Structural change in Medicare funding: Impact on the dietetics workforce

VIEWPOINT

Structural change in Medicare funding:Impact on the dietetics workforcendi_1362 170..175

Lana J. MITCHELL,1 Sandra CAPRA2 and Lesley MACDONALD-WICKS1

1School of Health Sciences, University of Newcastle, Callaghan, New South Wales, Australia, 2School of HumanMovement Studies, University of Queensland, Brisbane, Australia

AbstractAim: To review the dietetic workforce profile and share of Enhanced Primary Care claims in the context of theStrengthening Medicare support for allied health services.Methods: Dietitians Association of Australia membership data from 2004 to 2007 were analysed to assess changesin the number and work hours of private practice dietitians. Medicare data for 2004–2005 to 2006–2007 werereviewed regarding uptake and distribution of allied health consultations.Results: The number of allied health Enhanced Primary Care consultations doubled between 2004–2005 and2005–2006, with similar increases in 2006–2007. Physiotherapists claimed most, followed by podiatrists, thendietitians. Dietitians claimed most consultations per provider in 2004–2005 and 2005–2006, surpassed bypodiatrists and diabetes educators in 2006–2007. The number and full-time equivalents of private practice dieti-tians increased since 2004. Almost one-third of members were engaged in private practice work by 2007.Approximately half of these worked eight hours or fewer per week in this setting over the period surveyed(45.9–50.8%).Conclusions: Medicare funding for allied health has provided structural change and presents an opportunity forgrowth in the private sector of dietetics. While the number and full-time equivalents of private practice dietitiansincreased since 2004, the anticipated sharp increase relative to other work areas was not seen. Dietetics had a highuptake of Medicare consultations per provider and consultations increased each year; however, the declining shareof total consultations demonstrates that dietitians are not using the opportunity presented by Medicare to the samedegree as some allied health professions.

Key words: allied health, dietetic practice, dietitian workforce, Enhanced Primary Care, Medicare, private practice.

INTRODUCTION

Medicare Australia is the health insurance system that pro-vides eligible Australians with ‘affordable, accessible andhigh-quality health care’.1 Medicare superseded Medibank in19841 and since has undergone many revisions, one ofwhich was the ‘Strengthening Medicare’ package, whichaimed to improve access and affordability of medical servicesprovided out of hospital.2 ‘Allied health services under Medi-care’ were introduced in July 2004, making patients with acomplex chronic condition and a general practitioner (GP)-administered Enhanced Primary Care (EPC) plan eligible forrebates from Medicare for services supplied by registered

health professionals.1,3 Patients are eligible for a maximum offive allied health services per calendar year.1,3

The introduction of Medicare funding for consultationswith allied health professionals was a structural change tothe healthcare system that may act as an impetus to modifyhealth practice to a greater extent than that which couldcome from individual health professionals or clients. Thesuggestion is that changing the availability of funding forconsultations with health professionals will result in anincrease in the demand for such consultations. This may leadto a rise in the number of providers in private practice (PP),as consultations can only be reimbursed for practitionersworking in the private sector.

Funding and access issues present potential barriers toGPs referring their patients to health professionals whenthey perceive the need.4,5 Providing Medicare rebates forallied health professionals in primary care should reducedemand placed on already strained GP services, whilepatients will have access to more appropriate health care,potentially leading to a lower overall cost to the heath caresystem.4,5

L.J. Mitchell, BHSc (N&D) (Hons), APD, PhD CandidateS. Capra, PhD, AdvAPD, ProfessorL. MacDonald-Wicks, PhD, APD, Lecturer in Nutrition & DieteticsCorrespondence: L. Mitchell, School of Health Sciences, Universityof Newcastle, University Drive, Callaghan, NSW 2308, Australia.Email: [email protected]

Accepted April 2009

Nutrition & Dietetics 2009; 66: 170–175 DOI: 10.1111/j.1747-0080.2009.01362.x

© 2009 The AuthorsJournal compilation © 2009 Dietitians Association of Australia

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New opportunities in PP have meant that it has become amore established context for practice.6 To participate in theEPC program dietitians must be Accredited Practicing Dieti-tians (APDs). APD status is granted by the Dietitians Asso-ciation of Australia (DAA) to qualified dietitians who areengaged in continuing professional development.

