienced substantial improvement in functioning as a result of the case conference. She indicated that the The fact that the uptake of the item numbers has increased case conference was a powerful therapeutic event for her, over time is also consistent with the above evaluations [3- although she was not specific about the mechanism by 11], suggesting that any initiative of this kind may have a which change occurred: 'For twelve years I was in a dysfunc- 'settling in' period. It would be anticipated that this tional relationship with physical and mental abuse. At the case increase in uptake might continue, perhaps plateauing at conference it all just came out ... Since the case conference I'm a certain point. It was beyond the scope of the study to doing things now and leading a normal life. I'm not stressed out monitor the uptake in a formal way for longer than three and I'm not agoraphobic like I was.' years, but informal analysis of the psychiatrist-specific item numbers (via publicly available data accessible from the HIC website) suggests that the uptake of this subset of Page 9 of 12 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:33 http://www.anzhealthpolicy.com/content/2/1/33 item numbers has continued to grow. These data show final reason may involve the relatively greater level of that 44 case conferences were billed against the psychia- remuneration associated with organising and co-ordinat- trist-specific item numbers in the first two quarters of ing the case conference. 2003, 140 in the second two quarters of that year, 134 in the first two quarters of 2004, 256 in the second two quar- Community case conferences were more common than ters of that year, and 289 in the first two quarters of 2005. discharge case conferences. This difference may reflect the Data on psychiatrists' use of the more general physician profile of the population of consumers who see private numbers were not available from the HIC website, psychiatrists – most will be dwelling and functioning in because the publicly accessible statistics do not allow psy- the community most of the time; only some will require chiatrists to be distinguished from other physicians. inpatient admissions, and even these may be infrequent. It may also reflect the fact that, when consumers are dis- It was clear from interviews with psychiatrists who had charged from public sector inpatient units, the private not used the item numbers that a significant number were psychiatrist may not always be notified, so the opportu- not aware of their existence, and even those who were nity for setting up a case conference may be missed. expressed confusion about their operation. Once their awareness was raised, many indicated an intention to use Case conferences most commonly lasted 45 minutes or them in the future. Having said this, there will always be longer, presumably relating to the fact that sharing infor- some for whom the item numbers are perceived as not rel- mation and co-ordinating care requires time, particularly evant, too stringent in their conditions, and/or not associ- if a number of providers are involved. ated with sufficient levels of reimbursement. Increased, not decreased, levels and costs of overall care Relative popularity of different item numbers The fact that the introduction of the item numbers was The fact that some item numbers were more popular than associated with increased, rather than decreased, levels others is worth considering in detail. More case confer- and costs of overall care warrants further exploration. ences were billed against the item numbers designed for Inflation can be ruled out, since the total number of serv- all physicians (including psychiatrists) than against the ices increased and all costs were expressed in constant psychiatrist-specific item numbers, a difference that is 2002/03 prices. However, there might be increases in the most likely to be explained by the fact that the former overall level of services provided by psychiatrists, at least existed for two years before the latter were introduced. initially, because they could continue to see consumers Indeed, further analysis of the data revealed that in the last individually as well as being involved in case conferences. year, when both types of item number were available, Alternatively, psychiatrists may be more likely to render 57% of all claims were made against the psychiatrist-spe- case conferences for consumers whose needs are becom- cific item numbers. ing increasingly complex, and who are requiring greater professional input. Psychiatrists more commonly elected to use the item numbers that require attendance at the case conference by It should also be noted that the study could only capture two other providers, rather than those that require three care provided by private psychiatrists and paid for (prima- others to be present. It makes intuitive sense that case con- rily at least) through the HIC, and not care delivered by ferences with two other providers might have more intrin- other providers and paid for from other sources (e.g., care sic appeal, given the logistical difficulties in co-ordinating provided by staff of mental health services whose salaries meetings. are paid from state/territory health budgets). There may have been a reduction in the need for some of these serv- Psychiatrists were also more inclined to bill against item ices if care became more co-ordinated as a result of case numbers which recognised their role in organisation and conferences. co-ordination of the case conference, as opposed to partic- ipation only. There may be several reasons for this. One Although the introduction of the case conferencing item might be that 'taking charge' of the case conference fits numbers was not associated with the hypothesised reduc- with their consultant role. Another might be that they are tion in the level and cost of services by private psychia- relatively professionally isolated, and may therefore have trists, this is not necessarily a negative finding. If the greater imperatives for calling together others involved in increases in the quality of care outweigh the increases in a consumer's care than, for example, members of a public costs, they may still be cost-effective. Findings from the sector mental health team. A third reason may relate to interviews with psychiatrists who had used the item num- availability of billing options – two thirds of the item bers and consumers for whom case conferences had been numbers allow for organisation and co-ordination, com- rendered suggest that this may be the case. pared with only one third that allow for participation. A Page 10 of 12 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:33 http://www.anzhealthpolicy.com/content/2/1/33 Improved quality of care Authors' contributions The above notion of 'improved quality of care' warrants JP and PB conceptualised the evaluation and took the lead further exploration. It is fair to say that the case conferenc- on designing the study; AH assisted with refining the ing item numbers improved continuity of care (' [the] study design. JP liaised with the HIC in extracting the data ability to provide uninterrupted, coordinated care or serv- for Stages 1 and 2. JP and AH developed the interview ice across programs, practitioners, organisations and lev- schedules