One of the frequent queries raised during consultations has been in relation to professional medical indemnity arrangements, and how they will be managed in any expansion of training settings. Most consider that professional indemnity will not be an issue for rotations among public sector settings. However, for trainees rotating to the private sector, professional indemnity could be more complex, particularly if the trainees were to generate income through Medicare billing in those settings.
It is generally assumed that trainees are covered for professional indemnity by the institution for which they work. However, this is made more complex in circumstances where a trainee 'follows their boss' into a private hospital, for example for one day per week to assist in procedures and the arrangement is ad hoc and informal (a common situation in co-located public/private hospital facilities).
Current ad hoc and informal arrangements would be addressed through the introduction of a formalised system of training rotations.
Provision for medical indemnity can be made explicit when a trainee is formally seconded from a public teaching hospital, and covered either by their 'home' or 'host' setting.
In the case of indemnity cover for supervisors, most medical indemnity insurers provide cover for a supervising doctor when a claim is brought by a patient arising from the provision of clinical care by a person in a trainee or teaching role in a doctor’s practice. Generally the supervisor does not have to pay an additional premium to maintain cover under their own policy for their vicarious liability for the acts and omissions of the trainee. The cover usually stipulates that the trainee is in a college accredited training program/placement.
Additionally, all medical indemnity insurers also offer cover for students and trainees and the cost of these policies is targeted at such a level to not place any significant financial burden on the trainee or student.7
The Medical Indemnity Insurers Association of Australia (MIIAA) indicated in their submission to the Productivity Commission review of Australia's health workforce that indemnity concerns should be no barrier to training doctors in the private sector.8
It has been suggested that if there was large scale change there could be impetus to increase premiums and pressure placed on trainees to fund their own insurance cover. However, the MIIAA and the main insurance providers for each state indicated in consultations that premium rates were not expected to rise significantly in light of greater numbers of trainees undertaking training in expanded settings.
Occupational health and safety (OHS) and workers compensation issues were also raised. The workers compensation legislation (there are various Acts in each Australian jurisdiction) is not always clear and concern was expressed in consultations that, as with contract labour and group training organisation situations, an accident at a 'host' employer workplace might result in a joint liability process which would engage the 'home' employer. In such circumstances, it is not clear who would pay the deductible component or how the 'host' employer might recompense any rise in premium costs as a result of an accident. A solution may be to have a single employer, and seek reimbursement from secondment or 'host' employers (after first screening them for acceptable OHS systems prior to accreditation for training).
Given the diversity among the specialties and jurisdictions in relation to how expanded training settings are likely to be rolled out, rather than seeking to develop and apply a universal process for medical indemnity and similar issues, it is suggested that these issues be agreed by the relevant parties seeking to establish the rotation system. The Reference Group has therefore recommended that an operational principle guiding implementation should be that indemnity arrangements and other similar issues be addressed and agreed between all parties in any proposals seeking funding to implement the training arrangements. Costs associated with medical indemnity arrangements are considered in the Reference Group 1 report.
7 Postgraduates who earn greater than $1000 in gross billings are eligible to access the Commonwealth Premium Support Scheme (PSS) which supplements 80% of indemnity premium costs when they are over 7.5% of the doctor's gross billings.
8 Medical Indemnity Industry Association of Australia, Submission to the Productivity Commission, July 2005.