Healthy Communities: Patients' out-of-pocket spending on Medicare services, 2016–17 - Technical Note - Indicator specifications

Healthy Communities: Patients' out-of-pocket spending on Medicare services, 2016–17

Indicator specifications

Percentage of patients with out-of-pocket costs for non-hospital Medicare services

This specification applies to the following indicator:

  • Percentage of patients with out-of-pocket costs for non-hospital Medicare services.
Data source
Medicare Benefits Schedule (MBS) claims data 2016–17
Indicator description and calculation
Eligible claims

A claim is classified as a non-hospital attendance if the following condition is true:

  • The service is not conducted in a hospital to an admitted patient.

Non-hospital Medicare-subsidised services include: GP and practice nurse attendances, specialist attendances, obstetric attendances, pathology tests and collection items, diagnostic imaging, optometry, allied health attendances, radiotherapy and therapeutic nuclear medicine, operations, assistance at operations and other MBS services that were provided to patients not admitted to hospital. This includes eligible telehealth services.

This does not include services from the Child Dental Benefits Schedule.

Numerator Number of patients whose annual out-of-pocket cost (fee charged minus benefit paid) for all eligible claims processed between 1 July 2016 and 30 June 2017 was greater than zero.
Denominator Number of patients who claimed at least one non-hospital Medicare service processed between 1 July 2016 and 30 June 2017.
Calculation Numerator ÷ denominator
Geographic disaggregation PHN area and SA3 identified from patients’ enrolment postcode.
Notes

Data are reported by the financial year in which they were processed.

If a service was flagged as bulk-billed, then the fee charged was set to equal the benefit paid (so there was no out-of-pocket cost for that service).

Patients were excluded if the sum of eligible services in the year was less than one, or if their annual out-of-pocket expenditure was less than zero.

Costs associated with bulk-billing incentives or other top-up items are included in the analysis.

Further information on the MBS services and item types are available in Table 2 and at www.mbsonline.gov.auExternal link, opens in a new window..

Total out-of-pocket cost per patient for all non-hospital Medicare services (for patients with costs)

This specification applies to the following indicator:

  • Total out-of-pocket cost per patient for all non-hospital Medicare services (for patients with costs at the 25th, 50th, 75th and 90th percentiles).
Data source
Medicare Benefits Schedule (MBS) claims data 2016–17
Indicator description and calculation
Eligible claims

A claim is classified as a non-hospital attendance if the following condition is true:

  • The service is not conducted in a hospital to an admitted patient.

Non-hospital Medicare-subsidised services include: GP and practice nurse attendances, specialist attendances, obstetric attendances, pathology tests and collection items, diagnostic imaging, optometry, allied health attendances, radiotherapy and therapeutic nuclear medicine, operations, assistance at operations and other MBS services that were provided to patients not admitted to hospital. This includes eligible telehealth services.

This does not include services from the Child Dental Benefits Schedule.

Calculation

Each patients’ annual out-of-pocket cost for non-hospital Medicare services was calculated by subtracting the total benefits paid from the total fees charged for eligible claims processed between 1 July 2016 and 30 June 2017.

Patients’ with annual out-of-pocket costs at the 25th, 50th (median), 75th and 90th percentile were identified at each geographic disaggregation, for patients with an annual out-of-pocket cost greater than zero. This includes patients who had some, but not all of their services bulk-billed.

Geographic disaggregation PHN area and SA3 identified from patients’ enrolment postcode.
Notes

Data are reported by the financial year in which they were processed.

If a service was flagged as bulk-billed, then the fee charged was set to equal the benefit paid (so there was no out-of-pocket cost for that service).

Patients were excluded if the sum of eligible services in the year was less than one, or if their annual out-of-pocket expenditure was equal to or less than zero.

Costs associated with bulk-billing incentives or other top-up items are included in the analysis.

Further information on the MBS services and item types are available in Table 2 and at www.mbsonline.gov.auExternal link, opens in a new window..

