Nurse Practitioner Business Models and Arrangements

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					  Nurse Practitioner
  Business Models
  and Arrangements
  Final Report

  WA Health, Nursing and
  Midwifery Office

  March 2011




Delivering a Healthy WA
    Contents

    List of acronyms                                                     3

    1. Executive summary                                                 4
    1.1. Project scope                                                   4
    1.2. Approach                                                        4
    1.3. Background                                                      4
    1.4. Consultation themes and clinical models                         5
    1.5. Employment and business models                                  5
    1.6. Recommendations                                                 7


    2. Background                                                        9
    2.1. What is a nurse practitioner?                                   9
    2.2. State and national legislation and agreements                   11
    2.3. Medicare Australia requirements for access to the MBS and PBS   12
    2.4. Rural areas 19(2) exemption                                     17
    2.5. Impacts of the regulations                                      18


    3. Consultation themes and results                                   19
    3.1. Clinical models 20


    4. Business and employment models                                    27
    4.1. Financial modelling                                             27
    4.2. Full Public model                                               28
    4.3. Public Private Mix model                                        30
    4.4. Full private model                                              35


    5. Discussion                                                        37
    5.1. Models for further investment                                   37
    5.2. Industrial relations implications                               40
    5.3. Policy implications                                             40
    5.4. Development of a nurse practitioner workforce strategy          45
    5.5. Acceptability criteria                                          46
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    6. Recommendations                                                                48
          A Definition of ‘medical practitioner’                                      50
          B 19(2) Exemption terminology                                               51
          C Workshop participants – 7 December 2010                                   52
          D Summary of financial information                                          53
    D.2 Financial models                                                              55
    D.3 Hospital outpatient wound care service                                        56
    D.4 Residential care line                                                         61
    D.5 Rural public service                                                          66
    D.6 Paediatrics emergency diversion clinic                                        67


    Tables and figures
    Table 1: MBS items that can be claimed by a nurse practitioner                    12
    Table 2: Pathology and diagnostic MBS items that can be claimed by a nurse
    practitioner                                                                      15
    Table 3: Clinical model and business and employment model applied                 28
    Table 4: Characteristics of the Full Public model                                 29
    Table 5: Characteristics of the Public Private Mix model                          31
    Table 6: Characteristics of the Full Private model                                35
    Table 7: Federal policy implications                                              41
    Figure 1: MBS rebates (benefits paid) for nurse practitioner services by length
    of consultation                                                                   44
    Table 8: Nurse practitioner business and employment models:acceptability table 47
    Table 9: Average consultation length and respective MBS benefit paid              53
    Table 10: Distribution of activity under nurse practitioner MBS items by
    clinical model                                                                    53
    Table 11: Labour and cost inputs                                                  54




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    List of acronyms
    ED       Emergency Department
    FP       Full Private
    GP       General Practitioner
    MBS      Medicare Benefits Scheme
    NMBA     Nursing and Midwifery Board of Australia
    PBS      Pharmaceutical Benefits Scheme
    PMH      Princess Margaret Hospital
    PRNI     Privately Referred Non Inpatient
    PPM      Public Private Mix
    RCL      Residential Care Line
    WA       Western Australia
    WACHS    WA Country Health Service




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Delivering a Healthy WA
    1. Executive summary
    On the 16 March 2010, the Australian Senate passed legislation to provide eligible nurse
    practitioners and midwives with access to the Medical Benefits Scheme (MBS) and the
    Pharmaceutical Benefits Scheme (PBS). The changes to the Health Insurance Act 1973
    provides access for eligible nurse practitioners to Medicare, which includes the ability to
    provide Medicare rebateable services, request pathology and diagnostic imaging services
    and refer patients to specialist and consultant physicians within their scope of practice.


    1.1. Project scope
    KPMG was engaged by the Government of Western Australia’s Department of Health
    (WA Health) to identify and review the optimum business and employment models for
    promoting nurse practitioner services to ensure the Western Australian community gains
    maximum benefit from changes to the legislation. KPMG has analysed selected clinical,
    business and employment models to assist WA Health in identifying future investment
    opportunities, considerations and priorities.
    Financial modelling has been undertaken for a range of clinical scenarios against a
    range of business and employment models, in order to assist in determining the overall
    acceptability and viability of these models.


    1.2. Approach
    The clinical models examined for the purpose of this analysis are a:
    •   hospital outpatient wound care service;
    •   Residential Care Line service;
    •   public rural service; and
    •   paediatrics emergency department diversion clinic.
    The business and employment models examined were a:
    •   full public employment model;
    •   mixed public–private employment model and;
    •   full privately employed model.


    1.3. Background
    Section 2 of this report provides a high-level overview of the State and Commonwealth
    legislation and agreements that impact upon the role and function of nurse practitioners
    in Western Australia. A number of key implications for both nurse practitioners and WA
    Health have been identified including:
    •   the changes to the legislation provide access for eligible nurse practitioners
        to Medicare arrangements which include providing Medicare rebateable services,
        requesting pathology and diagnostic imaging services and referral of patients to
        specialist and consultant physicians;
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Delivering a Healthy WA
    •   section 19(2) of the Health Insurance Act 1973 states that, unless the Health Minister
        otherwise directs, a Medicare benefit is not payable in respect of a professional
        service that has been rendered by, or on behalf of, or under an arrangement with the
        Commonwealth, a State, a local governing body; or an authority established by a law of
        the Commonwealth, a State or internal Territory. Therefore, unless the Federal Minister
        for Health and Ageing otherwise directs, Medicare benefits are not payable where
        funding has already been provided under an arrangement with the Commonwealth,
        state or a local governing body; and
    •   access to nurse practitioner item numbers under the Medicare Benefits Schedule is
        restricted to private practitioners, as indicated by the issuing of a Medicare provider
        number by Medicare Australia. Full time employees of WA Health are not considered
        to be private providers.
    1.4. Consultation themes and clinical models
    Section 3 of this report provides an overview of key features of each of the clinical models
    investigated. Stakeholder interviews were conducted to inform these key features. The
    purpose of the consultations was to better understand current and potential clinical activity
    and gather key information associated with the relevant business and clinical models
    investigated.
    The consultations confirmed that the clinical activity of nurse practitioners will vary
    according to the type of service, complexity of the presentation, and whether this is a
    first presentation for the patient (i.e. longer consultation) or a follow up visit (i.e. shorter
    consultation). The specialist services – i.e. wound care and aged care services – are
    consistent and predictable in the number and length of consultations, whereas the primary
    care models – remote area and paediatrics emergency department diversion clinic – can
    be expected to be highly variable. Similarly, seasonal variations are more likely to be
    experienced in primary care services.
    Stakeholders also identified a range of other issues during consultations. These included
    potential industrial relations implications of new models, increased resourcing and staff
    requirements, stakeholder acceptability and clinical governance.
    1.5. Employment and business models
    Section 4 and 5 of this report describes potential employment and business models to
    support the clinical models and identifies a range of policy implications. The business
    / employment models are informed by advice and feedback provided by stakeholder
    consultation and by interpretation of relevant legislation and agreements with the
    Australian Government.
    The clinical models (as discussed previously) are applied to potential business /
    employment models that may support their development and application. The employment
    models identified are:
    •   a full public employment model;
    •   a mixed public–private employment model and;
    •   a full private practice model


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    Financial analysis is provided for each of the four nurse practitioner clinical models
    identified and the potential business / employment model. The analysis is provided for a
    range of business models where the nurse practitioner either retains the MBS or assigns
    it to the organisation. In addition, a range of employment arrangements are modelled to
    demonstrate the viability of the individual models.
    Models in which the nurse practitioner takes on all activity risk (such as the Full Private
    and Public-Private models where the nurse retains revenue) offer the greatest financial
    return for WA Health. However, these models also present the greatest risk for individual
    nurse practitioners and have a lower likelihood of acceptance because of this risk.
    While providing moderate financial return to a rural hospital with 19(2) exemption status,
    the nurse practitioner’s ability to remain a full time employee of the state and hence
    minimise the overall impact on their allowances and conditions, would be the model with
    the highest acceptability. It is noted from the financial modelling that MBS revenue could
    offset as much as 37 per cent of a nurse practitioner’s salary ($46,895) under this scenario.
    A shift to full private practice, whilst less complicated from a Commonwealth perspective,
    is unlikely to be fully embraced by nurse practitioners at this time as the structure of the
    rebates would only be viable in high volume environments with rapid patient turnover.
    A nurse practitioner that continues to practice in the way he / she is trained would most
    likely experience a loss in income. Although gap fees may be charged to improve the
    profitability of services, these would need to be significant to offset the loss in income
    and may exceed community acceptance. Opportunity may exist within areas of high
    volume such as the paediatrics emergency department diversion clinic to work with
    private stakeholders (such as divisions of general practice / Medicare Locals and private
    hospitals) to establish such a service.
    The Public-Private Mix model where the nurse practitioner assigns their revenue to the
    organisation offers potential for mutual benefit to both WA Health and the nurse practitioner.
    The model provides both the capacity to introduce a private model whilst maintaining an
    income guarantee for the nurse practitioner. This model, whilst conservative in revenue
    earned by the organisation, has high likelihood of nurse practitioner acceptability –
    especially at an 80 per cent public / 20 per cent private mix. This business and employment
    option is the most suitable for the hospital outpatient wound care service, Residential
    Care Line service and paediatrics emergency department diversion clinic.
    The success of the Public-Private Mix model depends on the nurse practitioner obtaining
    a Medicare provider number, which is reliant on demonstrating to Medicare that they are
    a private practitioner. It is also reliant on being acceptable to the Commonwealth with
    respect to sections 19(2) and 128c of the Health Insurance Act 1973. Given the inherent
    ambiguity within the legislation, it is recommended that legal advice be obtained as to
    whether the model is permissible under the regulations. If indicated by legal counsel,
    Commonwealth agreement may also be required.
    This report further identifies a range of issues that have emerged through analysis and
    consultation including that:
    •   nurse practitioners operating in private practice will require medical indemnity insurance.
        The financial cost to the individual nurse practitioner may represent a significant barrier
        for the successful implementation of this program across WA Health;
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    •   the introduction of Medicare billing for nurse practitioner services has potential industrial
        implications. If the Public / Private Mix model is pursued, it is likely that nurse practitioners
        may need to seek changes to their current Enterprise Bargaining Agreement (EBA) with
        WA Health. It should be noted that any alteration to the award structure covering nurse
        practitioners would not necessarily be supported by equivalent productivity increases
        or work value, and may have flow on effects to other nursing classifications;
    •   it appears that design of the nurse practitioner MBS item numbers does not adequately
        reflect the nursing model of care. The MBS item numbers that nurse practitioners have
        access to are maximised when consultation lengths are limited. The nursing model is
        more holistic – covering the physical, psychosocial and spiritual aspects of patient care
        and is built around more extended patient interaction;
    •   the current MBS item numbers that nurse practitioners have access to have a number
        of limitations; key among these are that:
        • nurse practitioners can not claim for practice nurse services performed on
           their behalf and under their delegation, using MBS item numbers 10993
           to 10999. Amendment of these item numbers should be sought to allow
           practice nurses to provide service on behalf of a nurse practitioner;
        • nurse practitioner item numbers are generalist in nature and do not
           reflect the specialist nurse practitioner workforce within WA, which is
           highly procedural. GPs have procedural MBS items covering specialist
           interventions and procedures. Appropriate procedural MBS item
           numbers should be developed for nurse practitioners also; and
    •   the regulatory and legislative changes are designed to support private practice
        and the improved delivery of primary care services across Australia. Currently
        WA has a specialist nurse practitioner workforce focused on secondary and
        tertiary care. A workforce strategy that supports the attraction and retention of
        nurse practitioners in areas such as primary care and rural and remote health
        to maximise benefits from the relevant changes would assist WA Health to
        encourage greater take up of MBS rebateable services for nurse practitioners.
    1.6. Recommendations
    The changes of the Health Insurance Act 1973 offers opportunity for WA Health and
    the nursing profession which may be realised by combining the appropriate clinical
    and business / employment models. However, these opportunities do not come without
    political, technical and financial challenges and risks.
    Core to the success of implementing these models is ensuring that they are acceptable to
    all key stakeholders and meet all Commonwealth and Medicare eligibility requirements.
    The following recommendations are made to assist WA Health in determining the most
    appropriate future investment opportunities, considerations and priorities for the State.
    1. Seek formal legal opinion from Health Legal Services and State Solicitors to determine
       whether any of the proposed business / employment models contravene sections 19(2)
       and 128c of the Health Insurance Act 1973 and relevant health care agreements.


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    2. Seek formal opinion from the WA Health Industrial Relations Service regarding potential
       impacts, risks, benefits and strategies relating to the WA Nursing Enterprise Bargain
       Agreement.
    3. Establish a Nurse Practitioner Working Group to undertake further development work
       to consider a range of outstanding issues. The purpose of the Working Group would
       be to advise WA Health on the development and implementation of nurse practitioner
       services in WA, including:
       • strategies for working with key stakeholders such as the Australian and Western
          Australian Governments, peak nursing groups and other stakeholders to achieve
          further policy and legislation reform to support nurse practitioner services;
       • solutions surrounding medical indemnity insurance for nurse practitioners,
          with a particular focus on affordability, as well as clarity regarding
          the implications of managing staff such as practice nurses;
       • develop a workforce strategy that includes a targeted recruitment plan to support
          the implementation of respective business / employment models, especially in
          the context of developing a primary care generalist nurse practitioner workforce.
    4. If indicated by legal counsel, consider seeking the agreement of the Federal Health
       Minister for the payment of Medicare benefits in respect of professional services
       rendered by nurse practitioners engaged under the Public Private Mix business /
       employment model.
    5. Consider working with the Australian Government and relevant stakeholders including
       peak nursing and general practice groups to seek amendment of the MBS item
       numbers 10993 to 10999 to allow practice nurses to provide service on behalf of a
       nurse practitioner. Consideration should also be given to the possibility of procedural
       items which are reflective of nurse practitioner specialist practice.
    6. In partnership with the WA Country Health Service, identify appropriate 19(2) exemption
       sites for establishing nurse practitioner services using clear selection criteria (such as
       ability to recruit a nurse practitioner and availability of local infrastructure to support
       MBS billing).
    7. Once eligibility and provider number issues have been addressed, commence a trial
       of approved clinical models in public / private mix models utilising agreed business /
       employment models to determine their financial viability, effectiveness and community
       benefit. Trials should include a formal evaluation over a period of six to 12 months that
       includes extensive stakeholder consultation, data analysis and a cost benefit analysis.
    8. Develop and deliver a range of education and business tools to support nurse
       practitioners in the establishment and management of their own business.




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Delivering a Healthy WA
    2. Background
    This section provides an overview of what a nurse practitioner is, what determines their
    scope of practice and what collaborative arrangements need to be in place to support their
    introduction into the health workforce. This information has been informed by a range of
    legislation and regulation, both National and State, such as the:
    •   Health Practitioner Regulation National Law (WA) Act 2010;
    •   WA Poisons Act 1964; and
    •   WA Poisons Regulations 1965.
    2.1. What is a nurse practitioner?
    A nurse practitioner is commonly defined as a nurse with extensive clinical skills and
    knowledge that allows them to undertake advanced practice in their area of expertise.
    The Australian Nursing and Midwifery Council define a nurse practitioner as a:
         Registered nurse educated and authorised to function autonomously and
         collaboratively in an advanced and extended clinical role. The nurse practitioner role
         includes assessment and management of clients using nursing knowledge and skills
         and may include, but is not limited to the direct referral of patients to other health care
         professionals, prescribing medications and ordering diagnostic investigations. The
         scope of practice of the nurse practitioner is determined by the context in which the
         nurse practitioner is authorised to practice.
    The role of the nurse practitioner is designed to enhance the services of other health
    and medical service providers. Nurse practitioners work collaboratively with other health
    professionals to provide advanced and extended care to the community, individuals, and
    families. Their scope of work extends beyond that of the registered nurse and includes:
    •   advanced clinical assessment;
    •   initiating, interpreting and responding to diagnostic tests;
    •   initiating and monitoring therapeutic regimes;
    •   prescribing medicines; and
    •   initiating and receiving referrals.1

    2.1.1. Nurse practitioners in Australia
    The nurse practitioner role has its roots in providing primary health care the United
    States in the early 1960s. Nurse practitioners were introduced to alleviate a shortage of
    primary care medical practitioners. Although the role emerged in Australia in the 1980s,
    the first recognised nurse practitioner was only authorised to practice in 2000, in New
    South Wales. Now nurse practitioners provide care in all eight states and territories, with
    all jurisdictions enacting legislation to protect the title of nurse practitioners and their
    associated extended practice privileges.




