Evaluation of the Medical Specialist Outreach Assistance Program and the Visiting Optometrists Scheme

7.1 Program effectiveness, cost effectiveness and equity

Page last updated: 28 February 2012

Stakeholder views

In the survey of MSOAP service providers, the majority assessed the scheme as being very effective or reasonably effective in terms of improving access to specialist services for non-Indigenous populations (97%) and Aboriginal and Torres Strait Islander populations (87%) (Table 59). The scheme was judged to be very effective in improving access for non-Indigenous people by 59% of services providers and very effective in improving access for Aboriginal and Torres Strait Islander people by 34% of services providers.

Table 59 MSOAP service provider views on the effectiveness of MSOAP in improving access to specialist services for people living in rural and remote Australia
How effective is MSOAP in improving access to specialist services for:
  Indigenous Australians Non-Indigneous people
1. Very effective 34% 59%
2. Reasonably effective 53% 38%
3. Not effective 14% 3%

Survey respondents made a range of suggestions for improving the effectiveness of the scheme (see Volume 3 Table 3.10). Suggestions for improving the program included the level or support or nature of services eligible under the program (83 suggestions), improvements to coordination and communication (44 suggestions), issues related to local services visited (27 suggestions) and administration of the program (11 suggestions). The main suggestions were to increase funding and number of visits funded under MSOAP (30 respondents), improve the administrative support and/or coordination at site/community visited (22 respondents), provide support under the program for complementary nurse/allied health service providers (14 respondents), provide for an improved or expanded upskilling role (13 respondents), and improve local primary care services (11 respondents).

Service providers were also asked about their billing practices related to outreach services (Table 60). A small proportion of service providers (5%) charged all their patients a gap payment. A further 21% of service providers charged a gap payment for some patients in the same way that applies in their principal practice, and 12% charged gap payments for some patients but were less likely to charge gap payment in the outreach setting. An estimated 38% of service providers bulk billed all their patients in outreach settings and 24% made no claim in relation to Medicare and did not charge patients a fee. Billing arrangements varied by specialty, with surgeons and obstetricians/gynaecologists less likely to bulk bill or have any additional charges. Billing practices also varied between the practice arrangements of the specialist (Table 61). Staff specialists were much more likely to bulk bill (51%) or make no Medicare claim/charge (24%). Private practice specialists were more likely to charge patients a gap fee.

Table 60 MSOAP service provider billing arrangements by specialty
  Medical Surgical Obstetrics & gynaecology Psychiatry Allied health Total
1. All patients are charged a gap payment 4% 15% 0% 4% 0% 5%
2. A proportion of patients are charged a gap payment in the same way as applies in your principal practice, and others bulk billed 18% 33% 54% 4% 0% 21%
3. A proportion of patients are charged a gap payment, but more patients are likely to be bulk billed compared with your principal practice 9% 26% 15% 13% 0% 12%
4. Patients seen are bulk billed under Medicare 48% 18% 15% 42% 18% 38%
5. No Medicare claim is made for patients seen and no patient charges are applied 21% 8% 15% 38% 82% 24%

Source: HPA survey of MSOAP service providers, 2011

Table 61 MSOAP service provider billing arrangements by practice arrangement
  Private practice with no or limited involvement with a public hospital Private practice with some or significant involvement with a public hospital as a VMO Staff Specialist Total
1. All patients are charged a gap payment 13% 9% 0% 5%
2. A proportion of patients are charged a gap payment in the same way as applies in your principal practice, and others bulk billed 34% 33% 5% 21%
3. A proportion of patients are charged a gap payment, but more patients are likely to be bulk billed compared with your principal practice 9% 20% 7% 12%
4. Patients seen are bulk billed under Medicare 34% 29% 51% 38%
5. No Medicare claim is made for patients seen and no patient charges are applied 9% 10% 37% 24%

Source: HPA survey of MSOAP service providers, 2011

The survey also provided some evidence on the involvement of MSOAP service providers prior to receiving MSOAP support (Table 78). This is relevant to considering the extent to which MSOAP has contributed to an expansion of outreach services. Seventeen per cent of respondents indicated that they had been involved with providing outreach services prior to receiving support from the program, and have not expanded service provision since receiving support. A further 44% of respondents were involved in outreach services prior to receiving support from the program, and have expanded service provision since receiving support. A further 38% were not involved in providing outreach services prior to receiving support under MSOAP.