Percentage of patients with out-of-pocket costs, by service type

This specification applies to the following indicators:

  • Percentage of patients with out-of-pocket costs for specialist attendances
  • Percentage of patients with out-of-pocket costs for GP attendances
  • Percentage of patients with out-of-pocket costs for diagnostic imaging services
  • Percentage of patients with out-of-pocket costs for obstetric attendances.
Data source
Medicare Benefits Schedule (MBS) claims data 2016–17
Indicator description and calculation
Eligible claims

Specialist attendances

A claim is classified as a specialist attendance if the following conditions are true:

  • the item is in the Broad Type of Service group:
    • Specialist attendance (C/200)
  • the service is not conducted in a hospital to an admitted patient.

Specialist attendances are Medicare-subsidised referred patient/doctor encounters, such as visits, consultations, and attendances by video conference, involving medical practitioners who have been recognised as specialists or consultant physicians for Medicare benefits purposes.

Specialist attendances exclude obstetric attendances, which are included in the ‘Obstetrics’ Broad Type of Service group in official MBS claims data.

GP attendances

A claim is classified as a GP attendance if the following conditions are true:

  • the item is in any of the following Broad Type of Service groups:
    • non-referred attendances – GP/VR GP (A/101)
    • non-referred attendances – Enhanced Primary Care (M/102)
    • non-referred attendances – Other (B/103).
  • the service is not conducted in a hospital to an admitted patient.

GP attendances are Medicare-subsidised patient/doctor encounters, such as visits and consultations, for which the patient has not been referred by another doctor.

GP attendances exclude services provided by practice nurses and Aboriginal and Torres Strait Islander health practitioners on a GP’s behalf.

Diagnostic imaging services

A claim is classified as a diagnostic imaging service if the following conditions are true:

  • the item is in the Broad Type of Service group:
    • Diagnostic Imaging (G/600)
  • the service is not conducted in a hospital to an admitted patient.

Diagnostic imaging services are Medicare-subsidised diagnostic imaging procedures such as x-rays, computerised tomography scans, ultrasound scans, magnetic resonance imaging scans and nuclear medicine scans.

Obstetric attendances

A claim is classified as an obstetric attendance if the following conditions are true:

  • the item is in the Broad Type of Service group:
    • Obstetrics (D/300)
  • the service is not conducted in a hospital to an admitted patient.

Obstetric attendances are Medicare-subsidised services for the purpose of planning and managing a pregnancy. These services can be provided by an obstetrician or GP; or by a midwife, nurse or Aboriginal and Torres Strait Islander health practitioner when the service is provided on behalf of, and under the supervision of, a medical practitioner.

Obstetric attendances do not include Midwifery Services, which are included in the M13 group in official MBS claims data (Table 2).

Numerator Number of patients whose annual out-of-pocket cost (fee charged minus benefit paid) for all eligible claims for the relevant service type processed between 1 July 2016 and 30 June 2017 was greater than zero.
Denominator Number of patients who had at least one eligible claim for the relevant service type processed between 1 July 2016 and 30 June 2017.
Calculation Numerator ÷ denominator
Geographic disaggregation PHN area and SA3 identified from patients’ enrolment postcode.
Notes

Data are reported by the financial year in which they were processed.

If a service was flagged as bulk-billed, then the fee charged was set to equal the benefit paid (so there was no out-of-pocket cost for that service).

Patients were excluded if the sum of eligible services in the year was less than one, or if their annual out-of-pocket expenditure on those eligible services was less than zero.

Patients’ out-of-pocket cost per service (for patients with costs), by service type

This specification applies to the following indicators, reported for patients with costs at the 25th, 50th, 75th and 90th percentile:

  • Patients’ out-of-pocket cost per specialist attendance
  • Patients’ out-of-pocket cost per GP attendance
  • Patients’ out-of-pocket cost per diagnostic imaging service
  • Patients’ out-of-pocket cost per obstetric attendance.
Data source
Medicare Benefits Schedule (MBS) claims data 2016–17
Indicator description and calculation
Eligible claims

Specialist attendances

A claim is classified as a specialist attendance if the following conditions are true:

  • the item is in the Broad Type of Service group:
    • Specialist attendance (C/200)
  • the service is not conducted in a hospital to an admitted patient.