    1. Australian Nursing Federation. A snapshot of nurse practitioners in Australia. Accessed 2 August 2010 at www.anf.org.au/pdf/Fact_Sheet_
    Snap_Shot_Nurse_Practitioners.pdf.                                                                                                           9

Delivering a Healthy WA
    Nurse practitioners work across a broad spectrum of specialties and settings. Research
    on the effectiveness of nurse practitioners has shown safe practice, cost effective care,
    and outcomes at a level at least similar to that of medical practitioners within similar
    clinical settings. 2
    Significantly, until November 2010 nurse practitioners working in clinical settings had no
    access to Medicare provider numbers or authority to prescribe through the Pharmaceutical
    Benefits Scheme. A recent survey of Australian nurse practitioners identified access to
    these two enabling features as the most significant aspects limiting their practice.3
    On the 16 March 2010, the Australian Senate passed legislation to provide eligible nurse
    practitioners and midwives with access to the Medical Benefits Scheme (MBS) and the
    Pharmaceutical Benefits Scheme (PBS). The legislative changes provide access for
    eligible nurse practitioners to Medicare arrangements which include providing Medicare
    rebateable services, requesting pathology and diagnostic imaging services, and referral
    of patients to specialist and consultant physicians. The legislation also allows nurse
    practitioners to prescribe certain medicines under the PBS, within their designated scope
    of practice and in accordance with relevant State / Territory legislation.
    2.1.2. National registration requirements
    The Health Practitioner Regulation National Law (WA) Act 2010 states that the Nursing
    and Midwifery Board of Australia (NMBA) may endorse the registration of a registered
    health practitioner whose name is included in the Register of Nurses as being qualified to
    practise as a nurse practitioner. 4
    To be eligible for endorsement as a nurse practitioner, the nurse must be able to
    demonstrate all of the following:
    •   general registration as a registered nurse with no restrictions on practice;
    •   advanced nursing practice in a clinical leadership role in the area of practice
        in which he or she intends to practice as a nurse practitioner, within the past
        five years, complemented by research, education and management;
    •   competence in the competency standards for nurse
        practitioners approved by the NMBA; and
    •   completion of the requisite qualification determined by the NMBA.5
    2.1.3. Western Australian requirements
    To practice in WA, a nurse practitioner must:
    •   be registered with the NMBA;
    •   be employed in a designated nurse practitioner area; and
    •   have agreed clinical protocols.



    2. Mundinger MO. Nurse practitioners: a safe and competent choice for primary care. Int Nursing Rev 2000; 17: 66-67.Accesed Proquest 23
    August 2010.
    3. Middleton,A ;Gardner,A & Della ,P (2010) The Status of Australian Nurse practitioners: the second national census’ Unpublished.
    4. Parliament of Western Australian. Health Practitioner Regulation National Law (WA) Act 2010. 30 August 2010.
    5. Nursing and Midwifery Board of Australia, 2010, Registration Standard for Endorsement of Nurse Practitioners.                          10

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    Designated nurse practitioner areas
    There are approximately 180 designated nurse practitioner areas covering the Perth
    metropolitan, WA Country Health Service remote area nursing posts, remote practice
    sites, emergency care services, Department of Corrective Services, private sector
    services, Australian Defence Force and Aboriginal community controlled health services.
    Designated nurse practitioner areas may be set for a specific service (e.g. Sir Charles
    Gairdner Hospital), organisation (e.g. Silver Chain Health Services) or location (e.g.
    Bremer Bay). Successful designation is not limited or determined by geography, sector or
    setting that the nurse practitioner operates within.
    Clinical protocols
    Clinical protocols are developed in collaboration and partnership with the health service
    / organisation as part of the process of having an area designated to employ a nurse
    practitioner.
    Amendments to the Poisons Regulations 1965 require that before the Western Australian
    Director General of Health can designate an area, clinical protocols for the specific area
    must be approved by:
    •   the officer of the department who is principally responsible for providing
        advice on matters related to nursing (currently the Chief Nursing Officer);
    •   the person holding or acting in the office of Executive Director, Personal Health
        Services in the department (currently the Chief Medical Officer); and
    •   the person holding or acting in the office of Executive Director, Population
        Health, or if there is no such office at the relevant time, the office of
        Executive Director, Public Health and Scientific Support Services in the
        department (currently the Executive Director of Population Health).
    2.2. State and national legislation and agreements
    Prior to undertaking any financial analysis it is important to understand the legislative and
    regulatory context in which nurse practitioners will operate into the future. This chapter
    sets out the legislated rules around permissible care (including referral, prescribing and
    diagnostic ordering), collaborative care, settings and scope of practice that will apply
    to nurse practitioners in Australia and Western Australia. The chapter also describes
    permissible access for nurse practitioners to the Medicare Benefits Schedule (MBS) and
    Pharmaceutical Benefits Scheme (PBS).
    This section of the report outlines:
    •   nurse practitioner access to the MBS and PBS; and
    •   the Remote Area 19(2) Exemption.
    •   The legislative framework scan has been informed by the following legislation:
    •   Health Insurance Act 1973; and
    •   National Health (Collaborative arrangements for nurse practitioners)
        Determination 2010, under the National Health Act 1953.


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    2.3. Medicare Australia requirements for access to the MBS and PBS
    The Medicare Program (‘Medicare’) provides access to medical and hospital services for
    all Australian residents and certain categories of visitors to Australia. Medicare Australia
    administers Medicare and the payment of Medicare benefits. The major elements of
    Medicare are prescribed in the Health Insurance Act 1973.
    The Health Legislation Amendment (Midwives and nurse practitioners) Act 20106 (the
    Act) was assented on 12 April 2010. It amended the Health Insurance Act 1973 and the
    National Health Act 1953 to enable eligible nurse practitioners to request appropriate
    diagnostic imaging and pathology services for which benefits may be paid under the
    Medicare Benefits Schedule (MBS). It also allows these health professionals to prescribe
    certain medicines under the Pharmaceutical Benefits Scheme (PBS).
    To be eligible to access MBS services or refer and request, the nurse practitioner must:
    •   be registered or authorised (however described) under State and Territory law; and
     Item              Description                                          Schedule                                       Benefit
     number                                                                 fee (100                                       paid
                                                                            %)                                             (85%)
     82200             Professional attendance by a participating nurse $9.20                                              $7.85
                       practitioner for an obvious problem characterised by
                       the straightforward nature of the task that requires
                       a short patient history and, if required, limited
                       examination and management.
     82205             Professional attendance by a participating nurse $20.15                                             $17.15
                       practitioner lasting less than 20 minutes and
                       including any of the following:
                       a) taking a history;
                       b) undertaking clinical examination;
                       c) arranging any necessary investigation;
                       d) implementing a management plan;
                       e) providing appropriate preventive health care;
                       for 1 or more health related issues, with appropriate
                       documentation.
     82210             Professional attendance by a participating nurse $38.25                                             $32.55
                       practitioner lasting at least 20 minutes and including
                       any of the following:
                       a) taking a detailed history;
                       b) undertaking clinical examination;
                       c) arranging any necessary investigation;
                       d) implementing a management plan;


    6. Commonwealth of Australia. Explanatory Memoranda: Health Legislation Amendment (Midwives and nurse practitioners) Bill 2009. Accessed
    11 November 2010 at www.austlii.edu.au/au/legis/cth/bill_em/hlaanurse practitionerb2009609/memo_0.html.                                    12

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                      e) providing appropriate preventive health care, for
                      1 or more health related issues, with appropriate
                      documentation.
     82215            Professional attendance by a participating nurse $56.30                                          $47.90
                      practitioner lasting at least 40 minutes and including
                      any of the following:
                      a)        taking an extensive history;
                      b)        undertaking clinical examination;
                      c)        arranging any necessary investigation;
                      d)        implementing a management plan;
                      e)        providing appropriate preventive health care,
                      for 1 or more health related issues, with appropriate
                      documentation.
    •    demonstrate that he or she has the appropriate qualifications and experience to meet the
         registration standard developed by the NMBA, which was developed for the purposes
         of the National Registration and Accreditation Scheme (NRAS), a single regulation and
         accreditation scheme for health professionals, including nurse practitioners;7 and
    •    be in private practice.8
    A participating nurse practitioner is an eligible nurse practitioner who has a Medicare
    provider number and who provides Medicare services in collaborative arrangements with
    one or more medical practitioners.
    To access the Medicare arrangements, eligible nurse practitioners need to apply to
    Medicare Australia for a provider number. A Medicare provider number will only be issued
    for nurse practitioners in private practice.9 A separate provider number is required for
    each location at which a nurse practitioner practices.
    2.3.1. MBS item numbers for professional attendances
    From 1 November 2010, eligible nurse practitioners are able to access specific items in
    the Medicare Benefits Schedule (MBS).
    New MBS items for services provided by participating nurse practitioners working
    collaboratively with doctors have been created. Participating nurse practitioners are limited
    to providing services within their authorised scope of practice and level of experience and
    competency. They are also able to refer their patients, under the MBS, to specialists /
    consultant physicians.
    To provide MBS services and prescribe certain PBS subsidised medicines, nurse
    practitioners will need to apply for a Medicare provider number and PBS prescriber
    number.


    7. Department of Health and Ageing. Medicare Benefits Schedule – Note M14.2. Accessed 11 November 2010 at www9.health.gov.au/mbs/
    fullDisplay.cfm?type=note&q=M14.2&qt=NoteID.
    8. Medicare Australia website. Nurse practitioners and midwives. Accessed 25 November 2010 at www.medicareaustralia.gov.au/provider/
    other-healthcare/nurse-midwives.jsp.
    9. Ibid.                                                                                                                               13

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    Medicare benefits are only payable for clinically relevant services. Clinically relevant in
    relation to nurse practitioner care means a service generally accepted by the nursing
    profession as necessary to the appropriate treatment of the patient’s clinical condition.
    Medicare benefits are only payable where the participating nurse practitioner provides
    care to not more than one patient on one occasion.
    Table 1 outlines the MBS items that a participating nurse practitioner can claim.
    Table 1: MBS items that can be claimed by a nurse practitioner 10
    Setting
    Professional attendance for MBS items 82200, 82205, 82210, 82215, may be provided in
    an appropriate setting that includes but is not limited to:
    •   the patient’s home;
    •   a nurse practitioner group practice;
    •   a nurse practitioner’s rooms; or
    •   a medical practice.
    Benefits paid vs schedule fee
    The payments of ‘benefits’ (or rebates) and ‘schedule fees’ for professional services are
    listed in the Medicare Benefits Schedule (MBS).
    The fee is referred to in these notes as the “schedule fee”. The schedule fee for any
    item listed in the MBS is that determined by Medicare Australia as being reasonable on
    average for that service having regard to usual and reasonable variations in the time
    involved in performing the service on different occasions and to reasonable ranges of
    complexity and technical difficulty encountered.
    ‘Benefits paid’ describes the rebate paid to eligible community members for services
    rendered to non-admitted patients.11 The benefit paid for most services is 85 per cent of
    the schedule fee.
    As a general rule scheduled fees are adjusted on an annual basis, usually in November.12
    Bulk billing and participating nurse practitioners
    Bulk billing is a matter for each participating nurse practitioner and involves acceptance
    by participating nurse practitioners of the relevant Medicare benefit assigned to them
    as payment in full for the service. If a participating nurse practitioner direct-bills, the
    participating nurse practitioner undertakes to accept the relevant Medicare benefit as full
    payment for the service. Additional charges for that service (irrespective of the purpose
    or title of the charge) cannot be raised against the patient.13
    2.3.2. MBS item numbers for pathology and diagnostics requests
    10. Medicare Financing and Analysis Branch. MBS items for nurse practitioners fact sheet. Medicare Australia website; undated. Accessed 25
    January 2011 at www.health.gov.au/internet/main/publishing.nsf/Content/midwives-nurse-practitioners/$File/MBSItemsNP.pdf.
    11. Australian Government Department of Health and Ageing website. Participating Nurse Practitioners Questions and Answers. Accessed 25
    January 2011 at www.health.gov.au/internet/main/publishing.nsf/Content/midwives-nurse-pract-qanda-nursepract#schedule
    12. See Australian Government Department of Health and Ageing. Medicare Benefits Schedule Book: Operating from 01 November 2010.
    Commonwealth of Australia; Canberra: 2010. Accessed 25 January 2011 at www.health.gov.au/internet/mbsonline/publishing.nsf/Content/C9
    E03510F96A7DD1CA2574E40017C116/$File/201011-Cat%202.pdf.
    13. Ibid.
    14. Ibid                                                                                                                                     14

Delivering a Healthy WA
    Table 2 outlines the pathology and diagnostic items that can be claimed by a nurse
    practitioner.
    Table 2: Pathology and diagnostic MBS items that can be claimed by a nurse practitioner14
    Item Number          Description
    Pathology      items A nurse practitioner may only request pathology services if this is
    65060      -  73810 within their scope of practice
    (inclusive)
    Diagnostic Imaging Services
    55036,       55070, Subgroup 1: General Ultrasound for the abdomen and breast
    55076
    55600                Subgroup 4: Urological Ultrasound for prostate
    55768                Subgroup 5: Obstetric and Gynaecological Ultrasound
    55800,       55804, Subgroup 6: Musculoskeletal Ultrasound
    55808,       55812,
    55816,       55820,
    55824,       55828,
    55832,       55836,
    55840,       55844,
    55848,       55850,
    55852
    57509,       57515, Subgroup 1: Radiographic X-ray examination of the extremities
    57521
    58503      -  58527 Subgroup 6: Radiographic X-ray examination of the thoracic
    (inclusive)          region


    Conditions for requests for pathology or diagnostic services
    The nurse practitioner requesting a pathology or diagnostic service for a patient must
    determine that the pathology service is necessary. In the case of pathology services,
    these may only be requested if they are in the nurse practitioner’s scope of practice.
    The pathology service may only be provided in response to a request from the treating
    nurse practitioner and the request must be in writing (or, if oral, confirmed in writing within
    fourteen days).
    The diagnostic service may only be provided in response to a request from the treating
    nurse practitioner, and the request must be in writing, signed and dated. The legislation
    provides that a request must be in writing and contain sufficient information, in terms
    that are generally understood by the profession, to clearly identify the item(s) of service
    requested. This includes, where relevant, noting on the request the clinical indication(s)
    for the requested service.
    It is not necessary that a written request for a diagnostic imaging service be addressed to
    a particular provider or that, if the request is addressed to a particular provider, the service
    must be rendered by that provider.
    A single request may be used to order a number of diagnostic imaging services. However,
                                                                                                       15