Table 62 MSOAP service provider involvement with outreach prior to receiving MSOAP supportTop of page
1. Involved in providing outreach prior to receiving MSOAP support - Have not expanded outreach since receiving MSOAP support 17%
2. Involved in providing outreach prior to receiving MSOAP support - Have expanded outreach since receiving MSOAP support 44%
3. Involved in providing outreach prior to receiving MSOAP support - Other 1%
4. Not involved in providing outreach prior to receiving MSOAP support 38%

Source: HPA survey of MSOAP service providers, 2011. See also Table 3.8 in Volume 3.

Service providers were also asked to assess the quality of clinical services in the outreach settings they visited, compared with their metropolitan/regional practice and also the quality of communication on clinical care with primary care providers. The majority of respondents reported quality was similar in the outreach setting to the metropolitan/regional settings. Fourteen per cent considered clinical quality superior in outreach settings and 18% considered clinical quality not as good. Interestingly, 16% considered the level of communication with the patient’s primary medical care provider to be superior in outreach settings and 8% considered the quality of communication to be not as good. This suggests that on these dimensions, quality of care is similar in the outreach settings to metropolitan and regional settings and communication with primary care medical providers slightly superior. This observation was made by some of the stakeholders interviewed for the project, who emphasised that the outreach arrangement often facilitate a shared care approach to service delivery, which is often missing in metropolitan settings.

Table 63 MSOAP service provider assessment of quality of clinical services and clinical communication in outreach settings
  Compared with what occurs in metropolitan / regional practice settings how would you assess the quality of:
  Clinical services supported through MSOAP? Communication on clinical care matters between you and your patient's GP/health service medical officer in the outreach locations?
1. Superior 14% 16%
2. Similar 68% 76%
3. Not as good 18% 8%

Source: HPA survey of MSOAP service providers, 2011. See also Table 3.11 in Volume 3.

In addition to the provision of direct patient care services, outreach service providers are often also involved upskilling of local health care staff and clinical teaching activities. The survey of MSOAP service providers gives some indication of the extent to which service providers are involved in these additional activities (Table 64). A major benefit of these activities is to improve the skills, capacity and confidence of local primary care staff in managing patients with particular medical conditions, particularly where the specialist is available on a liaison basis between visits.

Table 64 MSOAP service providers involvement with other functions during outreach visits by remoteness area of locationTop of page
What other functions do you undertake during the visit? Inner and Outer Regional Remote and Very Remote Total
1.1 Upskilling of Aboriginal Health workers 5% 21% 11%
2.1 Upskilling of local GP 30% 18% 26%
3.1 Upskilling of local medical officer 14% 17% 15%
4.1 Upskilling of nursing staff 22% 24% 23%
5.1 Upskilling of other health staff 16% 15% 16%
6.1 Teaching (i.e. medical students, trainees, etc.) 12% 4% 9%
7.1 Holding meetings (i.e. case conference, education) 1% 1% 1%

Source: HPA survey of MSOAP service providers, 2011. See also Table 3.27 in Volume 3.
Note: Providers may be involved with more than one additional function during outreach visits.

Primary care providers consulted, including those consulted through the community case studies, were all positive about outreach specialist services provided to their communities. They were strongly supportive of maintenance of services and expansion in areas of need. They valued continuity in the specialist service providers. They felt the outreach services enhanced their primary care capacity, sometimes through provision of upskilling, but also through less structured discussion of cases, and the capacity to consult with specialists by telephone in between visits. They felt telemedicine alternatives will be valuable, but saw an ongoing need for the maintenance of visiting services, potentially using telemedicine in between visits. The fact that some visiting specialists do not bulk bill was mentioned as a problem, particularly for Aboriginal and Torres Strait Islander patients.

Outreach services being provided into hospital settings were also considered important by managers of these hospitals. However, tensions sometimes emerged in these arrangements between the availability of local resources (e.g. nursing staff to support an operating theatre session and patient in wards) and the visiting specialist intention to provide services. Local priorities do not also match those of visiting services. One example of this was that a local health service had placed limits on numbers of patients receiving cataract surgery despite the availability of an outreach team.

Specialists participating in the program generally believed it was very effective, a finding confirmed by the survey of participating specialists (see Table 59). They saw the presence of a strong primary care health service with a high level of stability and continuity as an important base for providing outreach services. This was mentioned as a particular challenge for very remote locations where turnover in primary care staff is often high. They valued the availability of local staff for assisting with coordinating services and assisting with provision, but often saw this as being insufficient, particularly in more remote locations. Coordination of eye care services was mentioned as a major challenge which was working well in some locations, but very poor in many others. Specialists consulted believed the program had assisted in ensuring outreach services were placed on a more sustainable basis, not as reliant on the goodwill of service providers and had expanded outreach services.