Specialist attendances are Medicare-subsidised referred patient/doctor encounters, such as visits, consultations, and attendances by video conference, involving medical practitioners who have been recognised as specialists or consultant physicians for Medicare benefits purposes.

Specialist attendances exclude obstetric attendances, which are included in the ‘Obstetrics’ Broad Type of Service group in official MBS claims data.

GP attendances

A claim is classified as a GP attendance if the following conditions are true:

  • the item is in any of the following Broad Type of Service groups:
    • non-referred attendances – GP/VR GP (A/101)
    • non-referred attendances – Enhanced Primary Care (M/102)
    • non-referred attendances – Other (B/103).
  • the service is not conducted in a hospital to an admitted patient.

GP attendances are Medicare-subsidised patient/doctor encounters, such as visits and consultations, for which the patient has not been referred by another doctor.

GP attendances exclude services provided by practice nurses and Aboriginal and Torres Strait Islander health practitioners on a GP’s behalf.

Diagnostic imaging services

A claim is classified as a diagnostic imaging service if the following conditions are true:

  • the item is in the Broad Type of Service group:
    • Diagnostic Imaging (G/600)
  • the service is not conducted in a hospital to an admitted patient.

Diagnostic imaging services are Medicare-subsidised diagnostic imaging procedures such as x-rays, computerised tomography scans, ultrasound scans, magnetic resonance imaging scans and nuclear medicine scans.

Obstetric attendances

A claim is classified as an obstetric attendance if the following conditions are true:

  • the item is in the Broad Type of Service group:
    • Obstetrics (D/300)
  • the service is not conducted in a hospital to an admitted patient.

Obstetric attendances are Medicare-subsidised services for the purpose of planning and managing a pregnancy. These services can be provided by an obstetrician or GP; or by a midwife, nurse or Aboriginal and Torres Strait Islander health practitioner when the service is provided on behalf of, and under the supervision of, a medical practitioner.

Obstetric attendances do not include Midwifery Services, which are included in the M13 group in official MBS claims data (Table 2).

Calculation

Each patients’ annual out-of-pocket cost (fee charged minus benefit paid) for each type of attendance claimed between 1 July 2016 and 30 June 2017 divided by the number of corresponding attendances claimed by that patient in the period.

The amount that patients spent per attendance at the 25th, 50th (median), 75th and 90th percentile was identified at each geographic disaggregation, for patients with an annual out-of-pocket cost greater than zero. This includes patients who had some, but not all of their services bulk-billed.

Geographic disaggregation PHN area and SA3 identified from patients’ enrolment postcode.
Notes

Data are reported by the financial year in which they were processed.

If a service was flagged as bulk-billed, then the fee charged was set to equal the benefit paid (so there was no out-of-pocket cost for that service).

Patients were excluded if the sum of eligible services in the year was less than one, or if their annual out-of-pocket expenditure on the eligible services was equal to or less than zero.

Cost barriers to specialist, GP, imaging and/or pathology

Percentage of people who delayed or did not see a medical specialist, GP, get an imaging test and/or get a pathology test due to cost in the last 12 months, by PHN area, 2016–17.

Data source
Australian Bureau of Statistics (ABS) Patient Experiences in Australia Survey, 2016–17
Indicator description and calculation
Numerator

Sum of calibrated sample weights for people aged 15 years or over who reported delaying or not accessing either a medical specialist, GP, imaging and/or pathology test when needed due to cost and who were enumerated within the particular PHN area.

Denominator

All people aged 15 years or older who reported that they needed to see/have a medical specialist, GP, imaging and/or pathology test within the PHN area.

Note: The denominator was calculated as the sum of calibrated sample weights for adults who were enumerated within the PHN area.

Calculation (Numerator ÷ denominator) x 100
Protection of confidential data Percentages are calculated based on counts that have been randomly adjusted by the ABS to avoid the release of confidential data.
Confidence intervals As an indication of the accuracy of estimates, 95% confidence intervals were produced. These were calculated by the ABS using standard error estimates of the proportion.
Notes

Excludes pathology and imaging tests conducted in hospital, and any dental imaging tests.

If respondents sought clarification on the definition of medical specialist, interviewers were instructed to advise that medical specialists provide services which are covered, at least in part, by Medicare (e.g. dermatologists, cardiologists, neurologists and gynaecologists).