Delivering a Healthy WA
    all services provided under this request must be rendered within seven days after rendering
    the first service.
    2.3.3. Referral
    A participating nurse practitioner is able to refer private patients to a specialist and
    consultant physician as appropriate. However, this does not include referral for allied
    health care.
    A referral given by a participating nurse practitioner is valid until 12 months after the
    first service given in accordance with the referral. A referral to a specialist must be in
    writing in the form of a letter or a note to the specialist and must be signed and dated
    by the referring nurse practitioner. The referral must contain any information relevant to
    the patient and the specialist must have received the referral on or prior to providing a
    specialist consultation.
    There are exemptions from this requirement in an emergency if the specialist considers
    the patient’s condition requires immediate attention without a referral. In that situation, the
    specialist is taken to be the referring practitioner.
    2.3.4. Where Medicare benefits are not payable
    Medicare benefits are not available:
    •   where the service rendered does not meet the item description and associated
        requirements;
    •   is not personally performed by the participating nurse practitioner;
    •   for any time period in the consultation periods when the patient is not receiving active
        attention; e.g. the time the provider may take to travel to the patient’s home or where
        the patient is resting between blood pressure readings;
    •   services provided where the patient is not in attendance, such as the issuing of repeat
        prescriptions;
    •   for telephone attendances; and
    •   group sessions.
    Medicare benefits are also not payable for goods or appliances associated with the
    service, such as bandages or other skin dressings.
    Unless the Minister otherwise directs, Medicare benefits are not payable where funding
    has already been provided under an arrangement with the Commonwealth, state or a
    local governing body. Specifically:
    •   section 19(2) of the Health Insurance Act 1973 states that, unless the Health Minister
        otherwise directs, a Medicare benefit is not payable in respect of a professional
        service that has been rendered by, or on behalf of, or under an arrangement
        with the Commonwealth, a State, a local governing body; or an authority
        established by a law of the Commonwealth, a State or internal Territory; and
    •   section 128c of the Health Insurance Act 1973 prohibits specified persons
        (including nurse practitioners) from charging a fee for the provision of a public
        hospital service or from receiving any payment or other consideration from
        anyone in respect of the provision of a public hospital service to a public patient.
                                                                                                      16

Delivering a Healthy WA
        Other specified persons are medical practitioners, midwives and anyone acting
        on their behalf. A “public hospital service” means a hospital service provided in
        a public hospital or a hospital providing services to publicly funded patients.
    2.3.5. Pharmaceutical Benefits Scheme
    From 1 November 2010, authorised nurse practitioners will be able to access a limited list
    of items under the PBS, the total number being 3563.15 Authorisation for PBS prescribing
    purposes is in addition to authorisation for registration purposes.
    Prescribing under the PBS will be limited to certain PBS medicines and will only be permitted
    within the scope of practice of an authorised nurse practitioner, and in accordance with the
    State or Territory legislation under which they work. Medicines which can be prescribed
    by nurse practitioners are identified by ‘nurse practitioner’ in the PBS Schedule.
    PBS schedules
    The medicines that can be prescribed by nurse practitioners fall under the following
    schedules:
    •   Emergency Drug Supplies;
    •   General Schedule;
    •   S100 Opiate Dependence;
    •   Palliative Care; and
    •   Special Pharmaceutical Benefits.
    Additional conditions
    Further to prescribing within collaborative arrangements, certain medicines also have
    additional conditions for prescribing by nurse practitioners:
    •   continuing therapy only model, where the patient’s treatment and
        prescribing of a medicine has been initiated by a medical practitioner,
        but prescribing is continued by a nurse practitioner; and
    •   shared care model, where care is shared between a nurse practitioner
        and medical practitioner in a formalised arrangement with an agreed
        plan to manage the patient, in a patient-centred model of care.17
    2.4. Rural areas 19(2) exemption
    In September 2006, the Australian and Western Australian Governments signed a
    Memorandum of Understanding in relation to the Better Access to Primary Care Services
    in Rural Areas 19(2) exemptions initiative. Initially intended to end on 30 June 2010, the
    agreement has been extended until 30 June 2011.
    The Australian Government has declared its commitment to continue the Remote Area
    19(2) exemptions.17 The basis of the initiative is that to improve access to primary care


    15. Department of Health and Ageing website. PBS Schedule Search. Accessed 11 November 2010 at www.pbs.gov.au/pbs/
    search?base=prescribergroup:n.
    16. Department of Health and Ageing website. Nurse Practitioner PBS Prescribing. Accessed 11 November 2010 at www.pbs.gov.au/browse/
    nurse.
    17. See Department of Health and Ageing. Improving access to primary care in rural and remote areas – s19(2) exemptions initiative. Accessed
    15 November 2010 at www.yourhealth.gov.au/internet/yourhealth/publishing.nsf/Content/factsheet-gp-05.                                          17

Delivering a Healthy WA
    in rural and remote areas, the Australian Government will allow Medicare benefits to
    be claimed in respect of bulk-billed, non-admitted, non-referred professional services
    provided in emergency departments and outpatient clinics at some small rural hospitals.
    The patient is not charged a co-payment for services. Medicare benefits may be claimed
    by medical practitioners, nurses and allied health professionals under the 19(2) exemption;
    however, medical practitioners who intend to claim require a Medicare provider number
    specific to the location from which the service is provided.
    To be eligible for the Remote Area 19(2) exemption, a locality must:
    •   have a population of less than 7,000 people;
    •   not be in a major city; and
    •   be in an area of workforce shortage (as defined by the Commonwealth’s Area of
        Workforce Shortage Index).
    The current agreement between the Australian and Western Australian Governments
    requires the endorsement and written agreement of local primary care providers (including
    general practitioners, the Royal Flying Doctor Service and Aboriginal Health Services) of
    the 19(2) exemption.
    The funds generated must be used to enhance primary health care in the community in
    which the funds were generated.
    2.5. Impacts of the regulations
    The key implications for development of the nurse practitioner business cases arising
    from the Australian and Western Australian rules and regulations are that:
    •   WA must allocate designated nurse practitioner area status to sites that support the
        preferred models, and put in place clinical protocols for each nurse practitioner that
        specify their scope of practice, based on his or her experience and training;
    •   a collaborative arrangement for each nurse practitioner must be established with a
        medical practitioner and / or medical service;
    •   only services delivered personally, face-to-face to with the patient, by the nurse
        practitioner will be funded by Medicare Australia;
    •   Medicare Australia expects that access to the MBS will be by nurse practitioners
        operating as private practitioners; and
    •   where an arrangement exists between the State and the nurse practitioner, the Federal
        Health Minister’s agreement will be required for MBS payments for services delivered
        by the nurse practitioner.




                                                                                                  18

Delivering a Healthy WA
    3. Consultation themes and results
    This chapter sets out the themes and results arising from a number of consultations
    conducted with key stakeholders. The consultations informed the understanding of the
    four clinical models selected by the Department:
    •   hospital outpatient wound care service;
    •   Residential Care Line service;
    •   public rural service; and
    •   paediatrics emergency department diversion clinic.
    The consultations were conducted in order to:
    •   understand the current and potential clinical activity that could occur under each of the
        four clinical models investigated;
    •   test and validate assumptions relating to the business / employment models;
    •   seek expert opinion of key stakeholders on the scenario based clinical and business
        models; and
    •   identify how business and operational risks to nurse practitioners and the State can be
        mitigated.
    One-on-one interviews were conducted with the following stakeholders:
    •   Catherine Stoddart, Chief Nurse and Midwifery Officer; Michelle Dillon, Principal
        Nursing Advisor; and Annette Fraser, Senior Nursing Officer, Nursing and Midwifery
        Office, Western Australian Department of Health;
    •   Carol Douglas, Clinical Nurse Consultant,18 Residential Care Line, North Metropolitan
        Area Health Service;
    •   Deirdre Louw, Remote nurse practitioner, Bremer Bay;
    •   Pam Morey and Sue Davis, Sir Charles Gairdner Hospital;
    •   Anne Bourke, Sue Peters and Ben Irish, Princess Margaret Hospital;
    •   Paul Fraser and Anna McDonald, WA Country Health Service (WACHS);
    •   Don Black, Department of Health, Legal Services;
    •   Dr Peter Goldswain, Geriatric Medicine,19 Western Australian Department of Health;
        and
    •   Craig Gleeson, Principal Industrial Relations Consultant and Marshall Warner, WA
        Health Industrial Relations Service, Western Australian Department of Health.
    A workshop was held on 7 December 2010 to further test and validate assumptions and
    explore implications arising from the nurse practitioner clinical and business models. A list
    of workshop participants is located at Appendix C.
    Key consultation themes and results are discussed below.



    18. Ms Douglas is a qualified nurse practitioner, but is not currently practising in this role.
    19. Dr Goldswain is a geriatrician.                                                               19

Delivering a Healthy WA
    3.1. Clinical models
    The WA Department of Health required the modelling of a range of clinical scenarios to
    demonstrate the applicability and suitability of each business and employment model.
    The clinical models examined for the purpose of this analysis are a:
    •   hospital outpatient wound care service;
    •   Residential Care Line service;
    •   public rural area service; and
    •   paediatrics emergency department diversion clinic.
    Stakeholder interviews informed the descriptions of the models and anticipated activity
    outlined below.
    Clinical activity
    The interviews with Carol Douglas, Deirdre Louw; Pam Morey and Sue Davis; and Anne
    Bourke, Sue Peters and Ben Irish provided the basis of the clinical activity assumed for
    each of the four clinical models. It should be noted that the hospital outpatient wound
    (ulcers) service, Residential Care Line (aged care) service and rural health service
    (remote area primary care) are existing services that already employ nurse practitioners.
    There is not a paediatrics emergency department diversion clinic (primary care) currently
    operating in Perth. All clinical activity described is an estimates only.
    Clinical activity has been framed around the delivery of this care under the MBS items
    that can be claimed by a nurse practitioner. The clinical activity estimated for each of the
    four clinical models is detailed below.
    A number of general themes arose from these discussions. It is apparent that most nurse
    practitioners work in team-based settings, working collaboratively with other nurses and
    at times medical practitioners. Where nurse practitioners are working with other nurses,
    duties such as management and supervision of other staff can be expected and hence
    time available for clinical consultations is reduced.20
    Generally, the clinical activity appropriate to nurse practitioners is of higher complexity and
    hence requires longer consultations of around 20-30 minutes. The length of consultation
    will vary according to the type of service, complexity of the presentation, and whether
    this is a first presentation for the patient (i.e. longer consultation) or a follow up visit (i.e.
    shorter consultation). The specialist services – i.e. wound care and aged care services
    – are consistent and predictable in the number and length of consultations, whereas the
    primary care models – i.e. remote area and paediatrics emergency department diversion
    clinic – can be expected to be highly variable. Similarly, seasonal variations are more
    likely to be experienced by the primary care models; for example:
    •   Deirdre Louw, the remote area nurse practitioner interviewed, reported that the
        population of Bremer Bay can swell from a permanent population of 300 to over 10,000
        during the summer school holiday period; and



    20. A recent study of 293 Australian nurse practitioners’ activity found that participants spent 67.5 per cent of their time on delivering direct
    patient care, 10.0 per cent on administration and management, 5.0 per cent on education of patients, 5.0 per cent on education of nurses, 4.0
    per cent on education of medical and / or allied health colleagues, and 1.5 per cent on undertaking research. See Middleton S, Gardner A,
    Gardner G & Della P. The Status of Australian Nurse practitioners: the second national census. Unpublished; 2009.                                   20

Delivering a Healthy WA
    •   a metropolitan based paediatrics emergency department diversion
        clinic could be expected to experience additional demand relating to the
        cold and flu season or outbreaks of gastro and similar viruses.
    3.1.1. Hospital outpatient wound care service
    Chronic lower limb ulceration is a common and often recurrent condition in the elderly
    population. An epidemiological study conducted in Western Australia reported that
    approximately 15 per cent of people over 80 years of age had a leg ulcer.21 With an
    ageing population and increases in chronic disease, such as diabetes, that significantly
    impact on the need for specialist ulcer and wound care, services to treat and mange this
    condition will greatly increase.
    Effective management of a leg ulcer requires active follow-up and frequently places
    considerable demand on hospital, as well as community, medical and nursing resources.
    Leg ulcer clinics are commonplace across the hospital landscape across Australia and
    have been demonstrated to improve patients’ quality of life, decrease ulcer-healing times
    and are cost effective.22
    Leg ulcer and wound clinics operate in all tertiary hospitals across WA Health, where their
    focus is on the management of acute complex leg ulcer / wound patients. Significantly,
    as services from tertiary centres are moved to secondary / general hospitals, there may
    be opportunity to open services to support less complex workloads associated with
    secondary care.
    The hospital outpatient wound care service is modelled on the ulcer and stocking clinic
    operated by the Department of Vascular Surgery at the Sir Charles Gairdner Hospital in
    Perth. The Department of Vascular Surgery provides a comprehensive service for the
    inpatient and outpatient management of all vascular conditions. Currently there is one
    qualified nurse practitioner working for the designated nurse practitioner site.
     Type          Care            Team / solo          Activity       Sessions          Patients          Assumed               Other
                   setting                              volume         per week          per ses-          patient con-
                                                                                                                                 factors
                                                                                         sion              sultations for
                                                                                                           practitioner

     Spe-          Clinic          Team:           Low                 2 x 4 hour        12 patients 6 x 15 mins                 High consum-
     cialist                       nurse prac-                         sessions /        per ses-                                able costs
                                                                                                     16 x 20 mins
                                   titioner plus                       week              sion = 24
                                                                                                                                 Currently a
                                   3 advanced                                            / week      1 x 30 mins
                                                                                                                                 nurse practi-
                                   clinical nurses                                                         1 x 45 mins           tioner desig-
                                   advanced
                                                                                                                                 nated site
                                   clinical nurses
                                                                                                                                 Nurse practi-
                                                                                                                                 tioner insitu




    21. Baker S & Stacey M. Epidemiology of chronic ulcer in Australia in Aust N Z J Surgery 1994: 64:258-261.
    22. Hewett,A, Flekser R, Harcourt D & Sinha S. The evolution of a Hospital Based Leg Ulcer Clinic in Primary Intention, 2003: 11, (2) pp. 75-85.
    ISSN 1323-2495.                                                                                                                                    21

Delivering a Healthy WA
    3.1.2. Residential Care Line service
    The Residential Care Line (RCL) was established across WA Health in 2004 to assist in
    demand management for emergency departments through the prevention of unnecessary
    admissions of residential aged care patients. The RCL currently operates across North
    and South Metropolitan Area Health Services.
    The RCL outreach service provides a telephone triage service 8:00 am to 4:00 pm, 7
    days per week. The services includes nurse advice and / or facility visit for care planning,
    interventions or protocols relating to a resident’s care, including clarification of hospital
    discharge / treatment plans in more complex cases. For acute exacerbation or illness /
    injury, a nursing assessment is undertaken at the respective residential aged care provider,
    with intervention provided as required. A supporting geriatrician provides oversight and
    governance for the service.
    The RCL service at North Metropolitan Area Health Service was investigated for the
    purpose of the modelling. The Chronic and Acute Medicine Division at the Sir Charles
    Gairdner Hospital operates the service. Currently there is one nurse practitioner working
    for the service, although this provider is employed as a clinical nurse consultant. The
    service is not currently a designated nurse practitioner site.
    Type      Care        Team / solo    Activity   Sessions   Patients     Assumed          Other factors
              setting                    volume     per week   per ses-     patient con-
                                                               sion         sultations for
                                                                            practitioner

    Spe-      Telephone Team: nurse      Low        3 x 7.5    5 patients   5 x 45 mins      Significant
    cialist   & outreach practitioner               hour       per ses-                      travel time
                         plus 3 clini-              sessions   sion = 15                     between
                         cal nurse                  / week     / week                        consultations.
                         consultants
                                                                                             Not currently a
                                                                                             nurse practi-
                                                                                             tioner desig-
                                                                                             nated site

                                                                                             Nurse practi-
                                                                                             tioner insitu