Managers in local health services and in Divisions of General Practice considered that the program provided good value. Some had had a high level of involvement with priority setting for the program, but others believed they had not been sufficiently engaged. The staffing costs as well as MSOAP funding associated with staff based in regional hospitals can be significant. There is often a tension between the needs of the hospital in which the specialist is based and the demands for outreach services. Often outreach visits are cancelled because of these tensions, but also it was felt the needs of the hospital can be compromised because of the level of outreach service being provided. Some Divisions of General Practice saw a need to locate the management of MSOAP and its associated funding to an organisation representing the communities to which outreach services are provided.

Most fundholders felt that the program was very effective in getting services on the ground. They received very positive feedback on the value of outreach services from primary care providers in the locations visited. Some fundholders felt the achievements of the program were undersold and not explained to stakeholders and the public generally. Due to a lack of feedback, they felt it was difficult to ascertain how the program was performing or they were performing as a fundholder. They felt that the program needed to allocate resources on an ongoing basis to evaluation and feedback. A particular area mentioned was the lack of information about health outcomes related to the outreach services supported. All fundholders felt the administrative reporting processes detracted from program effectiveness (see discussion below), particularly in the lack of responsiveness and flexibility in decision making on specific service proposals. The lack of eligibility (under MSOAP Core) of services that complement specialist care, including allied health, was mentioned by all fundholders as a constraint on effectiveness. The lack of eligibility of dental care was also highlighted as a major limitation, given the needs in rural and remote locations.

In consultations with state/NT offices of DoHA we generally found that the program was considered to be effective on the whole, but was hampered by a range of practical and administrative issues. In some jurisdictions there were significant concerns with persistent under-spending, which was sometimes felt to reflect problems with the fundholder and administrative processes. Officers believed they were not able to fully understand the impact of the program in their jurisdiction and nationally because of poor access to program data.

Other national stakeholders often did not have access to information about MSOAP. Most suggested that the program was very effective and valued. Amongst some consulted there was a concern the program was supply driven rather demand driven. Several mentioned anecdotes in which the services supported by MSOAP reflected an arrangement convenient to the specialist, but not reflecting the significant local need.

Most stakeholders believed the programs have room for future growth, though proper guidance is needed for growth to be effective and directed to communities with highest level of need.

Evaluation Findings - Effectiveness

The evidence presented above suggests that MSOAP is having a material impact on access to specialist services for rural and remote Australia. The relative impact of MSOAP on access to specialist services was estimated in an earlier chapter (Chapter 5 - Table 50, Figure 15, Figure 16). Overall it is estimated that MSOAP Core has reduced the gap in access to specialist service between major cities and rural and remote Australia by 0.6 percentage points for inner regional areas, 2.2 percentage points for outer regional, 2.1 percentage points for remote and 9.4 percentage points for very remote. The relative importance of MSOAP varies across these areas. It represents 0.7% of services in inner regional, 3% in outer regional, 4.2% in remote and between 27.2 and 28.7% in very remote areas.

In addition to improving access, the program has had additional benefits including:
    • Strengthening the capacity of primary care, through upskilling, the provision of a consultation and liaison service outside the actual visit and other shared care style arrangements. This can result in a more capable primary care service with the confidence to manage more complex patients with ongoing needs in the community.
    • Increasing the attractiveness of primary care.
    • Particularly in regions where there is high turnover in primary care staff, providing continuity in managing patients with ongoing chronic health issues.
    • Reducing costs to patients and their families, the health system and the broader community through avoiding travel to regional or metropolitan centres to access specialist care.
The impact of the program on health outcomes is unknown and difficult to assess. Specialist services cover a wide range of conditions and interventions, some of which are acute and others chronic.