for Stage 3, with assistance from PB, JW and CF. els over time' [12]). This message consistently emerged JP and AH undertook the data management and analysis from the interviews with psychiatrists and consumers. It is activities associated with all three stages. JP and AH took less clear whether the item numbers demonstrated effec- primary responsibility for drafting the original version of tiveness (' [the] care, intervention or action achieves [the] the paper, and all other authors contributed substantially desired outcome in an appropriate timeframe' [12]). to revised drafts. All authors read and approved the final Interview respondents expressed mixed views in this manuscript. regard. Some psychiatrists indicated that case conferences had improved outcomes for consumers, although most Acknowledgements This work was funded by the National Health and Medical Research Coun- were unable to be specific about the nature of these out- cil. The authors would like to thank staff of the Health Insurance Commis- comes. Some consumers suggested that the case confer- sion for extracting relevant data and assisting with the recruitment of ences had resulted in improvements in their day-to-day psychiatrists. They would also like to thank Rob Carter, for providing eco- functioning, but others felt that no change had occurred. nomic advice on Stage 2. Finally, they would like to thank the psychiatrists who participated in interviews and assisted with the recruitment of con- Conclusion sumers, and the consumers who participated in interviews. The introduction of the MBS case conferencing item num- bers has not been met with overwhelming enthusiasm by References psychiatrists. Psychiatrists who have used the item num- 1. Australian Government Department of Health and Ageing: Medicare Benefits Schedule Book. Canberra, Australian Government bers are generally positive about them, as are consumers. Department of Health and Ageing Care; 2004. Psychiatrists who have not used them have generally not 2. King N: Template analysis. In Qualitative Methods and Analysis in Organizational Research Edited by: Symon G and Cassell C. London, done so because of a lack of knowledge, rather than direct Sage Publications; 1998. opposition. The use of the item numbers is increasing 3. Pirkis J, Livingston J, Morley B, Trauer T: The Public and Private over time, perhaps as psychiatrists become more aware of Partnerships in Mental Health Project: Final Evaluation Report. Melbourne, Centre for Health Program Evaluation, The their existence and of their utility in maximising quality of University of Melbourne; 2003. care. 4. Pirkis J, Livingston J, Herrman H, Schweitzer I, Gill L, Morley B, Yung A, Grigg M, Trauer T, Burgess P: Improving collaboration between private psychiatrists, the public mental health sec- If the case conferencing item numbers are to achieve their tor and general practitioners: Evaluation of the Partnership potential, some consideration might need to be given to Project. Australian and New Zealand Journal of Psychiatry 2004, 38:125-134. issues of process and structure. The degree of awareness of 5. Wilkinson D, McElroy H, Beilby J, Mott K, Price K, Morey S, Best J: the item numbers is sub-optimal. There is confusion over Uptake of health assessments, care plans and case confer- some of the conditions associated with the item numbers ences by general practitioners through the Enhanced Pri- mary Care programs between November 1999 and October (e.g., the definition of the term 'organise and co-ordinate', 2001. Australian Health Review 2002, 25:1-11. the nature of the other providers required to attend the 6. Wilkinson D, McElroy H, Beilby J, Mott K, Price K, Morey S, Best J: Variation in levels of uptake of enhanced primary care item case conference, the required duration of attendance by numbers between rural and urban settings, November 1999 other providers), and there are some stipulations which to October 2001. Australian Health Review 2002, 25:123-130. made it difficult for psychiatrists to make use of the item 7. Wilkinson D, Mott K, Morey S, Beilby J, Price K, Best J, McElroy H, Pluck S, Eley V: Evaluation of the Enhanced Primary Care numbers in particular circumstances (e.g. psychiatrists in (EPC) Medicare Benefits Schedule (MBS) Items and the rural and remote areas find it difficult to satisfy the General Practice Education, Support and Community Link- requirement of at least two other providers being present, ages Program: Final Report. Canberra, Commonwealth Depart- ment of Health and Ageing; 2003. child and adolescent psychiatrists are concerned about the 8. Blakeman TM, Harris MF, Comino EJ, Zwar NA: Evaluating general exclusion of teachers from the list of 'eligible' attendees). practitioners' views about the implementation of the enhanced primary care Medicare items. Medical Journal of Aus- Finally, there are issues concerning the level of remunera- tralia 2001, 175:95-98. tion that the item numbers attract, given the amount of 9. Blakeman TM, Zwar NA, Harris MF: Evaluating general practi- time required to organise and participate in them. The tioners' views on the enhanced primary care items for care planning and case conferencing: A one year follow up. Austral- Australian Government may wish to take these findings ian Family Physician 2002, 31:582-585. 'on board' in future iterations of the MBS. 10. Mitchell GK, De Jong IC, Del Mar CB, Clavarino AM, Kennedy R: General practitioner attitudes to case conferences: How can we increase participation and effectiveness? Medical Journal of Declaration of competing interests Australia 2002, 177:95-97. The authors declare that they have no competing interests. 11. Davies JW, Ward WK, Groom GL, Wild AJ, Wild S: The case-con- ferencing project: A first step towards shared care between Page 11 of 12 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:33 http://www.anzhealthpolicy.com/content/2/1/33 general practitioners and a mental health service. Australian and New Zealand Journal of Psychiatry 1997, 31:751-755. 12. National Mental Health Working Group Information Strategy Com- mittee Performance Indicator Drafting Group: Key Performance Indicators for Australian Public Mental Health Services: Information Strategy Committee Discussion Paper No. 6. Canberra, Australian Government Department of Health and Ageing; Publish with Bio Med Central and every scientist can read your work free of charge "BioMed Central will be the most significant development for disseminating the results of biomedical researc h in our lifetime." Sir Paul Nurse, Cancer Research UK Your research papers will be: available free of charge to the entire biomedical community peer reviewed and published immediately upon acceptance cited in PubMed and archived on PubMed Central yours — you keep the copyright BioMedcentral Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 12 of 12 (page number not for citation purposes) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australia and New Zealand Health Policy Springer Journals

Remunerating private psychiatrists for participating in case conferences

Loading next page...
 
/lp/springer-journals/remunerating-private-psychiatrists-for-participating-in-case-Dprx0x0ceB
Publisher
Springer Journals
Copyright
Copyright © 2005 by Pirkis et al; licensee BioMed Central Ltd.