                                                                                                               22

Delivering a Healthy WA
    3.1.3. Public rural service
    There is a large network of public hospitals and nursing posts spread across WA servicing
    rural and remote communities. The WA Country Health Service (WACHS) employs around
    5,662 FTE staff and contracts 150 Visiting Medical Officers across 70 hospitals and a
    large number of smaller health services and nursing posts.23 A large number of these
    support medium to small communities where the attraction and retention of key medical
    staff is difficult, highly seasonal and costly. In addition Aboriginal and Torres Strait Islander
    people represent 13.2 per cent of the population within the WA Country Health Service
    (WACHS) regions. Early access to health care and services is essential to ‘Closing the
    gap’ to improve Aboriginal health.
    As a result, a large number of these sites offer opportunity for nurse practitioner models to
    augment current service models to support the health needs of the community. The range
    of health services provided at such sites covers primary health care, emergency and
    hospital services, population health, mental health, Aboriginal and Torres Strait Islander
    health and aged care.
    The remote area service at Meekatharra was considered for the purpose of the modelling.
    Midwest Health Region, within WA Country Health Service, operates the service.
    Meekatharra has a local population of approximately 950 and is 765 km from Perth.
    Meekatharra supports a range of local Aboriginal communities in the surrounding area.
    Currently there is no nurse practitioner working for this service, although other remote
    area services employ nurse practitioners. The Emergency Care service at Meekatharra
    is a designated nurse practitioner site.24
     Type        Care             Team / solo         Activity      Sessions        Patients        Assumed              Other factors
                 setting                              volume        per week        per ses-        patient con-
                                                                                    sion            sultations for
                                                                                                    practitioner

     Gen-        Clinic &         Solo nurse          Low           3 x 7.5         20 patients 5 x 15 mins              High season-
     eralist     outreach         practitioner        (usual) to    hour            per ses-                             able variability
                                                                                                10 x 20 mins
                                                      very high     sessions        sion = 60
                                                                                                                         Supports
                                                      (peak         / week          / week      4 x 30 mins
                                                                                                                         RFDS service
                                                      tourist       (plus 24/7                      1 x 45 mins
                                                      season)       on call)                                             Currently a
                                                                                                                         nurse practi-
                                                                                                                         tioner desig-
                                                                                                                         nated site

                                                                                                                         No nurse prac-
                                                                                                                         titioner insitu




    23. See WA Country Health Service website. Accessed 24 January 2011 at www.wacountry.health.wa.gov.au/default.asp?documentid=393.
    24. Department of Health. WA Country Area Health Service Designated Sites at November 2010. Accessed 21 January 2011 at www.nursing.
    health.wa.gov.au/career/np_protocols.cfm.                                                                                               23

Delivering a Healthy WA
    3.1.4. Paediatrics emergency department diversion clinic
    Emergency departments across Australia are experiencing significant growth in demand
    for service. At centres across WA Health such as the Royal Perth, Fremantle and Armadale
    hospitals, initiatives such as co-located general practitioner (GP) services have been
    established to address this increasing demand. The services deal with relatively minor
    complaints or less severe illnesses and injuries and those that would normally be treated
    by GPs.
    The paediatrics emergency department diversion clinic is modelled on the estimated
    activity of the emergency department of the Princess Margaret Hospital (PMH) that could
    reasonably be diverted to a paediatric emergency department diversion clinic. The PMH
    Emergency Department has experienced significant growth in demand for paediatric
    emergency services. In 2008-09, the PMH Emergency Department saw 56,255 patient
    presentations. In 2009-10 this increased to 62,358. Of these, 45,000 were category 4
    patients and 750 were category 5 patients. These patient cohorts represent a good target
    group for a diversion clinic.
    The paediatrics emergency department diversion clinic would be multidisciplinary to
    support the needs of children and their family; i.e. it would feature staff such as a doctor
    (paediatrician or GP), nurse practitioner, practice nurse and receptionist in attendance.
    Patients would be seen in order of arrival, not order of priority. Patients requiring x-ray /
    ultrasound referrals could be organised from the service. As the clinic does not currently
    exist, it would face all issues associated with establishment including development of the
    clinic site, recruitment of staff and designation as a nurse practitioner site.
     Type        Care      Team / solo     Activity   Sessions   Patients   Assumed          Other factors
                 setting                   volume     per week   per ses-   patient con-
                                                                 sion       sultations for
                                                                            practitioner

     Spe-        Clinic    Team: nurse     High       24 hour,   Approx     15 x 15 mins     Some season-
     cialist /             practitioner               7 day      40,000                      able vari-
                                                                            7 x 20 mins
     Gen-                  plus medical               service    patients                    ability (e.g. flu
     eralist               practitioners                         per an-    2 x 30 mins      season, gastric
                           & nursing                             num =      0 x 45 mins      outbreaks)
                                                                 770 /
                                                                                             Not an estab-
                                                                 week
                                                                                             lished clinic

                                                                                             Not currently a
                                                                                             nurse practi-
                                                                                             tioner desig-
                                                                                             nated site

                                                                                             No nurse prac-
                                                                                             titioner insitu




                                                                                                                 24

Delivering a Healthy WA
    3.1.5. Additional consultation themes - barriers and risks relating to the clinical
    and business models
    A range of barriers and risks were consistently raised during stakeholder consultations
    that will be important to consider when developing or extending existing clinical models
    to take advantage of the changes to MBS and PBS rules. These relate to resource and
    staff requirements, business model viability, industrial implications and stakeholder
    acceptability which are expanded upon below.
    Resource and staff requirements
    In determining the business viability of each model, it will be necessary to consider costs
    of:
    •   resource requirements such as:
        • infrastructure requirements such as a private consultation room and access
            to facilities such as bathrooms, change rooms etc and maintenance costs;
        • hardware requirements and consumables such as a
            desk, phone, computer, stationary etc;
        • software requirements such as a standard operating system
            (e.g. Windows, Microsoft Office) and medical practice software;
            medical equipment and consumable requirements; and
        • outreach costs such as a mobile phone, laptop, car and
            maintenance costs (service, fuel, repairs);
    •   staff requirements such as:
        •   salary and allowances;
        •   insurance including medical indemnity insurance;
        •   professional development and education; and
        •   supervision.
    For most of the clinical models, the Government of Western Australia is already meeting
    resourcing and staffing costs and KPMG was not required to factor in all requirements
    into the business case modelling. However, it would be necessary to understand the
    impact of all requirements to develop a full understanding of the business viability of
    each model. This is particularly the case for start up models (such as the establishment
    of a paediatrics ED diversion clinic) and for fully privatised models (where the nurse
    practitioner would be expected to meet all costs).
    For example, it is estimated that the wound clinic operated by Sir Charles Gairdner
    Hospital has medical consumable costs relating to the provision of bandages, dressings,
    instruments and linen of over $60,000 per annum. Bandages and dressings – costing $23
    per kit – account for $58,000 of this total.
    Potential industrial relations implications
    Stakeholders also consistently identified potential industrial relations implications as a key
    concern. It was noted that changes to employment arrangements for Western Australia
    nurse practitioners could prompt the WA branch of the Australian Nursing Federation to
    seek compensation under the nursing enterprise bargaining agreement in areas such as:
                                                                                                     25

Delivering a Healthy WA
    •   remuneration including salary, penalties, superannuation and allowances;
    •   access to rights of private practice; and
    •   loadings for annual, sick, personal, professional development and long service leave.
    Stakeholders also stressed the importance of ensuring the clinical and business nurse
    practitioner models factor in dedicated time for management, administration and research
    in addition to clinical duties.
    Stakeholder acceptability
    Stakeholder acceptability was identified as an important consideration in determining
    the acceptability and ultimately the likely success of the clinical and business models.
    Critical stakeholders will include nurse practitioners, patients, medical practitioners and
    the Australian Government (particularly the Health Minister, Department of Health and
    Ageing and Medicare Australia).
    It was apparent from the interviews that acceptability of nurse practitioner led clinical
    models varies across the health system. Interviewees noted that:
    •   nurse practitioner acceptance is critical if appropriately skilled providers are to be
        attracted to positions, particularly where there may be impacts on income and job
        security;
    •   patient and community acceptability is more important for models where there is
        a greater element of choice as to who delivers care, and a public education and
        information campaign may be necessary to address concerns;
    •   medical practitioner acceptability will also be important to support collaborative
        arrangements, referrals (including referral of patients into nurse practitioner led
        services, e.g. by GPs) and to minimise risk that opinion leaders and influencers attempt
        to block reforms; and
    •   Australian Government acceptability will again be important given its role as funder
        and policy maker for MBS and PBS services.
    Significant effort will be required at the establishment of nurse practitioner clinical and
    business models to address stakeholder acceptability, proactively inform individuals and
    groups, and address concerns.
    Business model acceptability
    Further to nurse practitioner acceptance, the business models will need to be viable and
    sustainable if current and future nurse practitioners are to be attracted to positions. For
    example, it can be expected that qualified nurse practitioners currently working in other
    roles in the health system (e.g. as clinical nurse consultants or nursing directors) will
    require terms and conditions at least equivalent to those already received if they are to
    be attracted to the newly established models. This is even more so the case for privatised
    models.




                                                                                                   26

Delivering a Healthy WA
    4. Business and employment models
    This section identifies potential business and employment models for the Western
    Australian Department of Health to support the clinical models discussed in Chapter 3.
    The business models describe the options for the WA Department of Health to engage,
    support and / or enable nurse practitioners in implementing the clinical models whilst
    utilising MBS and PBS funding.
    The employment and business models are informed by advice and feedback provided by
    stakeholder consultation and by interpretation of relevant legislation and agreements with
    the Australian Government.
    Three business and employment model options have been identified and are described
    below. The identified clinical models (as discussed previously) are then considered
    and applied to the potential business models that may support their development and
    application. The business / employment models identified are:
    1.      Full Public;
    2.      Public Private Mix; and
    3.      Full Private.
    4.1. Financial modelling
    Financial modelling for each business and employment model applies potential activity
    for each clinical model using the assumed distribution of MBS benefits paid for the nurse
    practitioner item numbers. Assumptions regarding the distribution of MBS benefits paid
    have been informed by the stakeholder consultations, and are described under sections
    3.1.1 to 3.1.4 of this report. The aim of the financial modelling is to indicate potential
    financial viability and suitability of each model investigated.
    Financial analysis is provided for each of the four nurse practitioner clinical models
    identified and the potential business / employment model, as outlined under Table 3 below.
    The analysis is provided for a range of business models where the nurse practitioner
    either retains MBS earnings or assigns these to the organisation. In addition, a range
    of employment arrangements are modelled to demonstrate the viability of the individual
    models.
    With the exception of the public rural service, where a public model can apply, the following
    employment options were considered:
    •    100 per cent private employment model;
    •    50 per cent private and 50 per cent public employment model; and
    •    20 per cent private and 80 per cent public employment model.
    For each of these models, detailed financial modelling for each clinical model is provided
    in Appendix D, based on the assumed activity of one FTE nurse practitioner over a 12
    month period.




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Delivering a Healthy WA
    Table 3: Clinical model and business and employment model applied
    Clinical model         Business and em-      MBS assigned to       Per cent of time as
                           ployment model        organisation or       a private provider
                                                 retained by nurse
                                                 practitioner
    Hospital outpatient    Public-Private        Assign MBS                     50
    wound care service                                                          20
                                                 Retain MBS                     50
                                                                                20
                           Full Private          Retain MBS                    100
    Residential            Public-Private        Assign MBS                     50
    Care Line                                                                   20
                                                 Retain MBS                     50
                                                                                20
                         Full Private            Retain MBS                    100
    Public Rural Service Full Public             Assign MBS                      0
    Paediatric ED        Public-Private          Assign MBS                     50
    diversion clinic                                                            20
                                                 Retain MBS                     50
                                                                                20
                           Full Private          Retain MBS                    100


    For models where the nurse practitioner assigns MBS earnings to the state (such as
    Public Private Mix: Nurse practitioner assigns MBS) the financial analysis identifies the
    compensation that the employer (state) would need to provide the nurse practitioner to
    compensate for the potential loss of income and entitlements due to a reduction in public
    employment hours.
    For each of the models, the ‘break even daily patient throughput required’ by each nurse
    practitioner (one FTE) has been identified.


    4.2. Full Public model
    The services under this model are provided and governed by WA Health. WA Health
    employs the nurse practitioner who is then entitled to terms and entitlements of nurse
    practitioners as described under the WA nursing EBA. Patients who receive eligible
    primary care services from the nurse practitioner within this model are able to claim a
    Medicare rebate. The characteristics of the public model are described in Table 4.




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Delivering a Healthy WA
    Table 4: Characteristics of the Full Public model
    Permissible            •   Public rural service with Rural Areas 19(2) exemption
    clinical setting       Under the Better Access to Primary Care Services in Rural
                           Areas 19(2) exemptions initiative, the Australian Government
                           allows Medicare benefits to be claimed in respect of bulk-billed,
                           non-admitted, non-referred professional services provided in
                           emergency departments and outpatient clinics in communities
                           with a population of less than 7,000 people
                           Note: The 19(2) exemption business model only applies to
                           services delivered in communities with a population of less than
                           7,000. Therefore, the requirement of a sufficient population size
                           to justify the existence of the service may be a limiting factor,
                           particularly for a hospital outpatient service such as wounds care
                           or Residential Care Line.
    Nurse practitioner     • The nurse practitioner is an employee
    engagement                of the designated service.
                           •   MBS earnings are bulk billed to the patient (that is,
                               free at point of care) and are retained by the service.
                               This revenue can only be used to enhance primary
                               care services for the designated community.
    Considerations         •   Activity and service cost risks are carried by the service / State.
                           •   Both the State and Australian Governments must agree to
                               designate a community as a 19(2) exempt site. This includes
                               the following requirements:
                           •   population of less than 7,000 people;
                           •   signed agreement by local stakeholders that the community
                               receives designation for a 19(2) exemption; and
                           •   the community must have a general practitioner (GP) shortage
                               (defined as less than one GP per 1,400 people).
                           •   As local arrangements change, such as the arrival of new
                               primary health care practitioners, the agreement in writing
                               of all stakeholders to the service arrangements is required.
                               Representatives from WACHS advised that although a large
                               number of country sites may qualify for a 19(2) exemption,
                               designations can be difficult to obtain due to the need to
                               demonstrate agreement from all parties potentially affected by
                               the designation.
                           •   Local administrative practices and infrastructure will need to
                               be examined and assessed as many potential services may
                               not support MBS billing as they are currently structured.



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Delivering a Healthy WA
    Risks and              •   This model may be more palatable to nurse practitioners, as
    opportunities              the risk associated with service provision (namely income
                               maintenance when activity is low and professional indemnity)
                               is accepted by the State and the nurse practitioner remains a
                               salaried employee.
                           •   As the nurse practitioner is generating income on behalf of
                               the state, there are potential industrial implications. There
                               is the possibility of union bargaining for increased wages
                               or allowances, which may not be supported by productivity
                               increase or work value and may have flow on effects to the
                               rest of the health sector.
                           •   The cost of managing and acquitting a quarantined funding
                               stream may in some cases outweigh the benefit of the
                               potential revenue incurred through Medicare. This will need
                               to be modelled effectively to ensure that maximum benefit is
                               accrued and is not simply increasing administrative burden.
                           •   There is a small risk that community behaviour may change
                               as a result of the introduction of any billing service. Some
                               individuals perceive that as they are paying for the service
                               (regardless of it being free at point of care) that they are entitled
                               to use the service as they wish. This may increase demand for
                               primary care services, however, it could be equally argued that
                               this is simply meeting current unmet demand.

    Potential financial    Detailed modelling of the financial impact of this model is provided
    impacts                at Appendix D. However, the following should be noted:
                           •   under the public rural service model, there is no direct impact
                               on the nurse practitioner’s income or entitlements;
                           •   this model offers a revenue stream for WA Health. This could
                               offset as much as 37 per cent of a nurse practitioner’s salary
                               ($46,895) but will depend on activity levels and distribution of
                               eligible Medicare item numbers claimed (i.e. short, medium
                               and long consultations); and
                           •   in order to offset 100 per cent of the nurse practitioner’s salary
                               cost, an activity level of 49 patients per day is required.


