Review of methadone treatment in Australia

12.3 Option 3: client management model

Page last updated: October 1995

Under this option a single payment would be paid by the Commonwealth to cover the range of methadone services provided to clients in the private sector, and could also apply to services provided in the public sector funded by State governments, either directly or through competitive tendering. In the private sector, this could be arranged under the Health Program Grants scheme, whereby practitioners would be paid a standard annual fee per client under treatment. The fee would be calculated on the average annual cost of providing methadone services, having regard to the varying intensity of treatment at different stages of clients' participation. A differential fee may be required for complex and stable cases, to cater for the differences in treatment patterns and the qualifications and experience of the practitioners providing services. The costs of treatment presented in Section 10.2 may provide a basis for determining an appropriate fee level.

It is suggested that the annual fee be fixed, and set at the average cost of services across the first two years of treatment. While this approach may result in under-remuneration in some years (particularly the first year of treatment when treatment is more intense), the level of remuneration may be expected to even out over longer treatment periods. The alternative of a payment fee which reduces as a client's duration of treatment increases is likely to lead to abuse, whereby practitioners could either discharge clients (or encourage them to exit) and subsequently re-enter them for treatment in order to attract the higher payment level.

The fee itself could be paid monthly or quarterly, based on a client's ongoing participation in the program during the preceding period. The costs incurred in the private sector for treatment of other illnesses concurrent with methadone treatment would be billed separately under their existing CMBS item numbers, and monitored in the same way as under the current system.

12.3.1 Advantages of this option
12.3.2 Disadvantages of this option
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12.3.1 Advantages of this option

  • The general structure of a client management model is conducive to longer participation by clients in methadone programs, since the nature of the payment system is based on the concept of long term care. This is consistent with the clinical advantages of longer duration, where studies have demonstrated that all outcome indicators improve with duration of treatment.

  • This approach removes the incentive for over-servicing inherent in the existing fee for service model. Since medical practitioners are remunerated on the basis of ongoing client participation in the program, rather than on the basis of the quantum of services provided, this approach encourages a more rationed approach to service delivery commensurate with client needs.

  • The outcome to the Commonwealth of this approach is a more controlled expenditure on methadone services, since it would be determined primarily by the number of clients participating, rather than by any increases in the number of services provided per client.

  • The adoption of a fixed annual fee, rather than a fee that reduces with duration of treatment, rewards longer participation in methadone treatment and provides an incentive for medical practitioners to retain clients in the program for as long as possible.

  • By encouraging practitioners to review their service delivery patterns, this approach provides an incentive for models of best practice for stable clients. However, it may not do so for more complex cases unless differential payments are made to reflect the higher levels of service required for these clients. The model may be structured to meet this requirement, provided it works in concert with the service delivery model.

  • A client management model may encourage more cost effective methods of treatment within the private sector. Currently, virtually all counselling in the private sector is undertaken by medical professionals, since this is the sole basis by which they are remunerated. A client management model may encourage a more flexible approach involving trained nurses, counsellors and other health professionals in the private sector, the costs of which may be expected to be lower than the current system. Over time, this may therefore lead to lower costs in the private sector.

  • This approach works best where clients are stable, and their service needs are more consistent with standard methadone practices and guidelines. Given the models of service delivery proposed in South Australia and Victoria where stable clients are to be treated primarily in the private sector, this approach is consistent with the service delivery roles proposed for the private sector in these States. However, in Queensland and New South Wales, where a range of clients are treated in the private sector, this approach may be less suitable.
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12.3.2 Disadvantages of this option

  • While this approach may remunerate practitioners appropriately where clients are stable and a more defined treatment pattern may be followed, it does not cater well for more complex cases whose service needs exceed those catered for in the standard payment. The data provided by medical practitioners in New South Wales, which has been supported through discussions with practitioners in all States, has demonstrated the considerable variation in service level needs between clients. While some of this may be due to variations in clinical practices, some of the variation is also attributable to different client needs. This may reinforce the need for differential payments for different types of clients.

  • A single payment approach may lead to difficult and complex cases being excluded from treatment in the private sector, causing them to revert to public sector treatment, or to be excluded from treatment altogether. This has a number of implications, including concerns over the public sector's capacity to cater for these clients, as well as limiting client choice as to their provider of services. This reinforces the concept of providing differential payments for complex and stable cases.

  • The client management model may encourage under-servicing of clients, since medical practitioners are remunerated solely on the basis of a client's continued participation, and not on the level of service provided. Given that the demand for methadone services exceeds the capacity of the current system, practitioners may be relatively assured of attracting new clients, regardless of the quality of the service they provide. Under these circumstances, practitioners may be encouraged to provide minimal levels of service to sustain client participation, rather than levels of service more commensurate with clients' needs and well-being.

  • This approach may meet opposition from medical practitioners, who generally have reservations about client management models. However, these reservations often have as much to do with the level of payment within the model, rather than the nature of the model itself. Consequently, the reaction by medical practitioners to this approach may only be tested fully once the level of the client management fee has been proposed.

  • Given the possible unpopularity of this approach to some service providers, it may lead to fewer practitioners being attracted to methadone service delivery. This may lead to a reduction in the capacity of the system to extend services to areas currently under-serviced, or to expand to new areas in the future.

  • This approach has the potential for abuse where practitioners could bill for methadone treatment under the client management model as well as for treatment for other conditions under the fee for service structure in Medicare for other medical services. Unlike Option 2, where any financial incentive for this type of activity is reduced and more readily regulated, abuse under this option would more difficult to detect and respond to.

    This problem could be reduced by setting the single payment at a level to include all primary health care services which would be provided by the same medical practitioner as methadone services. Clients would then be excluded from claiming these services under other items within Medicare. Such an approach would require considerably more investigation to assess its feasibility and acceptability. Particular attention would need to be given to defining the range of services in scope of this arrangement, and to issues relating to consumer choice and mobility. It is unclear as to how psychiatric services would catered for under this approach, and what the role of psychiatrists would be in the provision of general medical services to their methadone clients.

  • Frequent client mobility is not well catered for under this model. Short term movements by clients between medical practitioners would introduce administrative complexities as to which practitioner should be paid and for what period. Longer term transfers of clients would be discouraged by practitioners, particularly where the fixed payment level provides an incentive for longer treatment periods by the same practitioner.
A variation to the client management model described above has also been considered, namely its application only to the larger specialist methadone clinics, where accusations of over-servicing have been most prevalent. Medical practitioners providing services as part of a wider practice would continue to be remunerated under a fee for service arrangement of the types described under Options 1 and 2. Under these circumstances, the relative advantages and disadvantages of the respective payment systems as described above may be expected in those areas in which they are applied.

The major additional advantage of such an approach is that it would focus the removal of the current potential for over-servicing in the area where it is seen to be most needed. It therefore results in minimal intrusion on the existing payment system in areas where it is considered to be working reasonably satisfactorily. On the other hand, the adoption of such an approach suffers from several additional disadvantages. These include the potential for abuse and confusion where clients are treated by the same medical practitioner at both specialist methadone clinics and at wider practices. Issues of boundary definition as to what constitutes methadone treatment and other treatment services are also made more complex under this approach.