Subject
Medicine & Public Health; Public Health; Social Policy
eISSN
1743-8462
DOI
10.1186/1743-8462-2-33
pmid
16359557
Publisher site
See Article on Publisher Site

Abstract

Background: On 1 November 2000, a series of new item numbers was added to the Medicare Benefits Schedule, which allowed for case conferences between physicians (including psychiatrists) and other multidisciplinary providers. On 1 November 2002, an additional set of numbers was added, designed especially for use by psychiatrists. This paper reports the findings of an evaluation of these item numbers. Results: The uptake of the item numbers in the three years post their introduction was low to moderate at best. Eighty nine psychiatrists rendered 479 case conferences at a cost to the Health Insurance Commission of $70,584. Psychiatrists who have used the item numbers are generally positive about them, as are consumers. Psychiatrists who have not used them have generally not done so because of a lack of knowledge, rather than direct opposition. The use of the item numbers is increasing over time, perhaps as psychiatrists become more aware of their existence and of their utility in maximising quality of care. Conclusion: The case conferencing item numbers have potential, but as yet this potential is not being realised. Some small changes to the conditions associated with the use of the item numbers could assist their uptake. Background other multidisciplinary providers. These item numbers In Australia, there has been growing concern that sub- were introduced in recognition of the fact that improved optimal collaboration between different providers may co-ordination in community settings has the potential to impede the quality and outcomes of care, both in the lead to improvements in consumer impacts/outcomes physical and mental health arenas. In order to facilitate through a more flexible, efficient and responsive match greater collaboration between providers, a series of new between consumers' needs and services [1]. The item item numbers was added to the Medicare Benefits Sched- numbers enabled physicians to take part in discharge or ule (MBS) on 1 November 2000, which provided remu- community case conferences of varying lengths with other neration for case conferences between physicians and providers. As a sub-group of physicians, psychiatrists were Page 1 of 12 (page number not for citation purposes) Table 1: Summary of criteria for individual case conferencing item numbers Provider No. of other Role Type Duration in minutes attendees Item Physician Psychiatrist 3 2 Organise and Participate Community Discharge 15–29 30–44 45+ Fee* Benefit Benefit No. (including only co-ordinate (75%)* (85%)* Psychiatrist) 820 Y Y Y Y Y $115.55 $86.70 $98.25 822 Y Y Y Y Y $173.40 $130.05 $147.40 823 Y Y Y Y Y $231.15 $173.40 $196.50 825 Y Y Y Y Y $83.05 $62.30 $70.60 826 Y Y Y Y Y $132.40 $99.30 $112.55 828 Y Y Y Y Y $181.80 $136.35 $154.55 830 Y Y Y Y Y $115.55 $86.70 $98.25 832 Y Y Y Y Y $173.40 $130.05 $147.40 834 Y Y Y Y Y $231.15 $173.40 $196.50 835 Y Y Y Y Y $83.05 $62.30 $70.60 837 Y Y Y Y Y $132.40 $99.30 $112.55 838 Y Y Y Y Y $181.80 $136.35 $154.55 855 Y Y Y Y Y $115.55 $86.70 $98.25 857 Y Y Y Y Y $173.40 $130.05 $147.40 858 Y Y Y Y Y $231.15 $173.40 $196.50 861 Y Y Y Y Y $115.55 $86.70 $98.25 864 Y Y Y Y Y $173.40 $130.05 $147.40 866 Y Y Y Y Y $231.15 $173.40 $196.50 * At July 2004 Source: Department of Health and Ageing [1] Australia and New Zealand Health Policy 2005, 2:33 http://www.anzhealthpolicy.com/content/2/1/33 Page 2 of 12 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:33 http://www.anzhealthpolicy.com/content/2/1/33 200 $30,000 $25,000 $20,000 Services 100 $15,000 Benefits paid $10,000 $5,000 0 $0 1/11/00 to 30/4/01 1/5/01 to 31/10/01 1/11/01 to 30/4/02 1/5/02 to 31/10/02 1/11/02 to 30/4/03 1/5/03 to 31/10/03 Note: All benefits paid expressed as constant 2002/03 prices, using deflators from the Australian Bureau of Statistics (Implicit Price Deflators – Gross Non-Farm Product) Ca Figure 1 se conferences rendered and benefits paid, by six-monthly period, 1 November 2000 to 31 October 2003 (n = 479) Case conferences rendered and benefits paid, by six-monthly period, 1 November 2000 to 31 October 2003 (n = 479). eligible to use these item numbers to improve their collab- The current paper reports on an evaluation of the intro- oration with other mental health care providers, including duction of these item numbers which aimed to: (a) exam- staff of state/territory funded inpatient and community ine the processes/operation of the case conferencing item mental health services, other private mental health care numbers, from the perspective of psychiatrists and con- specialists like psychologists, and GPs and other primary sumers; and (b) consider the costs associated with the case care practitioners. conferencing item numbers, and their impacts/outcomes for consumers. The original item numbers distinguished between organ- ising and co-ordinating a case conference (where three Method other providers had to be present), and participating in Design one (where two other providers had to be). The nature of The evaluation was approved by the University of Mel- mental health care meant that the more stringent attend- bourne's Human Research Ethics Committee, and com- ance requirements associated with organising and co- prised three stages. Stage 1 examined the uptake of the ordinating a case conference could not always be met, so, case conferencing item numbers. The then Health Insur- on 1 November 2002, an additional set of item numbers ance Commission (HIC), the Australian Government was added, designed especially for use by psychiatrists. agency responsible for rebates for private medical care, These new item numbers relaxed the attendance require- provided the study team with de-identified, aggregated ment for organising and co-ordinating a case conference, data on the nature and extent of use of the item numbers reducing the mandatory number of other providers to by private psychiatrists in the three years since their intro- two. Table 1 provides a breakdown of the item numbers, duction. The analysis considered uptake over time, but detailing the rebate associated with the different combina- did not separately examine the first two years (in which tions of psychiatrists' roles, number of other attendees, the 'physician' item numbers were introduced) and the consumers' settings, and case conference duration. third year (in which the 'psychiatrist-specific' item num- Page 3 of 12 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:33 http://www.anzhealthpolicy.com/content/2/1/33 Table 2: Nature of case conferences rendered, 1 November 2000 use them, and whether they thought they would be likely to 31 October 2003 (n = 479) to use them in future. Demographic details were also col- lected from both groups. Provider Psychiatrist only 37% Physician (including psychiatrist) 63% Other attendees Two 65% In Stage 3c, the psychiatrists who participated in Stage 3a Three 35% were asked to act as intermediaries. Those who agreed Role Organise and co-ordinate 72% were each sent additional information that explained Participate 28% Stage 3c, and asked to approach the two most recent con- Type Community 80% sumers for whom they had arranged a case conference, Discharge 20% and invite them to participate in a 30-minute phone inter- Duration 15–29 minutes 25% view. Consenting consumers were asked whether they 30–44 minutes 23% 45+ minutes 51% thought that case conferencing improved the quality of care they received, and whether case conferencing had any impact on outcomes for them. Demographic details were also collected. bers were introduced), on the grounds that the evaluation was concerned with the overall availability of an initiative Analysis that allowed psychiatrists to be remunerated for taking Analysis of the quantitative data in Stages 1 and 2 part in case conferences, and that the numbers available involved the generation of simple