   4.3. Public Private Mix model
   The Public Private Mix model describes a scenario under which the nurse practitioner
   works part time as an employee of the State and part time as a private provider. Under the
   Public Private Mix model, the participating nurse practitioner provides their professional
   services to patients in a private capacity while using the State’s facilities (such as a public
   hospital). Services may include outpatient consultations and referral to pathology and
   radiology services. The private / public spilt describes the distribution of activity and
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Delivering a Healthy WA
    sessions per week undertaken as a public employee and private practitioner each week.
    Patients who receive eligible primary care services from the nurse practitioner under this
    model are able to claim a Medicare rebate.
    Under this model, there are two possible scenarios for allocation of MBS earnings:
    •   the nurse practitioner may choose to retain MBS earnings as their private income; or
    •   the nurse practitioner may choose to assign MBS earnings to the State and be
        compensated through their salary and entitlements.
    •   The characteristics of the Public-Private Mix model are described in Table 5.
    Table 5: Characteristics of the Public Private Mix model
    Potential               •   Hospital outpatient wound care service
    permissible             •   Residential Care Line service
    clinical settings
    Nurse practitioner      •   The nurse practitioner operates as a private provider when
    engagement                  delivering care to private patients.
                            •   The nurse practitioner works part time as an employee of the
                                State and part time as a private provider.
                            •   With regard to care delivered to private patients, the nurse
                                practitioner may elect to either:
                            •   retain MBS earnings as their private income and meet their
                                operating expenses such as medical indemnity insurance,
                                medical consumables and infrastructure costs; or
                            •   be employed by the designated service and assign MBS
                                earnings to the service.
    Considerations          •   As previously noted, unless the Minister otherwise directs,
                                Medicare benefits are not payable where funding has
                                already been provided under an arrangement with the
                                Commonwealth, State or a local governing body. As such
                                this model would require the individual nurse practitioner
                                to obtain a Medicare provider number, which is reliant on
                                demonstrating to Medicare that they are a private practitioner.
                            •   In order to demonstrate independence from the State,
                                WA Health may consider charging the nurse practitioner
                                a nominal facility fee where public facilities are utilised.
                                The fee may cover public facilities such as local
                                administrative support and infrastructure to support
                                MBS billing. However, provision of such services may
                                not be currently supported by many hospitals given the
                                potential administrative burden of billing under the MBS.
                            Nurse practitioner retention of MBS earnings
                            •   Activity and service cost risks are accepted by the nurse
                                practitioner when MBS earnings are retained by the private
                                nurse practitioner provider.
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Delivering a Healthy WA
                     •   The nurse practitioner is responsible for a range of costs
                         associated with establishing a private practice. This would
                         include indemnity insurance, leave provisions, ongoing
                         professional development, facility costs, other goods and
                         services etc.
                     Nurse practitioner assignment of MBS earnings
                     •   Activity and service cost risks are accepted by the hospital
                         when MBS earnings are assigned by the nurse practitioner to
                         the organisation
     Risks and       •   The ‘right of private practice’ is currently not supported by the
     opportunities       current nursing award structure; it is likely the nursing award
                         would require amendment to accommodate this right. This
                         may have industrial implications including union bargaining for
                         increased wages or allowances which may not be supported
                         by productivity increase or work value and may have flow on
                         effects to the rest of the nursing sector.
                     •   This model represents a significant cultural shift for the
                         community. Opportunity exists to promote this model within
                         the wider community to improve acceptance.
                     •   The majority of nurse practitioners have limited experience
                         of operating as private providers (such as GPs). Opportunity
                         exists for the provision of support and education to individual
                         nurse practitioners on establishing and managing your ‘own
                         business’, focusing on improving commercial awareness and
                         business acumen.
                     Nurse practitioner retention of MBS earnings
                     •   Significant individual professional indemnity costs may
                         potentially limit the suitability of this model.
                     •   The market’s appetite to pay a price beyond the scheduled fee
                         will limit the financial viability of the model and ultimately the
                         uptake of the Full Private model.
                     •   There are significant business risks associated with establishing
                         and managing a private practice, such as maintaining records,
                         taxation, structuring your business etc.
                     Nurse practitioner assignment of MBS earnings
                     •   This model may be more acceptable to nurse practitioners,
                         as the risks associated with service provision (namely income
                         maintenance when activity is low and professional indemnity)
                         are accepted by the state and the nurse practitioner remains a
                         salaried employee.



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Delivering a Healthy WA
                          •   However, it is questionable whether nurse practitioner
                              can demonstrate that they are working in private practice,
                              independently of the State. The success of this model will
                              depend on acceptance by the Australian Government of
                              a scheme similar to the Privately Referred Non Inpatient
                              (PRNI) model used with specialist medical practitioners.
                              Legal advice is recommended before the State proceeds
                              with this model. The PRNI model is dependant on the
                              doctor having “Rights to Private Practice” – there is
                              no equivalent arrangement currently for nurses.
                          •   The cost of personal medical indemnity may inhibit the
                              uptake of this model. Under the Privately Referred Non
                              Inpatient (PRNI) scheme – a comparable approach for
                              engaging medical practitioners – participating providers
                              are able to access WA Health’s medical indemnity and
                              protocol scheme covering patients treated under the
                              initiative. Currently nurse practitioners are not covered
                              by this protocol. This will pose a significant cost impost
                              for the individual nurse practitioner to obtain individual
                              indemnity insurance. Opportunity may exist to extend
                              the indemnity protocol to nurse practitioners.
    Potential financial   Potential financial impact Detailed modelling of the financial
    impact                impact of this model is provided at Appendix D. However, the
                          following should be noted:
                          •   with regard to nurse practitioner retention of MBS earnings,
                              • hospital outpatient wound care service:
                              • there would be a direct impact on the nurse practitioner’s
                                 income or entitlements. This impact ranges from -$16,762
                                 for 20 per cent private to -$41,904 for 50 per cent private
                                 arrangement;
                              • conversely this model offers a financial offset for WA Health.
                                 The offset increases as more of the nurse practitioner’s
                                 time is spent as a private provider. This offset ranges from
                                 $25,111 for 20 per cent private employment to $62,776 for
                                 50 per cent private employment;
                              • Residential Care Line service:
                              • there would be a direct impact on the nurse practitioner’s
                                 income or entitlements. This impact ranges from -$23,292
                                 for 20 per cent private to -$58,230 for 50 per cent private
                                 arrangement;



                                                                                                 33

Delivering a Healthy WA
                     •    conversely this model offers a financial offset for WA Health.
                          The offset increases as more of the nurse practitioner’s time
                          is spent as a private provider. This offset ranges from $25,111
                          for 20 per cent private employment to $62,776 for 50 per cent
                          private employment;
                          • with regard to nurse practitioner assignment of MBS
                             earnings:
                          • hospital outpatient wound care service:
                          • there is no direct financial impact on income of the nurse
                             practitioner as the State provides a financial offset at the
                             total value of potential wage and allowances lost as a result
                             of taking up private practice;
                          • the organisation receives a small financial offset ranging
                             from $11,622 for 20 per cent private to $29,056 for 50 per
                             cent private;
                          • Residential Care Line service:
                          • there is no direct financial impact on income of the
                             nurse practitioner as the State provides a financial offset
                             at the total value of potential wage and allowances
                             lost as a result of taking up private practice;
                          • the organisation receives a small financial
                             offset ranging from $5,092 for 20 per cent
                             private to $12,729 for 50 per cent private.




                                                                                             34

Delivering a Healthy WA
    4.4. Full private model
    The Full Private model involves the nurse practitioner taking on all activity and employment
    related costs and risks. In its purest form this model meets the intent of the Health Legislation
    Amendment (Midwives and Nurse Practitioners) Act 201025 and the requirement that the
    nurse practitioner be in private practice. However, the financial viability of services under
    this model is low. The characteristics of the Full Private model are described in Table 6.
    Table 6: Characteristics of the Full Private model
     Appropriate                     •   Hospital outpatient wound care service
     clinical settings               •   Residential Care Line service
                                     •   Paediatrics emergency department diversion clinic
     Nurse practitioner              •   The nurse practitioner operates as a private provider.
     engagement                      •   The nurse practitioner retains MBS earnings as their personal
                                         income and meets their operating expenses such as medical
                                         indemnity, administration costs, other goods and services etc.
     Considerations                  •   Activity and service cost risks are carried by the individual
                                         nurse practitioner
                                     •   This model would require the individual nurse practitioner
                                         to obtain a Medicare provider number, which means
                                         demonstrating to Medicare that they are a private practitioner.
                                     •   Nurse practitioners would need to develop and manage
                                         administrative practices and infrastructure to support MBS
                                         billing.
     Risks and                       •   This model is likely to have low acceptability to nurse
     opportunities                       practitioners, as the risks associated with service provision
                                         (namely income maintenance when activity is low and
                                         professional indemnity) are carried by the individual.
                                     •   Opportunity exists for private nurse practitioner providers
                                         to deliver the service and offset costs by charging
                                         individual client fees beyond the MBS benefit paid (such
                                         as a private general practice, private hospital etc.).
                                     •   This model represents a significant cultural shift
                                         for the community. Opportunity exists to promote
                                         this model within the wider community.
                                     •   The majority of nurse practitioners have limited experience
                                         operating as private providers (such as GPs). Opportunity
                                         exists for the provision of support and education to
                                         individual nurse practitioners on establishing and
                                         managing your ‘own business’, focusing on improving
                                         commercial awareness and business acumen.



    25. Commonwealth of Australia. Explanatory Memoranda: Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009.
    Accessed 24 January 2011 at www.austlii.edu.au/au/legis/cth/bill_em/hlaanpb2009609/.                                               35

Delivering a Healthy WA
    Potential financial          Detailed modelling of the financial impact of this model
    impact                is provided at Appendix D. However in summary the following
                          should be noted:
                          •   for the hospital outpatient wound care service;
                              • there is a large direct impact on the nurse practitioner’s
                                 income and entitlements – a net impact of -$83,808 per
                                 annum;
                              • this model offers a large financial impact for WA Health. All
                                 income for the nurse practitioner is offset – $125,553 per
                                 annum – and the clinic would potentially divert up to 4,824
                                 occasional of service per annum;
                              • in order to meet lost of entitlements and income, a nurse
                                 practitioner must have an activity level of 50 patients per
                                 day;
                          •   for the Residential Care Line service:
                              • there is a significant direct impact on the nurse practitioner’s
                                 income and entitlements – a net impact of -$116,461 per
                                 annum;
                              • this model offers a large financial impact for WA Health. All
                                 income for the nurse practitioner is offset – $125,553 per
                                 annum – and the clinic would potentially divert up to 1,005
                                 occasional of service per annum;
                              • in order to meet a loss of entitlement and income, an nurse
                                 practitioner must have an activity level of 18 patients per
                                 day.
                          •   for the paediatrics emergency department diversion clinic:
                              • there is a significant direct impact on the nurse practitioner’s
                                 income and entitlements – a net impact of -$103,717 per
                                 annum;
                              • the clinic would potentially divert up to 4,800 occasional
                                 of service per annum away from the PMH emergency
                                 department; and
                              • in order to meet lost entitlements and income, a nurse
                                 practitioner must have an activity level of 65 patients per
                                 day.




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Delivering a Healthy WA
    5. Discussion
    This section discusses models for further investment, identifies the policy implications for
    supporting implementation and enhancement of the models, and provides an assessment
    of the models against agreed acceptability criteria.
    5.1. Models for further investment
    The appropriateness of the business / employment models as applied to the four clinical
    models is considered below.
    5.1.1. Hospital outpatient wound care service
    The most appropriate business / employment model for the hospital outpatient wound care
    service is the Public Private Mix model, with the nurse practitioner assigning MBS
    earnings to the State. The financial modelling detailed under Appendix D demonstrates
    that the state would need to make an incentive payment to nurse practitioners for account
    for lost earnings and entitlements if this model is to attract a workforce. An incentive
    payment of $28,447 per annum for a 20 per cent private model and $71,117 per annum
    for a 50 per cent private model would be required. The incentive payment is calculated
    within the modelling to compensate for lost income and operating expenses such as
    medical indemnity insurance.
    Under this model, the State can expect a net financial benefit (once MBS earnings are
    taken into account) of $11,622 per annum under the 20 per cent private model and
    $29,056 per annum under the 50 per cent private model.26
    The loss of income incurred by the nurse practitioner under all other scenarios modelled
    precludes these from further consideration. The modelling demonstrated that the MBS
    nurse practitioner payments are insufficient to support the nurse’s full-time salary.
     IMPLICATION:
     Acceptability of the Public Private Mix model should be confirmed.
     If indicated as acceptable, the hospital outpatient wound care service is best supported
     by the Public Private Mix, with the nurse practitioner assigning MBS earnings to the
     State.


    5.1.2. Residential Care Line service
    The most appropriate business and employment model for the Residential Care Line
    service is the Public Private Mix model, with the nurse practitioner assigning MBS earnings
    to the State. The financial modelling detailed under Appendix D demonstrates that the
    state would need to make an incentive payment to nurse practitioners for account for lost
    earnings and entitlements if this model is to attract a workforce. An incentive payment
    of $28,447 per annum for a 20 per cent private model and $71,117 per annum for a 50
    per cent private model would be required. The incentive payment is calculated within
    the modelling to compensate for lost income and operating expenses such as medical
    indemnity insurance.



    26. The net financial benefit calculated is specific to the clinical activity modelled.        37

Delivering a Healthy WA
    Under this model, the State can expect a net financial benefit (once MBS earnings are
    taken into account) of $5,092 per annum under the 20 per cent private model and $12,729
    per annum under the 50 per cent private model. 27
    The loss of income incurred by nurse practitioner under all other scenarios modelled
    precludes these from further consideration. The modelling demonstrated that the MBS
    nurse practitioner payments are insufficient to support the nurse’s full-time salary.
     IMPLICATION:
     Acceptability of the Public Private Mix model should be confirmed.
     If indicated as acceptable, the Residential Care Line service is best supported by the
     Public Private Mix, with the nurse practitioner assigning MBS earnings to the State.


    5.1.3. Public rural service
    The most appropriate business / employment model for the public rural service is the
    Public model, taking advantage of the Rural areas 19(2) exemption agreement. The
    financial modelling detailed under Appendix D demonstrates that a nurse practitioner
    employed by this service would generate MBS fees of $46,895,28 helping to offset the
    nurse practitioner’s salary and superannuation costs of $125,553.
    The public rural service model meets all the needs of stakeholders whilst offering the
    best value in terms of financial impact on the organisation and whilst maintaining the
    income of the nurse practitioner. In addition this model is supported by Commonwealth
    and State policy agreements and regulations, and has the capacity to improve services
    to disadvantaged communities and unmet demand in rural WA.
    However, for many rural and remote locations the Commonwealth already provides
    quarantined block funding for the provision of primary health care by State funded services.
    This provides the State with a guaranteed, known quantum of funding, whereas Medicare
    revenue generated under a Rural areas 19(2) exemption agreement is dependent on
    throughput, variable and hence less predictable. Prior to establishing new services under
    this model, it must be considered whether potential Medicare revenue is likely to be
    greater than quarantined block funding.
     IMPLICATION:
     The public rural service is best supported by the Public model, with all MBS earnings
     retained by the State.


    5.1.4. Paediatrics emergency department diversion clinic
    The most appropriate business and employment model for the paediatrics emergency
    department diversion clinic is the Public-Private Mix model, with the nurse practitioner
    assigning MBS earnings to the State. The financial modelling detailed under Appendix
    D demonstrates that the state would need to make an incentive payment to nurse
    practitioners for account for lost earnings and entitlements if this model is to attract a
    workforce. An incentive payment of $28,447 per annum for a 20 per cent private model
    27. The net financial benefit calculated is specific to the clinical activity modelled.
    28. The MBS fees calculated are specific to the clinical activity modelled.                    38

Delivering a Healthy WA
    and $71,117 per annum for a 50 per cent private model would be required. The incentive
    payment is calculated within the modelling to compensate for lost income and operating
    expenses such as medical indemnity insurance.
    Under this model, the State can expect a net financial benefit (once MBS earnings are
    taken into account) of $7,640 per annum under the 20 per cent private model and $19,101
    per annum under the 50 per cent private model.29 The State would further benefit from the
    diversion of 4,800 occasional of service per annum away from the paediatrics emergency
    department.
    The loss of income incurred by nurse practitioner under all other scenarios modelled
    precludes these from further consideration. The modelling demonstrated that the MBS
    nurse practitioner payments are insufficient to support the nurse’s full-time salary.
     IMPLICATION:
     Acceptability of the Public Private Mix model should be confirmed.
     If indicated as acceptable, the paediatrics emergency department diversion clinic is
     best supported by the Public Private Mix, with the nurse practitioner assigning MBS
     earnings to the State.