This paper aims to identify if those professions usuallyfound in PP would be in a better position to capitalise on theopportunity provided by the ‘Strengthening Medicare’package. By evaluating the number of EPC consultationsprovided per professional, the aim is to identify the spread ofEPC consultations through health professions, and identifyopportunities for growth or development. Therefore, Medi-care and dietetic workforce data were examined in order toidentify if this structural change brought about by thechange to Medicare funding has impacted on the dieteticprofession. It is hypothesised that the structural change toMedicare funding would result in a sharp increase in thenumber of private practitioners and/or hours worked. Thispaper does not attempt to explore dietitians’, GPs’, healthprofessionals’ or patients’ views of the EPC initiative as thishas been reported elsewhere.7–9

METHODS

Medicare EPC plan data

Data on the number of dietitian EPC consultations con-ducted each month as well as the number of allied healthpractitioners providing EPC consultations were obtainedfrom Medicare for three periods – 2004–2005, 2005–2006and 2006–2007. Provider data were based on the numberof providers delivering services, accounting for practitio-ners who have more than one provider number. DietitianEPC data were reported at the Division of General Practicelevel. Total EPC consultations conducted for each alliedhealth profession was accessed via the Medicare Australiawebsite.10

DAA membership data

De-identified DAA membership data were extracted at theend of each year from 2004 to 2007. Each year, membersreport on their average weekly hours in each listed worksetting. Postcodes were used to identify the Division ofGeneral Practice in which members were located. Data werethen reviewed to identify trends between DAA membershipand Medicare EPC consultations. Annual membership datawere statistically analysed to identify significance of changesin the number and work hours of PP dietitians in Australiaover the four-year period. PP dietitian full-time equivalents(FTEs) were calculated based on 40 hours/week. Thosemembers who indicated their greatest number of hours werein PP, including dietitians who work solely in PP, were con-sidered to be primarily working in PP. Only data from APDswere used. Students, those not currently working, associates,retirees and overseas workers were excluded. As dietitiansmust be APDs in order to participate in the EPC program,

it was assumed that DAA membership data included allMedicare providers.

Ethics approval

Data extraction was approved by Medicare Australia’sExternal Request Evaluation Committee, reference number2006/00845.

Data analysis

Data analysis was conducted using Microsoft Excel 2003 andIntercooled Stata 9.1.11 Chi-squared tests were used to deter-mine statistical significance of differences between categori-cal variables at the conventional 5% level.

RESULTS

DAA Provate Practice workforce

Between 2004 and 2007 DAA members who self-reportedworking in PP increased, from 512 in 2004 (28% of totalDAA membership) to 772 in 2007 (32.2%) (P = 0.0032)(Figure 1). This 51% increase in PP members between 2004and 2007 was below the median increase of 86% for all DAAwork area categories. However, as DAA work area categorieswere expanded in 2005, there were large artificial increasesin some work categories. Therefore, the increase in PPmembers between 2005 and 2007 of 35% is a more accuratereflection and is similar to the median increase of all workcategories of 36% (Table 1).

PP dietitian FTEs increased by 66% during 2004–2007(158–263) (Table 2). This was the median change for allwork categories. The change in FTEs during 2005–2007 was43% (median = 36%).

PP was the primary work category for 56% of dietitiansworking in PP in 2004, increasing to around 60% in 2005,

28% 30.9% 30.9% 32.2%

Figure 1 Total and private practice (PP) Dietitians Associa-tion of Australia (DAA) members, 2004–2007. (a) DAAmembers working in PP in Australia. (b) DAA membersworking in Australia.

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which was maintained in 2006 and 2007 (Table 3). Between2004 and 2007, approximately 43% of PP dietitians workedonly in PP. No significant differences were seen in the hoursworked in PP during this time (Table 4). Approximately halfof dietitians worked fewer than eight hours a week in PP,and 7–8% worked 40 hours or more.

Allied health EPC consultations

Between 2004–2005 and 2005–2006 the number of EPCconsultations claimed for all allied health more than doubled(211%), from 251 203 to 532 398 (Table 5).10 In 2006–2007 EPC consultations increased by 175%, totalling938 353 occasions of service. Physiotherapists had the mostclaimed EPC consultations overall, with 43.1% of the total in2004–2005, 38% in 2005–2006 and 34.8% in 2006–2007.

Podiatrists followed, with 20.4%, 28.1% and 33%, respec-tively. Dietitians were third, with 17.6%, 13.7% and11%, respectively. Exercise physiologists experienced largeincreases in consultations since their rebates were intro-duced in January 2006, with 0.7% of the total consultationsin 2005–2006, increasing to 3.1% in 2006–2007 (P <0.0001). The per cent claimed by diabetes educators, speechpathologists and occupational therapists has graduallyincreased, while the per cent claimed by psychologistsdecreased (P < 0.001). Aboriginal health workers, audiolo-gists, mental health workers, occupational therapists, osteo-paths and dental assessments, treatments and services eachcontributed 1% or less of the total (data included under‘other’). Total consultations increased between 2004–2005and 2006–2007 for all professions except Aboriginal healthworkers.