descriptive statistics. for sub-analyses would have been too small to allow Analysis of the qualitative data in Stage 3 employed tem- meaningful conclusions to be drawn. plate analysis, which involves identifying a key set of themes which relate to specific codes, and then producing Stage 2 examined the impact of the item numbers on a template to organise these codes [2]. other types of services provided by private psychiatrists. The HIC identified the consumer for whom each case con- Results ference had been arranged by his/her Medicare number Stage 1: Uptake of the case conferencing item numbers The uptake of the case conferencing item numbers in the and, using the Medicare number, extracted information on all services provided by private psychiatrists (both three years post- their introduction was low to moderate those who had participated in case conferences and those at best, although it did increase over time (see Figure 1). who had not) for these consumers (case conferences and Eighty nine private psychiatrists (less than 5% of all psy- direct consultations). These consumers acted as their own chiatrists) elected to use the item numbers. They rendered historical controls, and their consultations in equivalent a total of 479 case conferences, for which the HIC paid periods pre- and post- their first case conference were con- $70,584 (around 0.01% of all services provided by and sidered. De-identified, aggregated data were provided to benefits paid to private psychiatrists during the period). the study team. Table 2 shows that psychiatrists favoured the item num- Stage 3 examined the experiences of key informants with bers with the following characteristics: designed for use by the item numbers. Specifically, it involved interviews with all physicians; requiring only two other attendees to be private psychiatrists who had and had not used the item present; requiring them to take an organisational role; numbers (Stage 3a and 3b, respectively), and consumers facilitating community case conferences; and reimbursing for whom case conferences had been arranged (Stage 3c). for longer case conferences. In Stages 3a and 3b, the HIC acted as an intermediary, Stage 2: Impact of the case conferencing item numbers on approaching all private psychiatrists who had made use of the case conferencing item numbers as well as a random other types of services provided by private psychiatrists sample of 100 who had not. The HIC sought consent from Table 3 summarises the face-to-face services provided by these psychiatrists for the study team to approach them private psychiatrists for consumers for whom case confer- for a 15-minute phone interview. Those who had used the ences had been arranged, pre- and post- their first case item numbers were asked about the processes involved, conference. It shows that the total number of psychiatrists the perceived impacts for themselves and their consumers involved in the consumers' care in the post- period was regarding improvements in co-ordination of care, and greater than the 89 who took part in case conferences con- whether the opportunity for case conferencing had flow- cerning these consumers (at 163), but that this was fewer on effects in terms of better mental health outcomes for than the number involved in consumers' care in the pre- their consumers. Those who had not used the item num- period (at 184). Despite the decrease in the total number bers were asked about their knowledge of and attitudes of psychiatrists providing care from the pre- period to the towards the item numbers, why they had chosen not to post- period, the total and average number of services Page 4 of 12 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:33 http://www.anzhealthpolicy.com/content/2/1/33 Table 3: Services provided by private psychiatrists for consumers increased, as did the total and average benefits paid. To for whom case conferences had been arranged, pre- and post- ensure that the latter increase was not accounted for by their first case conference inflation alone, a best-case/worst-case sensitivity analysis was performed, where all of the pre- benefits paid were Pre- Post- assumed to have been in 1997/98 dollars and converted No. of providers 184 163 to 2002/03 dollars, and all of the post- benefits paid were Total services 4,861 5,499 assumed to have been in 2002/03 dollars. Even under Average services 26.42 33.74 these circumstances, the post- benefits paid were higher Total benefit paid – actual $455,743 $549,673 than the pre- benefits paid. Total benefit paid – adjusted ($511,891) ($549,673) Average benefit paid – actual $2,477 $3,372 Stage 3: Key informants' experiences with the case Average benefit paid – adjusted ($2,782) ($3,372) conferencing item numbers Response rates In total, 47 key informants were interviewed. Twenty you are really getting paid for ... But if you are not getting any- seven (30%) of the 89 psychiatrists who had used the case thing for it, then there is a great deterrent to doing it.' conferencing item numbers agreed to be interviewed, as did 16 (16%) of the 100 who had not. Three consumers Logistical issues associated with the item numbers and one proxy (the mother of an adolescent boy) also Respondents indicated that there were a number of logis- agreed to be interviewed. These four were drawn from a tical issues associated with the case conferencing item potential pool of 23 (17%), since nine psychiatrists had numbers. A number of psychiatrists noted that arranging each agreed to recruit two consumers and a further four times to meet with other care providers was 'really too had agreed to recruit one. much' and should attract 'double or triple the current rate.' This was exacerbated in circumstances where psychiatrists Table 4 profiles the interview respondents, and, where were using the item numbers that entailed their 'organis- possible, compares them with the sample from which ing and co-ordinating' the case conference, rather than they were drawn. Interviewed psychiatrists who had used just 'participating' in it, because many psychiatrists the item numbers were reasonably representative of their assumed that the former required them to take responsi- broader group in terms of their age profile and the bility for setting it up. In fact, 'organising and co-ordinat- number of years they had been qualified as psychiatrists, ing' refers to recording what took place during the case but were more likely to be female and to have attained conference, distributing a summary of this to the treat- their general medical qualifications earlier. Interviewed ment team, and ensuring that the consumer is informed psychiatrists who had not used the item numbers were about the outcomes of the case conference [1]. reasonably representative of their broader group in terms of their age and sex profile, but tended to be more recently Several respondents commented on difficulties meeting qualified (both as medical practitioners and as psychia- the requirement that at least two other providers be trists). No comparative data were available on the total present at the case conference. Sometimes, particularly in sample of potential consumer interviewees. rural areas, a second party was available (e.g., a GP), but not a third. On other occasions, potential participants in Stage 3a: Experiences of private psychiatrists who had the case conference did not qualify as 'formal care provid- made use of the case conferencing item numbers ers' [1] (e.g., a number of child and adolescent psychia- Financial incentives associated with the item numbers trists noted that teachers were integral to the team sharing Interview respondents were asked to consider their satis- responsibility for their consumer group, but did not faction, and often discussed this in terms of the remuner- 'count' towards the complement of other attendees). ation levels offered by the case conferencing item numbers. Many commented that the item numbers pro- Another observed difficulty was the fact that some