    5.1.5. Summary of models for investment
    Models in which the nurse practitioner takes on all activity risk (such as the Full Private
    and Public-Private models where the nurse retains revenue) offer the greatest financial
    return for WA Health. However, these models also present the greatest risk for individual
    nurse practitioners and have a lower likelihood of acceptance because of this risk.
    While providing moderate financial return to a rural hospital with 19(2) exemption status,
    the nurse practitioner’s ability to remain a full time employee of the state and hence
    minimise the overall impact on their allowances and conditions, would be the model with
    the highest acceptability. It is noted from the financial modelling that MBS revenue could
    offset as much as 37 per cent of a nurse practitioner’s salary ($46,895) under this scenario.
    A shift to full private practice, whilst less complicated from a Commonwealth perspective,
    is unlikely to be fully embraced by nurse practitioners at this time as the structure of the
    rebates would only be viable in high volume environments with rapid patient turnover.
    A nurse practitioner that continues to practice in the way he / she is trained would most
    likely experience a loss in income. Although gap fees may be charged to improve the
    profitability of services, these would need to be significant to offset the loss in income
    and may exceed community acceptance. Opportunity may exist within areas of high
    volume such as the paediatrics emergency department diversion clinic to work with
    private stakeholders (such as divisions of general practice / Medicare Locals and private
    hospitals) to establish such a service.
    The Public-Private Mix model where the nurse practitioner assigns their revenue to the
    organisation offers potential for mutual benefit to both WA Health and the nurse practitioner.
    The model provides both the capacity to introduce a private model whilst maintaining an
    income guarantee for the nurse practitioner. This model, whilst conservative in revenue


    29. The net financial benefit calculated is specific to the clinical activity modelled.          39

Delivering a Healthy WA
    earned by the organisation, has high likelihood of nurse practitioner acceptability –
    especially at an 80 per cent public / 20 per cent private mix. This business and employment
    option is the most suitable for the hospital outpatient wound care service, Residential
    Care Line service and paediatrics emergency department diversion clinic.
    The success of the Public-Private Mix model depends on the nurse practitioner obtaining
    a Medicare provider number, which is reliant on demonstrating to Medicare that they are
    a private practitioner. It is also reliant on being acceptable to the Commonwealth with
    respect to sections 19(2) and 128c of the Health Insurance Act 1973. Given the inherent
    ambiguity within the legislation, it is recommended that legal advice be obtained as to
    whether the model is permissible under the regulations. If indicated by legal counsel,
    Commonwealth agreement may also be required.
    Finally, the State should determine whether the net financial benefit is sufficient to support
    wider implementation of this model, noting the expected costs involved and potential for
    conflict with the Australian Government.
    5.2.    Industrial relations implications
    The introduction of legislation to enable nurse practitioners to generate revenue via the
    MBS has significant direct and indirect implications for WA’s nursing industrial system and
    associated awards and structures. Specifically:
    •   direct implications relate to the absence of the ‘right of private practice’ under the
        nursing enterprise bargaining agreement (EBA), which covers nurse practitioners.
        The nursing award structure may require amendment to accommodate this right.
        In addition, under the business / employment models where the nurse practitioner
        generates income on behalf of the State, there is the possibility of union pressure for
        increased wages or allowances to obtain a share of this income; and
    •   indirect implications relate to the potential for other professional health bodies and
        stakeholders to pressure for equivalent rights to those granted to nurse practitioners.
        It is important that at all stage of model development relevant key stakeholders are
        engaged and involved in the process.
    It should be noted that any alteration to the award structure covering nurse practitioners
    would not necessarily be supported by equivalent productivity increases or work value,
    and may have flow on effects to other nursing classifications
    IMPLICATION:
    Prior to development and implementation of nurse practitioner business and employment
    models, formal opinion should be sought from the WA Health Industrial Relations Service
    regarding potential impacts on the WA nursing enterprise bargaining agreement.


    5.3. Policy implications
    Policy implications relating to the federal and state levels of government have been
    identified from analysis of the clinical and business models. Current Commonwealth and
    State legislation and agreements impose a number of limitations on the implementation
    of nurse practitioner services. The full potential of the nurse practitioner role will require
    working with the Australian Government through the Minister for Health and Ageing,
                                                                                                     40

Delivering a Healthy WA
    Department of Health and Ageing and Medicare Australia, and the Government of
    Western Australia through the Minster for Health, the WA Department of Health and the
    WA Cabinet to address these limitations.
    It is recommended that WA Health establish a Nurse Practitioner Working Party to provide
    advice to WA Health on the development and implementation of nurse practitioner services
    in WA, including on Federal and State policy implications.
    Federal and State policy implications identified during the project are discussed below.
    5.3.1. Federal policy implications
    Policy implications to be addressed in partnership with the Australian Government are
    outlined in the following table.
    Table 7: Federal policy implications
    Policy limitation                              Actions
    Unless the Minister otherwise directs, contravene sections 19(2) and 128c
    Medicare benefits are not payable where of the Health Insurance Act 1973.
    funding has already been provided under • If indicated by legal counsel,
    an arrangement with the Commonwealth,            consider seeking the agreement
    State or a local governing body. Specifically:   of the Federal Health Minister for
    • section 19(2) of the Health Insurance the payment of Medicare benefits
       Act 1973 states that, unless the Health       in respect of professional services
       Minister otherwise directs, a Medicare        rendered by nurse practitioners
       benefit is not payable in respect of a        engaged under the Public Private Mix
       professional service that has been ren-       business and employment model.
       dered by, or on behalf of, or under an
       arrangement with the Commonwealth, a
       State, a local governing body; or an au-
       thority established by a law of the Com-
       monwealth, a State or internal Territory;
       and
    •   section 128c of the Health Insurance Act
        1973 prohibits specified persons (includ-
        ing nurse practitioners) from charging a
        fee for the provision of a public hospital
        service or from receiving any payment
        or other consideration from anyone in
        respect of the provision of a public hos-
        pital service to a public patient. A “pub-
        lic hospital service” means a hospital
        service provided in a public hospital or
        a hospital providing services to publicly
        funded patients.




                                                                                               41

Delivering a Healthy WA
     •   Policy Limitations                                              •   Actions
     •   Medicare Australia expects that access                          •   Seek legal opinion to determine whether
         to the MBS will be by nurse practitioners                           any of the proposed business and
         operating as private practitioners;                                 employment models contravene the
     •   Where an arrangement exists between                                 Medicare Australia requirement that
         the State and the nurse practitioner, the                           nurse practitioners must operate as
         Federal Health Minister’s agreement                                 private practitioners.
         will be required for MBS payments                               •   If indicated by legal counsel, consider
         for services delivered by the nurse                                 seeking the agreement of the Federal
         practitioner.                                                       Health Minister that nurse practitioners
                                                                             engaged under the Public Private Mix
                                                                             business and employment model be
                                                                             considered private practitioners.
     •   MBS item numbers 10993 to 10999                                 •   Consider working with the Australian
         cover services provided by a practice                               Government and relevant stakeh
         nurse on behalf of a medical practitioner.                          olders including peak practice nursing
     •   Although nurse practitioners routinely                              and general practice groups to seek
         manage and direct nursing staff in State-                           amendment of the MBS item numbers
         funded services, practice nurses will not                           10993 to 10999 to allow practice nurses
         be able to access these MBS items for                               to provide service on behalf of a nurse
         services provided on behalf of a nurse                              practitioner.
         practitioner.                                                   •   Risks relating to this strategy should be
                                                                             considered, including consequences
                                                                             for medical indemnity insurance for
                                                                             nurse practitioners arising from services
                                                                             performed on their behalf by practice
                                                                             nurses, and the potential for strong
                                                                             opposition from peak general practice
                                                                             groups
     •   Nurse practitioner item numbers                                 •   Consider working with the Australian
         are generalist in nature and do not                                 Government and relevant stakeholders
         reflect the specialist nurse practitioner                           including peak practice nursing and
         workforce within WA, which is highly                                general practice groups to develop
         procedural. GPs have procedural MBS                                 appropriate procedural MBS item
         items covering specialist interventions                             numbers for nurse practitioners.
         and procedures.
    Further opportunity exists for the State to work in partnership with the Commonwealth
    in areas of joint funding responsibility such as community, outpatients and aged care.
    It is noted that under the National Health and Hospital Network the Commonwealth
    Government will take on 100 per cent funding and policy responsibility for general practice,
    primary health care services, mental health care and aged care. (No timeline has yet
    been set for this). This will cover services currently provided by States and Territories
    including community health centres, primary health care service, immunisation and
    cancer screening programs.30
    30. National Preventative Health Taskforce. Taking Preventative Action – A response to Australia the Healthiest Country by 2020.
    Commonwealth of Australia; Canberra: 2010. Accessed 24 January 2011 at www.yourhealth.gov.au/internet/yourhealth/publishing.nsf/Content/
    report-preventativehealthcare.                                                                                                             42

Delivering a Healthy WA
    Clearly any model that supports better health care delivery and service provision to these
    settings of joint responsibility offers opportunity for the use of nurse practitioner models
    whilst maximising the ability to access MBS and PBS to support / offset the initiative.
    Optimisation of MBS benefits for items 82200-82215
    Figure 1 illustrates the structure of the nurse practitioner MBS item numbers. The
    figure graphs the fee earned per minute for each item number, with the average fee per
    consultation indicated by the horizontal lines.31
    The graph indicates that optimisation of funding varies by length of consultation. Returns
    are greatest when consultations are:
    •   for item 82200: limited to five to six minutes in length (falling from $1.57 to $1.31 per
        minute);
    •   for item 82205: limited to ten to 12 minutes in length (falling from $1.72 to $1.43 per
        minute);
    •   for item 82210: limited to 20-24 minutes in length (falling from $1.63 to $1.36 per
        minute); and
    •   for item 82215: limited to 40-41 minutes in length (falling from $1.20 to $1.17 per
        minute).
    It can be seen that returns are greatest for items 82205 and 82210, when consultation
    lengths are limited. Returns are lower for long consultations delivered under item 82215.
    It appears that design of the nurse practitioner MBS item numbers does not adequately
    reflect the nursing model of care. The nursing model is more holistic – covering off the
    physical, psycho-social and spiritual aspects of patient care and is built around more
    extended patient interaction.
     IMPLICATION:
     Consider whether further investigation in collaboration with the Australian Government
     regarding adjustments to MBS item number fees to promote greater uptake of the nurse
     practitioner item numbers is required.




    31. For item 82200, a minimum consultation length of five minutes and a maximum consultation length of 19 minutes is assumed. For item
    82205, a minimum consultation length of ten minutes and a maximum consultation length of 19 minutes is assumed.                          43

Delivering a Healthy WA
                                                                                                                                                                                                                44
Figure 1: MBS rebates (benefits paid) for nurse practitioner services by length of consultation
                       $2.00
                                                                                                                                                                                             82200 ($7.850)
                       $1.80
                                                                                                                                                                                             82205 ($17.15)
                       $1.60
                                                                                                                                                                                             82210 ($32.55)
                       $1.40
                                                                                                                                                                                             82215 ($47.90)
                       $1.20
Fee per m inut e ($)




                       $1.00
                       $0.80
                       $0.60




                                                                                                                                                                                                                            Delivering a Healthy WA
                       $0.40
                       $0.20
                       $0.00
                               1   2   3   4   5   6   7   8   9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
                                                                                                              Consult at ion lengt h (m ins)
        Delivering a Healthy WA
    5.3.2. State level implications for medical indemnity insurance coverage
    Personal indemnity costs represent a significant barrier for the successful implementation
    of this program across WA Health. In 2008-2009 average premiums for medical indemnity
    in Australia were $5,392. However, in real terms for selected specialties indemnity costs
    varied between $2,667 for non-procedural GPs to $48,910 for an obstetrician.32
    Currently, participating medical practitioners within the Privately Referred Non Inpatient
    (PRNI) scheme are able to access WA Health’s medical indemnity and protocol scheme
    covering patients treated under the PRNI initiative.
    Nurse practitioners are not covered under this scheme. Medical indemnity insurance
    costs will pose a significant cost impost for the individual nurse practitioner. Opportunity
    may exits for a submission to the Government of Western Australia Cabinet seeking to
    extend the indemnity protocol to nurse practitioners.
    There may also be impacts on nurse practitioners medical indemnity insurance if they are
    involved in managing other staff members such as nurses.
    It is recommended that initial scoping and assessment be undertaken to understand the
    full impact of medical indemnity and further opportunities that may exist to mitigate this
    risk.
     IMPLICATION:
     Further scoping and assessment be undertaken to understand the full impact of medical
     indemnity insurance and identify opportunities that may exist to mitigate this risk


    5.4. Development of a nurse practitioner workforce strategy
    The regulatory and legislative changes are designed to support private practice and the
    improved delivery of primary care services across Australia. The implementation of nurse
    practitioners offers the State opportunity for addressing projected workforce shortages
    across areas of high clinical need such as primary care, community health and rural and
    remote.
    Whilst financial analysis of the model indicates high variability in terms of financial impact,
    opportunity exists for the State to support a planned incremental rollout whilst accepting
    a small revenue return and incurring initial upfront investment.
    Currently WA has a specialist nurse practitioner workforce focused on secondary and
    tertiary care. A workforce strategy that supports the attraction and retention of nurse
    practitioners in areas such as primary care and rural and remote health to maximise
    benefits from the relevant changes would assist WA Health to encourage greater take up
    of MBS rebateable services for nurse practitioners.
    A nurse practitioner workforce strategy for WA would need to include:
    •   a targeted recruitment plan to support the implementation of respective business /
        employment models, especially in the context of developing a primary care generalist
        nurse practitioner workforce;

    32. Australian Consumer and Competition Commission. Medical Indemnity Insurance report- sixth monitoring report. Commonwealth of
    Australia; Canberra: 2009. Accessed 9 January 2011 at www.accc.gov.au/content/item.phtml?itemId=870359&nodeId=855f649d21dc22

                                                                                                                                       45
    3c6e324c47d4df58ad&fn=Medicalper%20cent20indemnityper%20cent20insurance,per%20cent20sixthper%20cent20monitoringper%20
    cent20report.pdf.




Delivering a Healthy WA
    •    a range of strategies to attract and retain nurse practitioners in areas of high community
         need. These strategies will need to address ongoing professional development, talent
         identification, succession planning and leadership.
    In addition the majority of nurse practitioners have limited experience operating as private
    providers (such as GPs). As a result opportunity exists for the provision of support and
    education to individual nurse practitioners on establishing and managing your ‘own
    business’, focusing on improving commercial awareness and business acumen. This will
    be essential in ensuring ongoing sustainability of nurse practitioners operating within a
    private environment.
    IMPLICATION:
    A nurse practitioner workforce strategy is required that includes a targeted recruitment
    plan to support the implementation of respective business and employment models.



    5.5. Acceptability criteria
    In order to better understand which models are to be considered for further investment,
    a set of acceptability criteria was developed for application to each of the business and
    employment model. The outcome of this process will determine the appropriateness for
    future investment by the Department of Health. Four acceptability criteria were agreed
    at the 7 December 2010 stakeholder workshop. The agreed acceptability criteria are as
    follows:
    1.       The clinical model is based on patients’ needs and not income generation.
    2.       The business model will not involve loss of income for participating nurse
             practitioners.
    3.       The business model is permissible under the Health Insurance Act 1973 and
             complies with the Australian Health Care Agreement.
    4.       The clinical and business models are acceptable to key stakeholders.
    In addition financial viability criteria have been applied that consider the overall financial
    impact on the organisation, community and the individual nurse practitioner.
    Table 8 applies each criterion to the proposed business models and their respective
    clinical models. The criteria have then been ranked to determine those models that would
    support the need for future investment. Models for future consideration need to meet all
    acceptability criteria.
    All described business and operational models have some benefits and risks associated
    with their acceptance and potential implementation. The acceptability criteria clearly
    identify those models that should be considered for further refinement and development.
    These models demonstrate greater acceptability across all key criteria.