Imaging tests or diagnostic imaging include all tests that produce images or pictures of the inside of the body in order to diagnose diseases. Tests involve the use of radiant energy, including x-rays, sound waves, radio waves, and radioactive waves and particles that are recorded by photographic films or other types of detectors.

Pathology tests refer to laboratory tests that includes analysis of specimens such as urine and blood in order to diagnose disease.

For further information refer to Patient Experiences in Australia: Summary of Findings, 2016–17 (ABS, 2017a)External link, opens in a new window.[http://www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/4839.0Explanatory%20Notes12016-17?OpenDocument].

Non-hospital Medicare attendances and expenditure per patient

This specification applies to the following measures, which are available in the accompanying Excel download:

  • Average out-of-pocket costs for all non-hospital Medicare services per patient
  • Average Medicare benefits expenditure on all non-hospital Medicare services per patient
  • Average number of all non-hospital Medicare services per patient.
Data source
Medicare Benefits Schedule (MBS) claims data 2016–17
Indicator description and calculation
Eligible claims

All non-hospital Medicare services (including services that were bulk-billed and services with out-of-pocket costs). A claim is classified as a non-hospital attendance if the following condition is true:

  • The service is not conducted in a hospital to an admitted patient.

Non-hospital Medicare-subsidised services include: GP and practice nurse attendances, specialist attendances, obstetric attendances, pathology tests and collection items, diagnostic imaging, optometry, allied health attendances, radiotherapy and therapeutic nuclear medicine, operations, assistance at operations and other MBS services that were provided to patients not admitted to hospital. This includes eligible telehealth services.

This does not include services from the Child Dental Benefits Schedule.

Numerator

Average out-of-pocket cost: Sum of fees charged minus sum of benefits paid for eligible claims. This includes costs associated with bulk-billing incentive items or other top-up items.

Medicare benefits expenditure: Sum of benefits paid for eligible claims. This includes costs associated with bulk-billing incentive items or other top-up items.

Non-hospital Medicare attendances: Sum of services from eligible claims. This does not include any bulk-billing incentive items or other top-up items.

Denominator Number of patients who claimed at least one non-hospital Medicare service processed between 1 July 2016 and 30 June 2017.
Calculation Numerator ÷ denominator
Geographic disaggregation PHN area identified from patients’ enrolment postcode.
Notes

Data are reported by the financial year in which they were processed.

If a service was flagged as bulk-billed, then the fee charged was set to equal the benefit paid (so there was no out-of-pocket cost for that service).

Patients were excluded if the sum of eligible services in the year was less than one, or if their annual out-of-pocket expenditure was less than zero.

Table 2. Medicare Benefits Schedule group, subgroups and items included in the Broad Type of Service (BTOS) groups

Description BTOS Letter Group/ Sub-group /Item
Non-referred attendances GP/VR GP 101 A A1, A7(193, 195, 197), A11(597, 599), A18, A22
Non-referred attendances - Enhanced Primary Care 102 M A14, A15(721-758), A17, A20(subgroup 1)
Non-referred attendances - Other 103 B A2, A5, A6, A7(173), A11(598, 600), A19, A20(subgroup 2), A23, A27, A30
Non-referred attendances - Practice Nurse Items 110 O M12
Allied Health 150 P M3, M6, M7, M8, M9, M10, M11, M15
Specialist attendances 200 C A3, A4, A8, A9, A12, A13, A15(820-880), A21, A24, A26, A28, A29, A31, A32, T6(17609-17690)
Obstetrics 300 D T4
Anaesthetics 400 E T7, T10
Pathology Episode Initiation 501 N P10, P11, P13
Pathology Tests 502 F P1-P9, P12
Diagnostic Imaging 600 G I1-16
Operations 700 H T8
Assistance at Operations 800 I T9
Optometry 900 J A10
Radiotherapy and Therapeutic Nuclear Medicine 1000 K T2, T3
Other MBS Services 1100 L C1, C2, C3, D1, D2, M1, M13, M14, O1-O11, T1(subgroups 1-13), T11