The provision of funding for medical specialist training in an expanded range of settings is consistently raised as a barrier to its implementation for two reasons. Firstly, it is yet to be negotiated how stakeholders will share and allocate this responsibility, and secondly explicit funding mechanisms have not been developed solely for training purposes.
In 2003, the Australian Health Ministers' Advisory Council (AHMAC) agreed that all jurisdictions and employers should contribute to the costs of training in an expanded range of settings. It is expected that the provision and quantum of funding by key stakeholders will be discussed by AHMAC and COAG in response to this report.
Specialty training is so varied that it would be difficult to apply one funding mechanism to all circumstances. Different settings and types of service delivery will have affinity with different funding approaches.
This section of the report summarises a number of existing mechanisms for distributing funds throughout the health system which could potentially be used to distribute funding for training. Each of these mechanisms has different advantages depending upon key variables, such as the nature of the specialty (for example, procedural or consultative) and the setting.
Contractual arrangements
With any funding mechanism, consideration needs to be given to the Health Insurance Act clause which prevents public employment entitlements being supplemented with Medicare benefits and rebates.To provide surgical training in the private sector in Queensland, the Australian Government provided Queensland Health with advice for incorporating rights of private practice into trainees' employment contracts. This stipulation importantly prevented the contravening of the Health Insurance Act when trainees claim services through Medicare.
Grants
The Advanced Specialist Training Posts in Rural Areas (ASTPRA) program, funded by the Australian Government to increase training in rural areas, is an example of a grants program. This program was not designed to provide training funds on a large scale, but is used as an incentive to redistribute specialist trainees from metropolitan areas.Payments under ASTPRA are made to jurisdictional health departments who then assess, allocate and distribute the funds to where they deem necessary. The ASTPRA program could be expanded to provide training in private settings, via jurisdictional health departments.
Lump sum funding from the Australian Government has also been used by the Royal College of Pathologists of Australasia (RCPA) to fund private sector pathology training placements. Participating training providers receive funds from the RCPA as a contribution towards trainees' salaries. Training providers must negotiate with trainees' 'home' public hospitals to ensure the continuity of their employment entitlements. A recent evaluation of this program reports that overall this funding method is effective at providing quality training experiences for pathologists. The transferability of this program to other specialties would need further consideration.
General practice training is independently organised through GPET Incorporated and supported by the Royal Australasian College of General Practice. GPET receives lump sum funding from the Australian Government for the management, coordination and provision of training. Trainees may receive salaries from employing practices, as well as claim Medicare rebates.
Medicare benefits schedule
Medicare benefits are only payable for services rendered by practitioners with Medicare provider numbers. Specialist trainees may attain a provider number when they are recognised as undertaking a training program listed for exemption under Section 3GA of the Health Insurance Act.The Outer Metropolitan Specialist Trainees’ Program (OMSTP) is one such Section 3GA project. It is funded by the Australian Government through individual contracts within training settings and enables payment of Medicare benefits for trainees’ services. The OMSTP has gone some way to resolving and identifying the issues for using Medicare as a funding mechanism for training.
Specialist trainees who have entered their training after a different medical career, such as general practice, may already have a provider number that they can continue to use in their new specialty training program.
The Australian Government is in the process of developing an additional Group A item to be used specifically by specialist trainees. It is anticipated that the new item will provide specialist trainees with a more sustainable source of income than through using the A2 items, particularly for consultative specialties.
Shared funding with the private sector
Several private pathology laboratories reported that they have created and self-funded a number of training positions. Their participation has been facilitated in some cases by their previous history as part of a public hospital service and their continued close physical and financial relationship.Private hospitals provided different views on the extent to which they are prepared to contribute funding to training activities. In some cases, this included the salary of advanced specialist trainees. In other cases the private hospitals were only willing to provide support for less tangible costs such as the additional human resources requirements for managing specialist trainees within the overall hospital workforce. It is clear that if a shared funding approach was pursued, fair funding provision guidelines would need to be agreed with major private teaching hospitals to ensure equity within these training environments.
There are other specialties where private hospitals have reported greater willingness to contribute to the funding of trainees by providing full salary costs. For example, private hospitals are prepared to employ anaesthetist trainees (even though there is very limited fee-raising potential), because of the importance of intensive care facilities to the infrastructure of some private hospitals and the health care accreditation requirement that intensive care units have minimum resident staff.