                                                                                                      46

Delivering a Healthy WA
    Table 8: Nurse practitioner business and employment models: acceptability table
    Model                             Acceptability              Financially Viability                    Score
                          1.Patient    2.C’wealth 3.Stake-    1.Organi-       2.Com-        3.Nurse
                          centred      accept-    holder ac- sation           munity        practi-
                                       ability    ceptability                               tioner
    Wound       Public-                                                                          9
                Private
                Private                                                                         7
    Residen-    Public-                                                                          9
    tial        Private
                Private                                                                         7
    Paediatrics Private                                                                         7
    ED
    Remote      Public                                                                      14



    Rating system
    Rating          Description                         Rating            Description
                 Option exceeds criteria                              Option partially meets option
                  Option meets criteria                                Option doesn’t meet criteria




                                                                                                                  47

Delivering a Healthy WA
    6. Recommendations
    The changes of the Health Insurance Act 1973 offers opportunity for WA Health and
    the nursing profession which may be realised by combining the appropriate clinical
    and business / employment models. However, these opportunities do not come without
    political, technical and financial challenges and risks.
    Core to the success of implementing these models is ensuring that they are acceptable to
    all key stakeholders and meet all Commonwealth and Medicare eligibility requirements.
    The following recommendations are made to assist WA Health in determining the most
    appropriate future investment opportunities, considerations and priorities for the State.
    1. Seek formal legal opinion from Health Legal Services and State Solicitors to determine
       whether any of the proposed business / employment models contravene sections
       19(2) and 128c of the Health Insurance Act 1973 and relevant health care agreements.
    2. Seek formal opinion from the WA Health Industrial Relations Service regarding
       potential impacts, risks, benefits and strategies relating to the WA Nursing Enterprise
       Bargain Agreement.
    3. Establish a Nurse Practitioner Working Group to undertake further development work
       to consider a range of outstanding issues. The purpose of the Working Group would
       be to advise WA Health on the development and implementation of nurse practitioner
       services in WA, including:
       • strategies for working with key stakeholders such as the Australian and
          Western Australian Governments, peak nursing groups and other stakeholders to
          achieve further policy and legislation reform to support nurse practitioner services;
       • solutions surrounding medical indemnity insurance for nurse
          practitioners, with a particular focus on affordability, as well as clarity
          regarding the implications of managing staff such as practice nurses;
       • develop a workforce strategy that includes a targeted recruitment plan to support
          the implementation of respective business / employment models, especially in
          the context of developing a primary care generalist nurse practitioner workforce.
    4. If indicated by legal counsel, consider seeking the agreement of the Federal Health
       Minister for the payment of Medicare benefits in respect of professional services
       rendered by nurse practitioners engaged under the Public Private Mix business /
       employment model.
    5. Consider working with the Australian Government and relevant stakeholders including
       peak nursing and general practice groups to seek amendment of the MBS item
       numbers 10993 to 10999 to allow practice nurses to provide service on behalf of a
       nurse practitioner. Consideration should also be given to the possibility of procedural
       items which are reflective of nurse practitioner specialist practice.
    6. In partnership with the WA Country Health Service, identify appropriate 19(2) exemption
       sites for establishing nurse practitioner services using clear selection criteria (such as
       ability to recruit a nurse practitioner and availability of local infrastructure to support
       MBS billing).

                                                                                                     48

Delivering a Healthy WA
    7. Once eligibility and provider number issues have been addressed, commence a trial
       of approved clinical models in public / private mix models utilising agreed business /
       employment models to determine their financial viability, effectiveness and community
       benefit. Trials should include a formal evaluation over a period of six to 12 months that
       includes extensive stakeholder consultation, data analysis and a cost benefit analysis.
    8. Develop and deliver a range of education and business tools to support nurse
       practitioners in the establishment and management of their own business.




                                                                                                   49

Delivering a Healthy WA
    A Definition of ‘medical practitioner’
    The Health Insurance Act 1973 defines a medical practitioner as:
      A person registered or licensed as a medical practitioner under a law of a State or
      Territory that provides for the registration or licensing of medical practitioners but does
      not include a person so registered or licensed:
      a) whose registration, or licence to practise, as a medical practitioner in any
         State or Territory has been suspended, or cancelled, following an inquiry
         relating to his or her conduct; and
      b) who has not, after that suspension or cancellation, again been authorised to
         register or practise as a medical practitioner in that State or Territory.
    A non-medical practitioner, according to the MBS, includes allied health professionals,
    dentists, dental specialists, practice nurses and nurse practitioners. Therefore, a nurse
    practitioner does not have the same responsibilities and powers to refer as a medical
    practitioner.




                                                                                                    50

Delivering a Healthy WA
    B 19(2) Exemption terminology
    Key terminology relating to designated locations under the Rural Areas 19(2) exempt
    initiative include:33
    •    non-admitted patients: A non-admitted patient is one who does not undergo a hospital’s
         formal admission process. There are three categories of non-admitted patient:
         • emergency department patient;
         • outpatient; and
         • a patient treated by hospital employees off the hospital
             site, including community / outreach services;
    •    Eligible services: Eligible services are non-admitted, non-referred professional
         services (including eligible nursing services) and eligible allied and dental services;
         and
    •    Eligible site: An eligible site is a health facility from which services are traditionally
         provided by the state health authority (including hospitals, multi-purpose services and
         community clinics) that are situated in a locality that is subject to a 19(2) exemption.
    Across WA, 11 sites currently have been granted a 19(2) exemption, although only two
    are currently operating. These are:
     •   Carnarvon                           •   Exmouth
     •   Fitzroy Crossing                    •   Laverton
     •   Leonora                             •   Meekatharra
     •   Mt Barker                           •   Norseman
     •   Ravensthorpe                        •   Shark Bay
     •   Warmun




    33. Commonwealth of Australia and Government of Western Australia. Memorandum of Understanding in relation to the Council of Australian
    Government’s “Better access to primary care services in rural areas initiative 19(2). 2006. Accessed 15 November 2010 at www.amawa.com.
    au/industrial/rural/mou_exemption.pdf.
                                                                                                                                              51

Delivering a Healthy WA
    C Workshop participants – 7 December 2010
    Participants at the workshop held 7 December 2010 included:
    •   Catherine Stoddart, Chief Nurse and Midwifery Officer, Nursing and Midwifery Office,
        Western Australian Department of Health;
    •   Michelle Dillon, Principal Nursing Advisor, Nursing and Midwifery Office, Western
        Australian Department of Health;
    •   Annette Fraser, Senior Nursing Officer, Nursing and Midwifery Office, Western
        Australian Department of Health;
    •   Maree Baxter, Acting Executive Director Nursing, South Metropolitan Area Health
        Service;
    •   Don Black, Principal Policy Advisor, Western Australian Department of Health;
    •   Paul Fraser, Workforce Support Officer, Western Australian Country Health Service;
    •   Craig Gleeson, Principal Industrial Relations Consultant, WA Health Industrial Relations
        Service, Western Australian Department of Health;
    •   Marie Graham, Nursing Director, Corporate Nursing, Sir Charles Gairdner Hospital;
    •   Coral Harkins, Acting Director of Nursing, Western Australian Country Health Service;
    •   Sue Peter, Nursing Director, Princess Margaret Hospital;
    •   Jane Reid, Project Officer, Western Australian Country Health Service;
    •   Vince Iani, Acting Manger Finance, Fremantle Hospital and Health Service;
    •   Kylie Mayo, Director, KPMG;
    •   Paul Whitby, Director, KPMG;
    •   Astrid Lowrey, Manager, KPMG;
    •   Steve Morris, Senior Advisor, KPMG; and
    •   Amy McKerracher, Advisor, KPMG.




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Delivering a Healthy WA
    D Summary of financial information
    A.1.1 Assumptions
    The tables below provide an overview of assumptions that support the development of
    the business and employment models and their respective financial analysis.
    •   Table 9 provides an overview of MBS distribution for each modelled scenario;
    •   Table 10 provide an over view of average length and attributed MBS fee; and
    •   Table 11 provides an overview of labour and associated costs used to model the
        scenarios.
    Table 9: Average consultation length and respective MBS benefit paid
    Consultation information – standard                    Average con-       MBS
                                                           sultation length   benefit paid
                                                           (minutes)
    Brief consultation (82200)                                    15          $9.20
    Standard consultation (82205)                                 20          $17.15
    Extended consultation (82210)                                 30          $32.55
    Long consultation (82215)                                     45          $47.90


    Table 10: Distribution of activity under nurse practitioner MBS items by clinical model
    Consultation in- Hospital out-          Residential     Rural area        Paediatrics ED
    formation – daily patient wound         Care Line       19(2) service     diversion clinic
                      care service          service
                      Per      No. per      Per     No.     Per       No.     Per      No. per
                      cent     day          cent    per     cent      per     cent     day
                                                    day               day
    Brief consultation   25       5         0       0       25        5       62       15
    (82200)
    Standard consul-     65       15        0        0      50        10      28       7
    tation (82205)
    Extended consul-     5        1         0        0      20        4       10       2
    tation (82210)
    Long consultation    5        1         100      5      5         1       0        0
    (82215)
    Consultations per    100      24        100      5      100       20      100      24
    day
    Consulta-                     8.1                3.8              7.3
    tion hours                                                                         7.1
    per day




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Delivering a Healthy WA
    Table 11: Labour and cost inputs
    Labour inputs
    Nurse practitioner salary (1 FTE)         $115,186
    Potential working days per week per FTE   5
    Labour entitlements                       Per cent
    Penalty for overtime                      0
    Superannuation                            9.0
    Annual leave                              6.8        25 days / 365
    Personal leave                            4.1        15 days / 365
    Rostered Days Off (RDOs)                  0.0        10 days / 365
    Long service leave                        3.5        90 days every
                                                         7 years
    Available working days per year           Days
    Days per year                             365
    Less: Weekends                            104
    Less: Public holidays                     10
    Less: Annual leave                        25
    Less: Personal leave                      15
    Less: RDOs                                0
    Less: Training and continuing             10
    professional development (CPD)
    Available working days per year           201
    Other cost inputs
    Facility fee ($ / hour)                   $0
    Insurance ($ / year)                      $6,000
    Set up costs                              $0




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Delivering a Healthy WA
    D.2 Financial models
    Appendices A.2.1.1-A.5.2.2 provide a range of financial and business models. The
    following business and employment models have been considered
    •   Hospital Outpatient Wound Care Service
    - Nurse Practitioner Retains the MBS
        • 100 per cent private
        • 50 per cent private 50 per cent public
        • 20 per cent public and 50 per cent private
    - Nurse Practitioner Assigns the MBS
        • 50 per cent private 50 per cent public
        • 20 per cent public and 50 per cent private
    •   Residential Care Line
    - Nurse Practitioner Retains the MBS
        • 100 per cent private
        • 50 per cent private 50 per cent public
        • 20 per cent public and 50 per cent private
    - Nurse Practitioner Assigns the MBS
        • 50 per cent private 50 per cent public
        • 20 per cent public and 50 per cent private
    •   Public rural service with Rural Areas 19(2) exemption
    - Nurse Practitioner Assigns the MBS
        • 100 per cent public
    •   Paediatric ED Diversion
    - Nurse Practitioner Retains the MBS
        • 100 per cent private
        • 50 per cent private 50 per cent public
        • 20 per cent public and 50 per cent private
    - Nurse Practitioner Assigns the MBS
        • 50 per cent private 50 per cent public
        • 20 per cent public and 50 per cent private




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Delivering a Healthy WA
    D.3 Hospital outpatient wound care service
    A.3.1 Nurse practitioner retains MBS accepts risk
    A.3.1.1 100 per cent private
    Summary for nurse practitioner       Employment     Status quo   Net position
                                         model                       to status quo
    Income
    Base state salary & superannuation $0               $125,553     ($125,553)
    Total claimable MBS fees             $80,792        $0           $80,792
    Total income                         $80,792        $125,553     ($44,761)
    Costs of employment model
    Facility fee                         $0             $0           $0
    Insurance                            ($6,000)       $0           ($6,000)
    Lost entitlements                    ($33,047)      $0           ($33,047)
    Total costs                          ($39,047)      $0           ($39,047)

    Net financial impact for NP          $41,745        $125,553     ($83,808)


    Summary for nurse practitioner       Employment     Status quo   Net position
                                         model                       to status quo
    Salary costs
    Base state salary & superannuation $0               ($125,553)   $125,553
    Total salary costs                 $0               ($125,553)   $125,553
    Income
    Facility fee                         $0             $0           $0
    Total income                         $0             $0           $0

    Net financial impact for organisation $0            ($125,553)   $125,553
    / state
    Patient throughput                    4,824         0            4,824




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Delivering a Healthy WA
    A.3.1.2 50 per cent private 50 per cent public
    Summary for nurse practitioner       Employment   Status quo   Net position
                                         model                     to status quo
    Income
    Base state salary & superannuation $62,776        $125,553     ($62,776)
    Total claimable MBS fees             $40,396      $0           $40,396
    Total income                         $103,172     $125,553     ($22,380)
    Costs of employment model
    Facility fee                         $0           $0           $0
    Insurance                            ($3,000)     $0           ($3,000)
    Lost entitlements                    ($16,524)    $0           ($16,524)
    Total costs                          ($19,524)    $0           ($19,524)

    Net financial impact for NP          $83,649      $125,553     ($41,904)


    Summary for organisation / state Employment       Status quo   Net position
                                     model                         to status quo
    Salary costs
    Base state salary & superannuation ($62,776)      ($125,553)   $62,776
    Total salary costs                 ($62,776)      ($125,553)   $62,776
    Income
    Facility fee                         $0           $0           $0
    Total income                         $0           $0           $0

    Net financial impact for organisation ($62,776)   ($125,553)   $62,776
    / state

    Patient throughput                   2,412        0            2,412




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Delivering a Healthy WA
    A.3.1.3 20 per cent private 80 per cent public
    Summary for nurse practitioner       Employment    Status quo   Net position
                                         model                      to status quo
    Income
    Base state salary & superannuation $100,442        $125,553     ($25,111)
    Total claimable MBS fees             $16,158       $0           $16,158
    Total income                         $116,601      $125,553     ($8,952)
    Costs of employment model
    Facility fee                         $0            $0           $0
    Insurance                            ($1,200)      $0           ($1,200)
    Lost entitlements                    ($6,609)      $0           ($6,609)
    Total costs                          ($7,809)      $0           ($7,809)

    Net financial impact for NP          $108,791      $125,553     ($16,762)


    Summary for                          Employment    Status quo   Net position
    organisation / state                 model                      to status quo
    Salary costs
    Base state salary & superannuation ($100,442)      ($125,553)   $25,111
    Total salary costs                 ($100,442)      ($125,553)   $25,111
    Income
    Facility fee                         $0            $0           $0
    Total income                         $0            $0           $0

    Net financial impact for organisation ($100,442)   ($125,553)   $25,111
    / state

    Patient throughput                   965           0            965




                                                                                    58

Delivering a Healthy WA
    A.3.2 Nurse Practitioner assigns MBS- Organisation accepts risk
    A.3.2.1 50 per cent private 50 per cent public
    Summary for nurse practitioner       Employment   Status quo      Net position
                                         model                        to status quo
    Income
    Base state salary                    $57,593      $115,186        ($57,593)
    Penalties                            $0           $0              $0
    Superannuation                       $5,183       $10,367         ($5,183)
    Incentive payment                    $71,117      $0              $71,117
    Total claimable MBS fees             $40,396      $0              $40,396
    Total income                         $174,289     $125,553        $48,736
    Costs of employment model
    Facility fee                         ($37,396)    $0              ($37,396)
    Insurance                            ($3,000)     $0              ($3,000)
    Lost entitlements                    ($8,340)     $0              ($8,340)
    Total costs                          ($48,736)    $0              ($48,736)