Table 1 Number of dietitians by Dietitians Association of Australia work categories and percentage change between 2004–2007 and 2005–2007

2004n

2005n

2006n

2007n

2004–2007change (%)

2005–2007change (%)

Community nutrition 258 300 279 341 ⇑32 ⇑14Food service(a) 7 82 93 109 ⇑1457 ⇑33Government department/non-government organisations 81 175 241 263 ⇑225 ⇑50Industry (including consultants)/marketing/public relations 88 128 147 175 ⇑99 ⇑37Inpatient/outpatient facility (including public, private, aged

care, psychiatric)(a)1042 798 912 1023 ⇓2 ⇑28

Mixed practice (including sole/rural practitioner) n/a 72 89 101 n/a ⇑40Public health 154 123 130 162 ⇑5 ⇑32Private practice/consultancy 512 570 656 772 ⇑51 ⇑35Research/education 114 186 239 279 ⇑145 ⇑50Do not work in nutrition and/or dietetics 49 48 89 91 ⇑86 ⇑90(a) In 2004 category was ‘food service institution’; therefore, those working in foodservice in hospitals would have been included in thosecategories.Categories changed slightly between 2004 and 2005, which may account for more changes between these years.

Table 2 Dietitian full-time equivalents by Dietitians Association of Australia work categories and percentage change between2004–2007 and 2005–2007

2004n

2005n

2006n

2007n

2004–2007change (%)

2005–2007change (%)

Community nutrition 167.1 157.5 154.5 193.5 ⇑16 ⇑23Food service(a) 2.7 24.0 28.5 29.7 ⇑990 ⇑24Government department/non-government organisations 61.6 121.9 165.3 181.8 ⇑195 ⇑49Industry (including consultants)/marketing/ public relations 74.3 92.8 99.6 118.7 ⇑6 ⇑28Inpatient/outpatient facility (including public, private, aged

care, psychiatric)(a)707.5 533.3 618.0 689.3 ⇓3 ⇑29

Mixed practice (including sole/rural practitioner) n/a 48.4 61.5 70.6 n/a ⇑46Public health 95.1 71.8 79.9 98.3 ⇑3 ⇑37Private practice/consultancy 158.3 183.3 223.9 262.6 ⇑66 ⇑43Research/education 66.2 101.5 126.4 137.5 ⇑108 ⇑36Do not work in nutrition and/or dietetics 32.4 30.4 52.4 56.0 ⇑73 ⇑84(a) In 2004 category was ‘food service institution’; therefore, those working in foodservice in hospitals would have been included in thosecategories.Full-time equivalents based on 40 hours of work per week.

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Table 3 Private practice (PP) for Dietitians Association of Australia members as context of practice 2004–2007

Context

2004 2005 2006 2007

n (%) n (%) n (%) n (%)

Primary work(a) 286 (55.9) 340 (59.6) 387 (59.0) 458 (59.3)Sole work(b) 220 (43.0) 260 (45.6) 281 (42.8) 330 (42.7)2nd work 207 (40.4) 209 (36.7) 247 (37.7) 284 (36.8)3rd work 18 (3.5) 18 (3.2) 18 (2.7) 28 (3.6)4th work 1 (0.2) 3 (0.5) 4 (0.6) 2 (0.3)Total PP dietitians(c) 512 (100.0) 570 (100.0) 656 (100.0) 772 (100.0)(a) Working more hours in PP than any other work category. Includes PP as sole work.(b) Working solely in PP.(c) Excludes sole work as already counted in primary.

Table 4 Self-reported work hours in private practice of Dietitians Association of Aus members, 2004–2007

2004 2005 2006 2007

n (%) n (%) n (%) n (%)

�8 hours 260 (50.8) 278 (48.8) 301 (45.9) 362 (46.9)9–19 hours 141 (27.5) 153 (26.8) 194 (29.6) 215 (27.8)20–29 hours 50 (9.8) 73 (12.8) 68 (10.4) 87 (11.3)30–39 hours 24 (4.7) 24 (4.2) 40 (6.1) 46 (6.0)40–49 hours 29 (5.7) 34 (6.0) 46 (7.0) 54 (7.0)�50 hours 8 (1.6) 8 (1.4) 7 (1.1) 8 (1.0)Total 512 (100.0) 570 (100.0) 656 (100.0) 772 (100.0)