It is concluded that the key issues in the program’s design that impact the overall effectiveness of the program are:
    • Variation in how the program is run across states/Northern Territory. This has led to differences in the identification of need and development of services to address that need. While there is a requirement to adapt services for local needs, some national reference points would improve planning and priority setting. Overall there is a need for better mechanisms for identifying priorities and gaps in outreach services that will most impact gaps in health status for rural and remote populations.
    • Integration of visiting services with local primary care services is important for service effectiveness. MSOAP has been a vehicle through which primary care and specialists have been able to develop relationships and shared care arrangements. It will be important to emphasise these issues in the development of services in the future
    • The program needs to recognise and support coordination at the local (community) level, particularly for Aboriginal and Torres Strait Islander health services and services in remote Australia. Some stakeholders believe the current gaps were not so much about clinical support at the local level but practical coordination. Examples are ensuring local physical facilities are not over-subscribed or advising visiting service providers that a planned visit will be problematic (e.g. because of sorry business, providing a driver to transport patients to the health clinic.)
    • The program needs to recognise and support coordination and sharing of information at the regional level. For example, there is a need for better mechanisms to sharing information about all outreach services going to each locality, including outreach services not funded by MSOAP or VOS.

Evaluation findings - Cost effectiveness

Cost effectiveness of the program was also considered. The average cost per patient consultation, based on actual reported patients and expenditures, is estimated at $93 (excluding fundholder and DoHA administration costs). This ranges from $71 per patient consultation in inner regional locations to $157 in very remote areas.

A contextual issue is that medical benefits paid for a specialist consultation were around $69 per consultation in 2009-10 and the average patient out of pocket contribution was $30 per consultation (Medicare Statistics). Therefore, MSOAP direct costs are 150% of the consultation fee and around 200% of the consultation fee in very remote areas.

As discussed below, various strategies could be adopted that would improve overall cost effectiveness of the program by reducing its costs. These include:
    • Reducing unnecessary administration through reducing the number of fundholders, number of funding agreements and rationalising reporting requirements under funding agreements.
    • Improving the targeting of services through better planning.
    • Improving coordination of services at a regional and local level, particular in remote areas.
    • Encouraging high quality integration and coordination with primary care providers.
Alternatives to outreach speciality care include:
    • Patient assisted travel and accommodation (average cost of $200 per patient assisted trip).
    • Consultations by telemedicine.
    • Use of primary care providers only.
These options are not mutually exclusive and combinations of these are feasible. Other benefits of outreach care need to be considered in cost effectiveness, including how outreach services strengthen and support primary care providers. Outreach services represent a cost effective alternative to patient assisted travel, and GP only care. However, various configurations of shared care and telemedicine (some of which are currently supported in the program) should also be considered. The program needs mechanisms to be able to support alternative mechanisms of delivering outreach services where these may represent a more effective or efficient option.

Evaluation findings – Equity

There is evidence the current allocation of funds does not fully reflect relative need both between and within jurisdictions. There is an opportunity to update weightings to reflect better information on relative cost and need for specialist services. The current weights for MSOAP Core were developed to reflect the RRMA classification and therefore do not translate directly to the ASGC remoteness classification. An alternative approach would be to use an analysis of MBS specialist services to estimate the relative needs of different remoteness areas and use the data on costs of services presented earlier in this report to weight services for differential costs in service delivery. Table 65 illustrates one possible approach. In this approach a pragmatic objective is set: to reduce the gap between the level of specialist service provision for each remoteness area and the level of service provision in major cities by 50%. The level of specialist services to achieve this objective is estimated. This is weighted by the relative cost per patient of each service, from 0.77 in inner regional to 1.69 in remote. From these two factors an overall population weighting is derived.

Table 65 – Possible approach to calculation of relative weights for allocation of MSOAP funds
  Specialist service per 1,000 Services required to reduce gap by 50% Relative cost of services Services weighted for relative cost Overall share of services weighted for relative cost Population '000 Alternative Weighting
Major cities 1,189            
Inner Regional 1,062 269 0.77 220 21 4,240 0.33
Outer Regional 895 283 0.82 369 35 1,926 1.22
Remote 581 98 1.44 254 24 321 5.03
Very Remote 429 65 1.69 203 19 172 7.54
Total 1,122 742 1.00 1,047 100 6,659 1.00

We believe there is a need for full consultation on alternative weightings as there are several other factors that could be considered (e.g. the level of specialist services per capita in remoteness areas RA2-RA5 varies significantly between jurisdictions).

For MSOAP-ICD funding has been allocated between jurisdictions based on the unweighted Aboriginal and Torres Strait Islander population in remoteness areas RA2-RA5 in each jurisdiction (plus the minimum administration loading). We believe that this approach fails to adequately take into account the additional cost of providing services in more remote regions. As MSOAP-ICD is expanded, we recommend that weighting for relative cost be included in the formula for setting target allocations, as illustrated in the following table.