provid- vided them 'with the opportunity to be part of a decision-mak- ers arrived late, left early or did not attend at all. GPs were ing forum that is not typically feasible in private practice', commonly cited, but there were others as well (e.g., com- because of the fee-for-service environment. munity mental health team members). Respondents understood that these providers have hectic, unpredicta- Having said this, the majority view was that the remuner- ble schedules, but were frustrated that their partial or non- ation provided 'helpful compensation', rather than covering attendance had financial implications, as indicated by the their full costs in terms of time spent arranging or partici- following quotation: 'There is a requirement that the special- pating in case conferences. This view was exemplified in ist or GP has to be there the whole time, which is ludicrous. If statements like: '... I mean, you put in much more work than someone says, "Thanks, that was good, but I've got to go now", they can't be paid for that.' This impacted on how likely psy- Page 5 of 12 (page number not for citation purposes) Table 4: Profile of interview respondents Psychiatrists who had used the case Psychiatrists who had not used the Consumers for whom case conferencing item numbers case conferencing item numbers conferences had been arranged Interviewed Eligible for Interviewed Eligible for Interviewed Eligible for (n = 27) interview (n = 16) interview (n = 4) interview (n = 89) (n = 100) (n = 23) Age group <18 bbbb 25% c 18–25 bbbb 0% c 25–34 0% 0%0%0% 50% c 35–44 19% 20% 25% 20% 25% c 45–54 48% 44% 31% 34% 0% c 55–64 30% 27% 25% 28% 0% c 65+ 4% 6% 19% 15% 0% c Missing 0% 3%0%2%0% c Sex Males 52% 67% 75% 74% 25% c Females 48% 29% 25% 24% 75% c Missing 0% 3%0%2%0% c Year qualified as doctor pre 1960 4% 20% 13% 35% b b 1960 – 1969 15% * 25% * b b 1970 – 1979 41% 16% 19% 16% b b 1980 – 1989 33% 49% 44% 33% b b 1990 – 1999 7% 9% 0% 13% b b 2000 – 2004 0% * 0% * b b Missing 0% 3%0%2% b b Year qualified as psychiatrist pre 1960 0% 4% 0% 18% b b 1960 – 1969 4% * 13% * b b 1970 – 1979 11% * 25% 13% b b 1980 – 1989 26% 27% 13% 21% b b 1990 – 1999 41% 45% 50% 34% b b 2000 – 2004 19% 16% 0% 12% b b Missing 0% 3%0%2% b b a. Mother of respondent interviewed b. Not applicable c. Data unavailable Australia and New Zealand Health Policy 2005, 2:33 http://www.anzhealthpolicy.com/content/2/1/33 Page 6 of 12 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:33 http://www.anzhealthpolicy.com/content/2/1/33 chiatrists were to be involved in further case conferences ing for 'speedy communication and the understanding of all unless the requirements changed: 'That only has to happen involved.' They felt that being able to sit down with other twice, and you begin to think it's just not worth it.' providers face-to-face enabled them to clarify the problem and develop an action plan which everybody agreed A number of psychiatrists cited travel time as a problem. upon. Psychiatrists reported that case conferencing had Even those who were positive about the item numbers clear advantages over trying to communicate with other noted that they often felt hesitant to attend case confer- providers either by phone or through letters, and often ences because of the time involved in getting to the meet- constituted the first opportunity for all relevant providers ing: 'I see a lot of people from a long way away. I could travel to meet. Some went as far as to say, 'There really wouldn't up to one hour one way to be involved in it. That is a disincen- be any other way of communicating with everyone if we hadn't tive for me doing this kind of thing.' done a case conference.' Several psychiatrists expressed frustration at having 'claims Respondents noted that case conferences clarified the rejected' by the HIC. In their eyes, these rejections often roles and responsibilities of each provider, and helped occurred for minor reasons, and had a major impact on them to perform these roles optimally. They cited exam- the likelihood that they and their colleagues would take ples such as, '... in one case, the social worker had skill in the part in future case conferences. treatment of trauma and once I realised this I was able to hand over this aspect of management to the social worker.' Some psychiatrists indicated that they and their col- leagues had experienced confusion over some of the con- Respondents observed that the case conferencing item ditions associated with the item numbers. For example, numbers had a direct impact on the quality of assessment there was a lack of clarity regarding the term 'formal care and treatment. With regard to assessment, respondents providers of a different discipline', creating confusion reported that communicating with other providers at a about whether other physicians (e.g., paediatricians) case conference enhanced their understanding of the con- could be included in the total number. sumer. Consumers with complex needs often have prob- lems in multiple domains of life, and several psychiatrists Impact of case conferences on psychiatrists' roles described how case conferences aided their assessment According to respondents, case conferencing allowed capacity because other attending providers could give them to take on a consultant role, permitting them to them better insight into consumers' strengths and weak- offer specialist advice. They indicated that both parties nesses. With regard to treatment, many respondents com- benefited from this role. They enjoyed the break from mented that treatment planning was improved by direct care delivery, and appreciated meeting with col- including 'different views from different people', although leagues working in the field, making statements like, 'Just some added the caveat that they had to be careful to weigh to have more contact with GPs and other mental health profes- up the relative merits of suggestions offered by different sionals is really rewarding.' They also felt that other provid- participants. ers (particularly GPs) were better equipped to deliver optimal care, suggesting that 'It educates the GP and helps Impact of case conferences on consumer outcomes the management of other patients ... the GP is going to use the The majority of respondents indicated that case confer- ences impacted positively on consumer outcomes. Some knowledge gained in a case conference to help manage patients for the foreseeable future.' had difficulty in 'pinning down' exactly how this occurred, remarking that the case conference helped them Impact of case conferences on co-ordination of care to gain a more comprehensive understanding of different Overwhelmingly, respondents indicated that case confer- facets of the consumer's life, which translated into ences improved co-ordination of care, particularly to con- improved treatment and greater consumer satisfaction. sumers with complex needs and/or problems in multiple One psychiatrist summarised this in the following way, areas of life – e.g., those with a dual diagnosis of mental 'Whatever helps me understand the person, and their treatment illness and intellectual disability, those with chronic men- network, helps the patient. The patient is often not going to tal health problems and/or problems that were not know how it's helped, but it gives me a broader understanding responsive to routine drug treatments, and children and and I can use that in different ways. That is psychiatry!' adolescents. As one provider put it, '... with these multiple problems, there is often a need for ... lots of other providers case Others were more specific, citing tangible outcomes that conferencing is most useful in this situation.' they believed to be a direct result of case conferencing. For example, several psychiatrists reported that a case confer- A number of psychiatrists noted that case conferencing ence had enabled the treatment team to improve manage- facilitated information transfer between providers, allow- ment when the consumer was in