Table 5 Number and distribution of Enhanced Primary Care (EPC) consultations for each allied health profession during2004–2005 to 2006–2007

2004–2005 2005–2006 2006–2007

n (%)(c) n (%)(c) n (%)(c)

Physiotherapy No. of EPC(a) 108 267 (43.1) 202 465 (38.0)* 326 832 (34.8)*EPC/provider 27.4 41.6 56.6

Podiatry No. of EPC 51 243 (20.4) 149 516 (28.1)* 310 023 (33.0)*EPC/provider 34.5 85.2 158.8

Dietetics No. of EPC 44 089 (17.6) 72 827 (13.7)* 102 764 (11.0)*EPC/provider 89.4 115.6 132.3

Psychology No. of EPC 23 092 (9.2) 45 541 (8.5)* 49 190 (5.2)*EPC/provider 16.7 21.1 19.2

Exercise physiology No. of EPC 0(b) (0.0) 3 929 (0.7)* 29 369 (3.1)*EPC/provider 0 29.3 87.1

Speech pathology No. of EPC 3 051 (1.2) 11 371 (2.1)* 27 287 (2.9)*EPC/provider 9.4 18 28.5

Diabetes educator No. of EPC 735 (0.3) 7 781 (1.5)* 15 993 (1.7)*EPC/provider 17.9 103.7 140.3

Occupational Therapy No. of EPC 1 510 (0.6) 4 928 (0.9)* 9 136 (1.0)**EPC/provider 7.5 14.2 17.4

Mental health No. of EPC 748 (0.3) 2 730 (0.5)* 3 903 (0.4)*EPC/provider 7.9 13.9 15.8

Other No. of EPC 18 468 (7.4) 35 239 (6.6)* 63 856 (6.8)*Total No. of EPC 251 203 536 327 938 353(a) Data accessed from the Medicare Website.10 EPCs based on the date the service were processed by Medicare Australia.(b) Exercise physiology was introduced in January 2006.(c) Per cent of total EPC consultations.* P < 0.0001, ** P < 0.001.Allied health professions are in order of highest number of EPC consultations to lowest during 2006–2007. P values refer to change inpercentage of total EPC consultations per profession divided by total EPC consultations overall between each year. ‘Other’ includeschiropractic, osteopathy, dental treatment, dental assessment, dental service, audiology and aboriginal health.



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Dietitian EPC consultations

The number of EPC consultations for dietetic servicesincreased by 65% between 2004–2005, when they were firstintroduced, and 2005–2006 (P < 0.0001) (Table 5). Between2005–2006 and 2006–2007 they increased by 41% (P <0.0001). The most populated states had the most claims.

EPC consultations per provider

Dietetics had the most EPC consultations claimed per pro-vider in both 2004–2005 and 2005–2006 periods, with 89.4and 115.6, respectively (Table 5). By 2006–2007, despitedietitian consultations increasing to 132.3 per provider, thiswas surpassed by podiatrists and diabetes educators. Diabe-tes educators, podiatrists, exercise physiologists and dieti-tians experienced the greatest increases in the number ofconsultations per provider. Aboriginal health and psychol-ogy were the only professions to see a decline in the numberper provider.

DISCUSSION

DAA PP workforce

The increase in the number and percentage of PP dietitianssince 2004 suggests that opportunity in this area of dietet-ics is increasing; however, this trend is reflected in all DAAmembership and the anticipated sharp increase relative toother work areas was not seen. The increase in member-ship numbers may be due to more graduates rather than achange in the workforce environment. If this is the caseand new graduates are starting in PP, there is potential needfor university courses to be providing graduates with PPskills.

Between 2004 and 2007 there was a 50% increase in thenumber of PP dietitians (P = 0.003). The increase in thenumber of EPC consultations provided by dietitians mayaccount for some of the 66% increase in PP FTEs over thefour years. However, data from the Australian Health Insur-ance Association (unpublished data, 2008) indicate thatthere were decreases in private health insurance (PHI)dietetic claims during this time. While there were increasesin the amount of PHI dietetics claims up to June 2004(2001–2002 to 2002–2003: 7.7%; 2002–2003 to 2003–2004: 14.2%), after the introduction of Medicare alliedhealth rebates in July 2004 PHI claims on dietetic servicesreduced (2003–2004 to 2004–2005: -6.7%). After thisinitial decrease it stabilised (2004–2005 to 2007–2008:1.9%).