Table 66 – Impact of including weightings to reflect the relative cost of service delivery for MSOAP–ICDTop of page
  Weights NSW Vic. Qld WA SA Tas. NT Total
Aboriginal and Torres Strait Islander Population '000
Major cities   64 15 41 27 13 - - 160
Inner Regional   49 11 30 6 2 9 - 108
Outer Regional   27 5 43 12 6 7 14 113
Remote   6 0 13 14 1 0 15 49
Very Remote   1 - 20 19 4 0 37 82
Total   148 31 146 78 26 17 67 513
Population in RA2 - RA5   84 16 105 51 13 17 67 353
Percentage share   24% 4% 30% 14% 4% 5% 19% 100%
Weighted population - Cost weightings '1000
Major cities - - - - - - - - -
Inner Regional 0.77 38 8 23 5 2 7 - 83
Outer Regional 0.82 22 4 35 10 5 6 11 92
Remote 1.44 9 0 18 19 2 1 22 71
Very Remote 1.69 2 - 34 33 6 0 63 138
Total 1.00 71 12 110 67 15 14 97 385
Percentage share   19% 3% 29% 17% 4% 4% 25% 100%

Note: This table does not include the impact of the ‘minimum’ base allocation

A similar issue applies for MSOAP Maternity, which uses unweighted births occurring in remoteness areas RA2-RA5 in each jurisdiction. We consider that weighting for relative cost is also appropriate for these allocations. However, because of the size of funds involved, implementation of weights for cost should only be considered where additional funds are allocated to the program.
  1. Recommendations

    New funding under the Rural Health Outreach Fund should be targeted at regions and communities with the highest levels of need. Better mechanisms are required to assess levels of need and gaps in access; and take into account the cost of service delivery in more remote locations. This may mean that the funding formula used for allocating funds between jurisdictions may need to change. Changes to allocations between jurisdictions should be achieved through targeting the allocation of new funding, rather than distribution of existing funding.
  2. To improve the effectiveness of outreach services, the types of service eligible for support should be extended. The following extensions are recommended:
      1. Under the Rural Health Outreach Fund, eligibility should be extended to services involving clinical support staff accompanying the medical specialist, including nurses and allied health, where the clinical support staff member is usually required for the delivery of the clinical services provided by the medical specialist.
      2. Telemedicine services should continue to be supported where these are not eligible for subsidy under Medicare.
      3. Under MSOAP-ICD, eligibility should be extended to include support for local coordination of outreach services. This largely relates to funding of local staff in Aboriginal and Torres Strait Islander health services (both non-government and government) to assist with local coordination issues including: scheduling of visiting specialists and patients, ensuring physical space is available for a specialist visit, ensuring visiting specialists are aware of cultural or other events that might impact patient attendance, reminding patients when a specialist visit is imminent, arranging or providing transportation so patients are physically able to attend clinics, and assisting with follow-up issues after a specialist visit.
      4. Under the Rural Health Outreach Fund and MSOAP-ICD, funding should be provided for regional outreach coordinator positions, focussed on outreach services into remote and very remote communities.
      5. The Commonwealth Government should consider opportunities to support outreach Ear Nose and Throat (ENT) specialist outreach services for Aboriginal and Torres Strait Islander peoples under MSOAP.
  3. State, territory and Commonwealth governments should consider opportunities to use the administrative arrangements available under MSOAP for outreach dental health services for remote communities.
  4. DoHA develop mechanisms for sharing comprehensive information about outreach health services available in all rural and remote communities across Australia. Although not specifically within the scope of this review, this should also apply to locally available services. There are several components in achieving this recommendation, including:
      1. Funding agreements with service providers participating under MSOAP and VOS should stipulate that information about the visiting service they have agreed to provide will be made available to the public and shared for planning and coordination purposes.
      2. Information on outreach services outside MSOAP is also required (e.g. those supported by the state/territory health authorities).
      3. Comprehensive information should be openly available to the public and health service providers.
      4. Good mechanisms are required to ensure information is current.
  5. When selecting or reviewing specialists participating in MSOAP, fundholders should examine the billing practices, particularly where this affects access by very disadvantaged groups.
  6. Population weights used to determine the allocation of MSOAP Core and MSOAP-ICD funding across jurisdiction be updated to better reflect relative needs across remoteness regions and the higher cost of supporting outreach services in more remote regions. There should be consultation with all relevant parties before changes to the underlying formula are implemented. Resulting changes to allocations between jurisdictions should be achieved through targeting of new funding, rather than distribution of existing funds.Top of page