    Net financial impact for NP          $125,553     $125,553        $0


    Summary for                          Employment   Status quo      Net position
    organisation / state                 model                        to status quo
    Salary costs
    Base state salary & superannuation ($62,776)      ($125,553)      $62,776
    Incentive payment                    ($71,117)    $0              ($71,117)
    Total salary costs                   ($133,893)   ($125,553)      ($8,340)
    Income
    Facility fee                         $37,396      $0              $37,396
    Total income                         $37,396      $0              $37,396

    Net financial impact for organisation ($96,497)   ($125,553)      $29,056
    / state

    Patient throughput                   2,412        0               2,412




                                                                                      59

Delivering a Healthy WA
    A.3.2.2 20 per cent private 80 per cent public
    Summary for nurse practitioner       Employment    Status quo   Net position
                                         model                      to status quo
    Income
    Base state salary                    $92,149       $115,186     ($23,037)
    Penalties                            $0            $0           $0
    Superannuation                       $8,293        $10,367      ($2,073)
    Incentive payment                    $28,447       $0           $28,447
    Total claimable MBS fees             $16,158       $0           $16,158
    Total income                         $145,047      $125,553     $19,495
    Costs of employment model
    Facility fee                         ($14,958)     $0           ($14,958)
    Insurance                            ($1,200)      $0           ($1,200)
    Lost entitlements                    ($3,336)      $0           ($3,336)
    Total costs                          ($19,495)     $0           ($19,495)

    Net financial impact for NP          $125,553      $125,553     $0


    Summary for                          Employment    Status quo   Net position
    organisation / state                 model                      to status quo
    Salary costs
    Base state salary & superannuation ($100,442)      ($125,553)   $25,111
    Incentive payment                    ($28,447)     $0           ($28,447)
    Total salary costs                   ($128,889)    ($125,553)   ($3,336)
    Income
    Facility fee                         $14,958       $0           $14,958
    Total income                         $14,958       $0           $14,958

    Net financial impact for organisation ($113,930)   ($125,553)   $11,622
    / state

    Patient throughput                   965           0            965




                                                                                    60

Delivering a Healthy WA
    D.4   Residential care line
    A.4.1 Nurse practitioner retains MBS and accepts risk
    A.4.1.1 100 per cent private
    Summary for nurse practitioner       Employment   Status quo   Net position
                                         model                     to status quo
    Income
    Base state salary & superannuation $0             $125,553     ($125,553)
    Total claimable MBS fees             $48,140      $0           $48,140
    Total income                         $48,140      $125,553     ($77,413)
    Costs of employment model
    Facility fee                         $0           $0           $0
    Insurance                            ($6,000)     $0           ($6,000)
    Lost entitlements                    ($33,047)    $0           ($33,047)
    Total costs                          ($39,047)    $0           ($39,047)

    Net financial impact for NP          $9,092       $125,553     ($116,461)


    Summary for                          Employment   Status quo   Net position
    organisation / state                 model                     to status quo
    Salary costs
    Base state salary & superannuation $0             ($125,553)   $125,553
    Total salary costs                 $0             ($125,553)   $125,553
    Income
    Facility fee                         $0           $0           $0
    Total income                         $0           $0           $0

    Net financial impact for organisation $0          ($125,553)   $125,553
    / state

    Patient throughput                   1,005        0            1,005




                                                                                   61

Delivering a Healthy WA
    A.4.1.2 50 per cent private 50 per cent public
    Summary for nurse practitioner       Employment   Status quo   Net position
                                         model                     to status quo
    Income
    Base state salary & superannuation $62,776        $125,553     ($62,776)
    Total claimable MBS fees             $24,070      $0           $24,070
    Total income                         $86,846      $125,553     ($38,707)
    Costs of employment model
    Facility fee                         $0           $0           $0
    Insurance                            ($3,000)     $0           ($3,000)
    Lost entitlements                    ($16,524)    $0           ($16,524)
    Total costs                          ($19,524)    $0           ($19,524)

    Net financial impact for NP          $67,322      $125,553     ($58,230)


    Summary for                          Employment   Status quo   Net position
    organisation / state                 model                     to status quo
    Salary costs
    Base state salary & superannuation ($62,776)      ($125,553)   $62,776
    Total salary costs                 ($62,776)      ($125,553)   $62,776
    Income
    Facility fee                         $0           $0           $0
    Total income                         $0           $0           $0

    Net financial impact for organisation ($62,776)   ($125,553)   $62,776
    / state

    Patient throughput                   503          0            503




                                                                                   62

Delivering a Healthy WA
    A.4.1.3 20 per cent private 80 per cent public
    Summary for nurse practitioner       Employment    Status quo   Net position
                                         model                      to status quo
    Income
    Base state salary & superannuation $100,442        $125,553     ($25,111)
    Total claimable MBS fees             $9,628        $0           $9,628
    Total income                         $110,070      $125,553     ($15,483)
    Costs of employment model
    Facility fee                         $0            $0           $0
    Insurance                            ($1,200)      $0           ($1,200)
    Lost entitlements                    ($6,609)      $0           ($6,609)
    Total costs                          ($7,809)      $0           ($7,809)

    Net financial impact for NP          $102,261      $125,553     ($23,292)


    Summary for                          Employment    Status quo   Net position
    organisation / state                 model                      to status quo
    Salary costs
    Base state salary & superannuation ($100,442)      ($125,553)   $25,111
    Total salary costs                 ($100,442)      ($125,553)   $25,111
    Income
    Facility fee                         $0            $0           $0
    Total income                         $0            $0           $0

    Net financial impact for organisation ($100,442)   ($125,553)   $25,111
    / state

    Patient throughput                   201           0            201




                                                                                    63

Delivering a Healthy WA
    A.4.2 Nurse Practitioner assigns MBS – organisation accepts risk
    A.4.2.1 50 per cent private 50 per cent public
    Summary for nurse practitioner       Employment    Status quo      Net position
                                         model                         to status quo
    Income
    Base state salary                    $57,593       $115,186        ($57,593)
    Penalties                            $0            $0              $0
    Superannuation                       $5,183        $10,367         ($5,183)
    Incentive payment                    $71,117       $0              $71,117
    Total claimable MBS fees             $24,070       $0              $24,070
    Total income                         $157,963      $125,553        $32,410
    Costs of employment model
    Facility fee                         ($21,070)     $0              ($21,070)
    Insurance                            ($3,000)      $0              ($3,000)
    Lost entitlements                    ($8,340)      $0              ($8,340)
    Total costs                          ($32,410)     $0              ($32,410)

    Net financial impact for NP          $125,553      $125,553        $0


    Summary for                          Employment    Status quo      Net position
    organisation / state                 model                         to status quo
    Salary costs
    Base state salary & superannuation ($62,776)       ($125,553)      $62,776
    Incentive payment                    ($71,117)     $0              ($71,117)
    Total salary costs                   ($133,893)    ($125,553)      ($8,340)
    Income
    Facility fee                         $21,070       $0              $21,070
    Total income                         $21,070       $0              $21,070

    Net financial impact for organisation ($112,823)   ($125,553)      $12,729
    / state

    Patient throughput                   503           0               503




                                                                                       64

Delivering a Healthy WA
    A.4.2.2 20 per cent private 80 per cent public
    Summary for nurse practitioner       Employment    Status quo   Net position
                                         model                      to status quo
    Income
    Base state salary                    $92,149       $115,186     ($23,037)
    Penalties                            $0            $0           $0
    Superannuation                       $8,293        $10,367      ($2,073)
    Incentive payment                    $28,447       $0           $28,447
    Total claimable MBS fees             $9,628        $0           $9,628
    Total income                         $138,517      $125,553     $12,964
    Costs of employment model
    Facility fee                         ($8,428)      $0           ($8,428)
    Insurance                            ($1,200)      $0           ($1,200)
    Lost entitlements                    ($3,336)      $0           ($3,336)
    Total costs                          ($12,964)     $0           ($12,964)

    Net financial impact for NP          $125,553      $125,553     $0


    Summary for                          Employment    Status quo   Net position
    organisation / state                 model                      to status quo
    Salary costs
    Base state salary & superannuation ($100,442)      ($125,553)   $25,111
    Incentive payment                    ($28,447)     $0           ($28,447)
    Total salary costs                   ($128,889)    ($125,553)   ($3,336)
    Income
    Facility fee                         $8,428        $0           $8,428
    Total income                         $8,428        $0           $8,428

    Net financial impact for organisation ($120,461)   ($125,553)   $5,092
    / state

    Patient throughput                   201           0            201




                                                                                    65

Delivering a Healthy WA
    D.5   Rural public service
    A.5.1 Nurse practitioner assigns MBS – organisation accepts risk.
    Summary for nurse practitioner       Employment   Status quo        Net position
                                         model                          to status quo
    Income
    Base state salary & superannuation $125,553       $125,553          $0
    Total income                         $125,553     $125,553          $0
    Costs of employment model
    Total costs                          $0           $0                $0

    Net financial impact for NP          $125,553     $125,553          $0


    Summary for                          Employment   Status quo        Net position
    organisation / state                 model                          to status quo
    Salary costs
    Base state salary & superannuation ($125,553)     ($125,553)        $0
    Total salary costs                 ($125,553)     ($125,553)        $0
    Income
    Total claimable MBS fees             $46,895      $0                $46,895
    Total income                         $46,895      $0                $46,895

    Net financial impact for organisation ($78,657)   ($125,553)        $46,895
    / state

    Patient throughput                   2,412        0                 2,412




                                                                                        66

Delivering a Healthy WA
    D.6   Paediatrics emergency diversion clinic
    A.6.1 Nurse practitioner retains MBS and accepts risk
    A.6.1.1 100 per cent private
    Summary for nurse practitioner       Employment   Status quo   Net position
                                         model                     to status quo
    Income
    Base state salary & superannuation $0             $125,553     ($125,553)
    Total claimable MBS fees             $60,883      $0           $60,883
    Total income                         $60,883      $125,553     ($64,670)
    Costs of employment model
    Facility fee                         $0           $0           $0
    Insurance                            ($6,000)     $0           ($6,000)
    Lost entitlements                    ($33,047)    $0           ($33,047)
    Total costs                          ($39,047)    $0           ($39,047)

    Net financial impact for NP          $21,836      $125,553     ($103,717)


    Summary for                          Employment   Status quo   Net position
    organisation / state                 model                     to status quo
    Salary costs
    Base state salary & superannuation $0             ($125,553)   $125,553
    Total salary costs                 $0             ($125,553)   $125,553
    Income
    Facility fee                         $0           $0           $0
    Total income                         $0           $0           $0

    Net financial impact for organisation $0          ($125,553)   $125,553
    / state

    Patient throughput                   4,824        0            4,824




                                                                                   67

Delivering a Healthy WA
    A.6.1.2 50 per cent private 50 per cent public
    Summary for nurse practitioner       Employment   Status quo   Net position
                                         model                     to status quo
    Income
    Base state salary & superannuation $62,776        $125,553     ($62,776)
    Total claimable MBS fees             $30,441      $0           $30,441
    Total income                         $93,218      $125,553     ($32,335)
    Costs of employment model
    Facility fee                         $0           $0           $0
    Insurance                            ($3,000)     $0           ($3,000)
    Lost entitlements                    ($16,524)    $0           ($16,524)
    Total costs                          ($19,524)    $0           ($19,524)

    Net financial impact for NP          $73,694      $125,553     ($51,859)


    Summary for                          Employment   Status quo   Net position
    organisation / state                 model                     to status quo
    Salary costs
    Base state salary & superannuation ($62,776)      ($125,553)   $62,776
    Total salary costs                 ($62,776)      ($125,553)   $62,776
    Income
    Facility fee                         $0           $0           $0
    Total income                         $0           $0           $0

    Net financial impact for organisation ($62,776)   ($125,553)   $62,776
    / state

    Patient throughput                   2,412        0            2,412




                                                                                   68

Delivering a Healthy WA
    A.6.1.3 20 per cent private 80 per cent public
    Summary for nurse practitioner       Employment    Status quo   Net position
                                         model                      to status quo
    Income
    Base state salary & superannuation $100,442        $125,553     ($25,111)
    Total claimable MBS fees             $12,177       $0           $12,177
    Total income                         $112,619      $125,553     ($12,934)
    Costs of employment model
    Facility fee                         $0            $0           $0
    Insurance                            ($1,200)      $0           ($1,200)
    Lost entitlements                    ($6,609)      $0           ($6,609)
    Total costs                          ($7,809)      $0           ($7,809)

    Net financial impact for NP          $104,809      $125,553     ($20,743)


    Summary for                          Employment    Status quo   Net position
    organisation / state                 model                      to status quo
    Salary costs
    Base state salary & superannuation ($100,442)      ($125,553)   $25,111
    Total salary costs                 ($100,442)      ($125,553)   $25,111
    Income
    Facility fee                         $0            $0           $0
    Total income                         $0            $0           $0

    Net financial impact for organisation ($100,442)   ($125,553)   $25,111
    / state

    Patient throughput                   965           0            965




                                                                                    69

Delivering a Healthy WA
    A.6.2 Nurse practitioner assigns MBS – organisation accepts risk
    A.6.2.1 50 per cent private 50 per cent public
    Summary for nurse practitioner       Employment    Status quo      Net position
                                         model                         to status quo
    Income
    Base state salary                    $57,593       $115,186        ($57,593)
    Penalties                            $0            $0              $0
    Superannuation                       $5,183        $10,367         ($5,183)
    Incentive payment                    $71,117       $0              $71,117
    Total claimable MBS fee              $30,441       $0              $30,441
    Total income                         $164,334      $125,553        $38,782
    Costs of employment model
    Facility fee                         ($27,441)     $0              ($27,441)
    Insurance                            ($3,000)      $0              ($3,000)
    Lost entitlements                    ($8,340)      $0              ($8,340)
    Total costs                          ($38,782)     $0              ($38,782)

    Net financial impact for NP          $125,553      $125,553        $0


    Summary for                          Employment    Status quo      Net position
    organisation / state                 model                         to status quo
    Salary costs
    Base state salary & superannuation ($62,776)       ($125,553)      $62,776
    Incentive payment                    ($71,117)     $0              ($71,117)
    Total salary costs                   ($133,893)    ($125,553)      ($8,340)
    Income
    Facility fee                         $27,441       $0              $27,441
    Total income                         $27,441       $0              $27,441

    Net financial impact for organisation ($106,452)   ($125,553)      $19,101
    / state

    Patient throughput                   2,412         0               2,412




                                                                                       70

Delivering a Healthy WA
    A.6.2.2 20 per cent private 80 per cent public
    Summary for nurse practitioner       Employment    Status quo   Net position
                                         model                      to status quo
    Income
    Base state salary                    $92,149       $115,186     ($23,037)
    Penalties                            $0            $0           $0
    Superannuation                       $8,293        $10,367      ($2,073)
    Incentive payment                    $28,447       $0           $28,447
    Total claimable MBS fee              $12,177       $0           $12,177
    Total income                         $141,065      $125,553     $15,513
    Costs of employment model
    Facility fee                         ($10,977)     $0           ($10,977)
    Insurance                            ($1,200)      $0           ($1,200)
    Lost entitlements                    ($3,336)      $0           ($3,336)
    Total costs                          ($15,513)     $0           ($15,513)

    Net financial impact for NP          $125,553      $125,553     $0


    Summary for                          Employment    Status quo   Net position
    organisation / state                 model                      to status quo
    Salary costs
    Base state salary & superannuation ($100,442)      ($125,553)   $25,111
    Incentive payment                    ($28,447)     $0           ($28,447)
    Total salary costs                   ($128,889)    ($125,553)   ($3,336)
    Income
    Facility fee                         $10,977       $0           $10,977
    Total income                         $10,977       $0           $10,977

    Net financial impact for organisation ($117,912)   ($125,553)   $7,640
    / state

    Patient throughput                   965           0            965




                                                                                    71

Delivering a Healthy WA

				
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