crisis and/or required Page 7 of 12 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:33 http://www.anzhealthpolicy.com/content/2/1/33 hospitalisation, providing examples like the following: Some respondents indicated that they had taken part in 'We had a case conference and it worked very well ... in fact case conferences but had not billed for them, because it that was one and half years ago, and the patient has not had had not occurred to them to do so. One psychiatrist who an admission since, or a crisis contact with the GP. So it has had attended case conferences but not charged for them saved money' was asked why and replied, 'Laziness! They are simply not in the forefront of my mind. I have done them, but I have not Respondents were also asked to consider whether case charged for them. It is the secretaries that have to do the billing. conferences had the potential to lead to negative out- I simply have not mentioned it to them, and if you don't talk to comes, and the majority did not believe this to be the case. them they can't charge for them.' Most reported that they engaged in several practices to minimise the likelihood of this occurring, such as explain- Others felt that organising a case conference in a manner ing the nature of the case conference beforehand, inviting that satisfied the HIC's criteria was time consuming and the consumer to attend, and reviewing the process with difficult, and that the remuneration offered was incom- him or her afterwards. Several noted that some consumers mensurate with this effort. This view is summarised by felt intimidated by their treatment providers meeting to one psychiatrist who said, 'It's just too hard to arrange a time discuss them, especially if they were not present at the case to meet with people, then plan it and run it. The payment you conference, but that this was usually resolved by offering get for that does not compensate for the time you spend arrang- reassurance. ing it.' Stage 3b: Experiences of private psychiatrists who had not Several respondents reported that they used alternatives to made use of the case conferencing item numbers case conferencing to communicate with other providers. Reasons for non-use of the item numbers Often this involved contacting other professionals 'bit by The reasons for respondents' non-use of the item numbers bit', either by telephone or via letter, or using a single serv- were explored. As a first step, respondents were asked ice provider as a conduit for communicating with the rest whether they were aware of the case conferencing item of the team. numbers before they were contacted by the study team, Likelihood of future use of the item numbers and, if so, whether they knew how they operated. Six respondents (37%) were unaware of the item numbers, Respondents were asked about the likelihood that they and a further six (37%) were unsure about how they would use the case conferencing item numbers in future. worked. In total, then, 12 respondents (75%) had insuffi- Five (31%) indicated that the item numbers were not rel- cient knowledge of the item numbers to make use of evant to their practice and were therefore unlikely to use them. them in the future. Even some of those with a basic understanding of the Respondents for whom the item numbers were relevant existence and operation of the item numbers were not fell into three camps concerning the issue of future use. In fully cognizant of the conditions associated with them, the first group were three psychiatrists (19%) who per- and this had contributed to their non-use of the item ceived that the remuneration provided by through the numbers. To illustrate, one psychiatrist believed that all item numbers did not outweigh the logistical difficulties providers had to be physically present at the case confer- involved in case conferencing. They preferred to continue ence. He wanted to link up with the other providers by tel- to use their current 'bit by bit' model of contact with other econferencing, but he did not believe this was acceptable providers. under the conditions of the item numbers and had conse- quently not used them. In fact, teleconferencing is permis- A second group of six psychiatrists (33%) indicated that sible [1]. they would use the item numbers subject to checking the conditions associated with their use. For example, one Those respondents who were aware of the existence and psychiatrist in a rural area commented, 'Yes, I'm likely to operation of the item numbers had elected not to use use it provided the payment structure reflects the extra difficul- them for a variety of reasons. For some, the item numbers ties of meeting in person for rural health professionals. I'm talk- were not seen as relevant, either because their private prac- ing about travel time, long distances etc.' tice was so small that involvement in case conferences was not practical, or because they saw very few consumers Finally, two psychiatrists (13%) indicated that they would with complex needs for whom case conferences would definitely use the item numbers in the future, having been have been warranted. made aware of their existence and operation. One of these psychiatrists stated, 'Since this has been brought to my atten- Page 8 of 12 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:33 http://www.anzhealthpolicy.com/content/2/1/33 tion, and more importantly to my office manager's attention, Discussion we'll bill more for this. I'll do it in the future.' Study limitations Two study limitations should be borne in mind in inter- Stage 3c: Experiences of consumers for whom case preting the above findings. The first relates to the quanti- conferences had been arranged tative data provided by the HIC for Stages 1 and 2. The Attendance by consumers at case conferences HIC provided these data at an aggregated level, in order to Three respondents had been present at the case confer- protect the confidentiality of individual psychiatrists and ences convened to co-ordinate their care. Of these, two consumers. This was entirely appropriate, but it limited attended face-to-face, and one attended via video link. All the analyses that could be performed, particularly since were positive about their involvement, indicating that it the relatively low level of uptake of the item numbers 'allowed them to be heard.' One consumer did not attend, meant that the overall numbers were small. and was angry about this because she wanted to have input into the meeting. However, she was ultimately The second limitation relates the use of intermediaries to pleased with the outcome of the case conference. recruit interview participants. Again, this was considered proper practice, since it meant that the study team could Impact of case conferences on co-ordination of care not identify any psychiatrist or consumer unless they Three respondents reported that, in their experience, case expressly consented to be interviewed. However, it placed conferences enhanced co-ordination of care. In particular, constraints on the study team's control over the recruit- they noted that case conferences allowed providers to clar- ment process, which undoubtedly affected the response ify their treatment roles. Respondents reported that clear- rates. In spite of a second invitation letter being sent from ing up confusion at the 'provider end' improved clarity at the HIC to psychiatrists, and reminder calls being made to 'their end.' One respondent explained this in the following psychiatrists to encourage them to recruit consumers, the way: 'I suppose that the lines became clearer as to what every- response rates for Stage 3 were relatively low. one's job was.' Interpreting the findings Respondents also indicated that case conferences Patterns of uptake Despite the above caveats, the study provides useful eval- improved communication between all parties, helping providers to develop an appreciation of each other's uative information about the case conferencing item points of view and work as a team. As one respondent put numbers. The key finding – that although the uptake of it, 'I found them really valuable. Having all the professionals the item numbers has been slow, psychiatrists who have there gave an open forum for me to present my views to them ... used them have been extremely positive about them, cit- It meant that other professionals could also have input. Every- ing benefits for them and their consumers (particularly one was working together as a team.' those with complex needs and/or multiple providers) – is consistent with the small amount of related work that has Impact of case conferences on consumer outcomes been done in this area in Australia. Evaluations of initia- Respondents were asked whether they noted changes in tives designed to expand the activities in which psychia- their 'health and wellbeing' following the case conference, trists and GPs could be involved (the Partnership Project and gave mixed responses. Two expressed the view that and the Enhanced Primary Care MBS item numbers, although their coordination of care had improved, this respectively) found that although relatively few providers had not impacted on their day-to-day functioning. A took advantage of the opportunity to be involved in and third, the parent of the adolescent boy, said that the case remunerated for case conferences, those who did found conferences arranged for her son made a small but signif- them professionally satisfying and believed that they icant improvement to his welfare, describing them as 'a improved co-ordination of care for consumers with com- contributing factor.' The fourth respondent reported that plex needs [3-11]. she experienced substantial improvement in functioning as a result of the case conference. She indicated that the The fact that the uptake of the item numbers has increased case conference was a powerful therapeutic event for her, over time is also consistent with the above evaluations [3- although she was not specific about the mechanism by 11], suggesting that any initiative of this kind may have a which change occurred: 'For twelve years I was in a dysfunc- 'settling in' period. It would be anticipated that this tional relationship with physical and mental abuse. At the case increase in uptake might continue, perhaps plateauing at conference it all just came out ... Since the case conference I'm a certain point. It was beyond the scope of the study to doing things now and leading a normal life. I'm not stressed out monitor the uptake in a formal way for longer than three and I'm not agoraphobic like I was.' years, but informal analysis of the psychiatrist-specific item numbers (via publicly available data accessible from the HIC website) suggests that the uptake of this subset of Page 9 of 12 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:33 http://www.anzhealthpolicy.com/content/2/1/33 item numbers has continued to grow. These data show final reason may involve the relatively greater level of that 44 case conferences were billed against the psychia- remuneration associated with organising and co-ordinat- trist-specific item numbers in the first two quarters of ing the case conference. 2003, 140 in the second two quarters of that year, 134 in the first two quarters of 2004, 256 in the second two quar- Community case conferences were more common than ters of that year, and 289 in the first two quarters of 2005. discharge case conferences. This difference may reflect the Data on psychiatrists' use of the more general physician profile of the population of consumers who see private numbers were not available from the HIC website, psychiatrists – most will be dwelling and functioning in because the publicly accessible statistics do not allow psy- the community most of the time; only some will require chiatrists to be distinguished from other physicians. inpatient admissions, and even these may be infrequent. It may also reflect the fact that, when consumers are dis- It was clear from interviews with psychiatrists who had charged from public sector inpatient units, the private not used the item numbers that a significant number were psychiatrist may not always be notified, so the opportu- not aware of their existence, and even those who were nity for setting up a case conference may be missed. expressed confusion about their operation. Once their awareness was raised, many indicated an intention to use Case conferences most commonly lasted 45 minutes or them in the future. Having said this, there will always be longer, presumably relating to the fact that sharing infor- some for whom the item numbers are perceived as not rel- mation and co-ordinating care requires time, particularly evant, too stringent in their conditions, and/or not associ- if a number of providers are involved. ated with sufficient levels of reimbursement. Increased, not decreased, levels and costs of overall care Relative popularity of different item numbers The fact that the introduction of the item numbers was The fact that some item numbers were more popular than associated with increased, rather than decreased, levels others is worth considering in detail. More case confer- and costs of overall care warrants further exploration. ences were billed against the item numbers designed for Inflation can be ruled out, since the total number of serv- all physicians (including psychiatrists) than against the ices increased and all costs were expressed in constant psychiatrist-specific item numbers, a difference that is 2002/03 prices. However, there might be increases in the most likely to be explained by the fact that the former overall level of services provided by psychiatrists, at least existed for two years before the latter were introduced. initially, because they could continue to see consumers Indeed, further analysis of the data revealed that in the last individually as well as being involved in case conferences. year, when both types of item number were available, Alternatively, psychiatrists may be more likely to render 57% of all claims were made against the psychiatrist-spe- case conferences for consumers whose needs are becom- cific item numbers. ing increasingly complex, and who are requiring greater professional input. Psychiatrists more commonly elected to use the item numbers that require attendance at the case conference by It should also be noted that the study could only capture two other providers, rather than those that require three care provided by private psychiatrists and paid for (prima- others to be present. It makes intuitive sense that case con- rily at least) through the HIC, and not care delivered by ferences with two other providers might have more intrin- other providers and paid for from other sources (e.g., care sic appeal, given the logistical difficulties in co-ordinating provided by staff of mental health services whose salaries meetings. are paid from state/territory health budgets). There may have been a reduction in the need for some of these serv- Psychiatrists were also more inclined to bill against item ices if care became more co-ordinated as a result of case numbers which recognised their role in organisation and conferences. co-ordination of the case conference, as opposed to partic- ipation only. There may be several reasons for this. One Although the introduction of the case conferencing item might be that 'taking charge' of the case conference fits numbers was not associated with the hypothesised reduc- with their consultant role. Another might be that they are tion in the level and cost of services by private psychia- relatively professionally isolated, and may therefore have trists, this is not necessarily a negative finding. If the greater imperatives for calling together others involved in increases in the quality of care outweigh the increases in a consumer's care than, for example, members of a public costs, they may still be cost-effective. Findings from the sector mental health team. A third reason may relate to interviews with psychiatrists who had used the item num- availability of billing options – two thirds of the item bers and consumers for whom case conferences had been numbers allow for organisation and co-ordination, com- rendered suggest that this may be the case. pared with only one third that allow for participation. A Page 10 of 12 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:33 http://www.anzhealthpolicy.com/content/2/1/33 Improved quality of care Authors' contributions The above notion of 'improved quality of care' warrants JP and PB conceptualised the evaluation and took the lead further exploration. It is fair to say that the case conferenc- on designing the study; AH assisted with refining the ing item numbers improved continuity of care (' [the] study design. JP liaised with the HIC in extracting the data ability to provide uninterrupted, coordinated care or serv- for Stages 1 and 2. JP and AH developed the interview ice across programs, practitioners, organisations and lev- schedules for Stage 3, with assistance from PB, JW and CF. els over time' [12]). This message consistently emerged JP and AH undertook the data management and analysis from the interviews with psychiatrists and consumers. It is activities associated with all three stages. JP and AH took less clear whether the item numbers demonstrated effec- primary responsibility for drafting the original version of tiveness (' [the] care, intervention or action achieves [the] the paper, and all other authors contributed substantially desired outcome in an appropriate timeframe' [12]). to revised drafts. All authors read and approved the final Interview respondents expressed mixed views in this manuscript. regard. Some psychiatrists indicated that case conferences had improved outcomes for consumers, although most Acknowledgements This work was funded by the National Health and Medical Research Coun- were unable to be specific about the nature of these out- cil. The authors would like to thank staff of the Health Insurance Commis- comes. Some consumers suggested that the case confer- sion for extracting relevant data and assisting with the recruitment of ences had resulted in improvements in their day-to-day psychiatrists. They would also like to thank Rob Carter, for providing eco- functioning, but others felt that no change had occurred. nomic advice on Stage 2. Finally, they would like to thank the psychiatrists who participated in interviews and assisted with the recruitment of con- Conclusion sumers, and the consumers who participated in interviews. The introduction of the MBS case conferencing item num- bers has not been met with overwhelming enthusiasm by References psychiatrists. Psychiatrists who have used the item num- 1. Australian Government Department of Health and Ageing: Medicare Benefits Schedule Book. Canberra, Australian Government bers are generally positive about them, as are consumers. Department of Health and Ageing Care; 2004. Psychiatrists who have not used them have generally not 2. King N: Template analysis. In Qualitative Methods and Analysis in Organizational Research Edited by: Symon G and Cassell C. London, done so because of a lack of knowledge, rather than direct Sage Publications; 1998. opposition. The use of the item numbers is increasing 3. Pirkis J, Livingston J, Morley B, Trauer T: The Public and Private over time, perhaps as psychiatrists become more aware of Partnerships in Mental Health Project: Final Evaluation Report. Melbourne, Centre for Health Program Evaluation, The their existence and of their utility in maximising quality of University of Melbourne; 2003. care. 4. Pirkis J, Livingston J, Herrman H, Schweitzer I, Gill L, Morley B, Yung A, Grigg M, Trauer T, Burgess P: Improving collaboration between private psychiatrists, the public mental health sec- If the case conferencing item numbers are to achieve their tor and general practitioners: Evaluation of the Partnership potential, some consideration might need to be given to Project. Australian and New Zealand Journal of Psychiatry 2004, 38:125-134. issues of process and structure. The degree of awareness of 5. Wilkinson D, McElroy H, Beilby J, Mott K, Price K, Morey S, Best J: the item numbers is sub-optimal. There is confusion over Uptake of health assessments, care plans and case confer- some of the conditions associated with the item numbers ences by general practitioners through the Enhanced Pri- mary Care programs between November 1999 and October (e.g., the definition of the term 'organise and co-ordinate', 2001. Australian Health Review 2002, 25:1-11. the nature of the other providers required to attend the 6. Wilkinson D, McElroy H, Beilby J, Mott K, Price K, Morey S, Best J: Variation in levels of uptake of enhanced primary care item case conference, the required duration of attendance by numbers between rural and urban settings, November 1999 other providers), and there are some stipulations which to October 2001. Australian Health Review 2002, 25:123-130. made it difficult for psychiatrists to make use of the item 7. Wilkinson D, Mott K, Morey S, Beilby J, Price K, Best J, McElroy H, Pluck S, Eley V: Evaluation of the Enhanced Primary Care numbers in particular circumstances (e.g. psychiatrists in (EPC) Medicare Benefits Schedule (MBS) Items and the rural and remote areas find it difficult to satisfy the General Practice Education, Support and Community Link- requirement of at least two other providers being present, ages Program: Final Report. Canberra, Commonwealth Depart- ment of Health and Ageing; 2003. child and adolescent psychiatrists are concerned about the 8. Blakeman TM, Harris MF, Comino EJ, Zwar NA: Evaluating general exclusion of teachers from the list of 'eligible' attendees). practitioners' views about the implementation of the enhanced primary care Medicare items. Medical Journal of Aus- Finally, there are issues concerning the level of remunera- tralia 2001, 175:95-98. tion that the item numbers attract, given the amount of 9. Blakeman TM, Zwar NA, Harris MF: Evaluating general practi- time required to organise and participate in them. The tioners' views on the enhanced primary care items for care planning and case conferencing: A one year follow up. Austral- Australian Government may wish to take these findings ian Family Physician 2002, 31:582-585. 'on board' in future iterations of the MBS. 10. Mitchell GK, De Jong IC, Del Mar CB, Clavarino AM, Kennedy R: General practitioner attitudes to case conferences: How can we increase participation and effectiveness? Medical Journal of Declaration of competing interests Australia 2002, 177:95-97. The authors declare that they have no competing interests. 11. Davies JW, Ward WK, Groom GL, Wild AJ, Wild S: The case-con- ferencing project: A first step towards shared care between Page 11 of 12 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:33 http://www.anzhealthpolicy.com/content/2/1/33 general practitioners and a mental health service. Australian and New Zealand Journal of Psychiatry 1997, 31:751-755. 12. National Mental Health Working Group Information Strategy Com- mittee Performance Indicator Drafting Group: Key Performance Indicators for Australian Public Mental Health Services: Information Strategy Committee Discussion Paper No. 6. Canberra, Australian Government Department of Health and Ageing; Publish with Bio Med Central and every scientist can read your work free of charge "BioMed Central will be the most significant development for disseminating the results of biomedical researc h in our lifetime." Sir Paul Nurse, Cancer Research UK Your research papers will be: available free of charge to the entire biomedical community peer reviewed and published immediately upon acceptance cited in PubMed and archived on PubMed Central yours — you keep the copyright BioMedcentral Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 12 of 12 (page number not for citation purposes)

Journal

Australia and New Zealand Health PolicySpringer Journals

Published: Dec 18, 2005

References