Examination of the data indicates that those dietitiansworking in PP are predominantly doing so in conjunctionwith other work, and this may limit their ability to takeadvantage of this opportunity to grow their businesses.However, those dietitians who act in an entrepreneurial wayor who are wishing to grow their PP business may be in abetter position to act on this structural change and use thisopportunity.

Allied health EPC consultations

It is expected that this trend of increasing EPC consultationswill continue as GPs, allied health providers and patientsbecome more familiar with the services that are available.While EPC consultations increased each year for all profes-sions except one, the percentage of total consultationschanged, indicating the market share that each professionheld. This reflects how each profession performed relativeto others.

Compared with many other health professions, dieteticsdid not have a large number of EPC providers. Therefore, inclaiming the third highest number of EPC consultations,dietetics achieved the highest number per provider in thefirst two years of the initiative. This suggests that dietitiansinitially engaged in the Medicare changes and used thisopportunity to some advantage. However, by 2006–2007dietitians dropped from the highest number of EPCs perprovider to the third highest, with podiatrists and diabeteseducators achieving a greater number per provider. Diabetesis one of the main chronic diseases for which patients areeligible for this initiative. This may provide an explanation asto why podiatrists, diabetes educators and dietitians con-ducted the most EPC consultations per provider, and podia-trists and dietitians conducted the second and third highestnumbers of consultations overall. While diabetes educatorsas a group did not provide a large number of EPC consulta-tions, their output was second highest per provider in2005–2006 and 2006–2007. The opportunity for diabeteseducators was recognised by its profession, with the August2007 supplement of the Australian Diabetes Educators maga-zine being dedicated to PP.12 This supplement had a strongemphasis on using Medicare EPC items as an income sourcefor those working in PP. Support and training from profes-sional associations may possibly encourage health profes-sionals to be more confident and willing to see patientsunder the Medicare scheme.

Despite the decrease from 2004–2005 to 2006–2007 inthe percentage of EPC consultations claimed by physiothera-pists, they have maintained the highest number of EPCconsultations overall. This may be due to the large size of theprofession and their dominance in the private sector, as wellas their role in the treatment of many chronic diseases. Theirhigher percentage initially may be due to being better knownor more accessible at the commencement of the initiative,and while the number of consultations provided increased,their percentage of total allied health consultations droppedas other professions increased their engagement.

The perceived need for a service may influence the numberof EPC consultations allocated to a profession, as with thelimitation of five EPC services per calendar year GPs mustprioritise patients’ complex care needs. Educating GPsregarding the role of dietitians in chronic disease managementis critical in maximising dietetics allocation. However, it is notalways feasible for GPs to involve the required professions ifMedicare-registered individuals are not accessible. As rebatesfor all allied health EPC services are the same, the perceivedadequacy of the rebate by practitioners may influence interest

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in providing the service. The decline in psychology EPCconsultations may be due to the availability of Medicarerebates for allied mental health services,3 which providehigher rebates and more visits per patient. Professions desir-ing an increase in the private sector are more likely to seek theMedicare market. Research into these areas is required toassess their impact on the change in work patterns.

Limitations to data

Membership data are self-reported and are accurate on theday collected, as people may join at any time throughout theyear. To reduce this variability the membership data werecollected at similar time points each year. EPC data from theMedicare website10 are based on the dates the claims areprocessed rather than delivered, while dietitian EPC datapurchased from Medicare is based on the date of delivery;however, it is not likely that this would alter the values to anyreal extent.

CONCLUSION

The introduction of Medicare funding for patients withchronic disease under the EPC system has provided a struc-tural and funding stimulus for the allied health workforce.Uptake of this initiative has been positive, with a doubling ofallied health EPC consultations each year since 2004–2005.While dietitians claimed the highest number of EPC consul-tations per provider in the first two years and experienced anincrease in the number of PP dietitians, growth was not ashigh as anticipated, with the percentage of total EPC con-sultations provided by dietetics decreasing. These datasuggest that this opportunity for dietitians is substantial, butthe failure to continue rapid growth suggests that it would beworthwhile for more professional development and prepa-ration in business and entrepreneurship for practitioners.

ACKNOWLEDGEMENTS

We thank Glennyss Leyne, Sue Cassidy, Elizabeth Ferres andCedric Bear at the DAA National Office for the provision of

de-identified DAA membership data. We would also like tothank the Health Insurance Commission for extracting theMedicare data.

REFERENCES

1 Medicare Australia. Mediguide—A Guide to Medicare and OtherMedicare Australia Health Programs. Canberra: AustralianGovernment, 2007.

2 Department of Health and Ageing. Annual Report 2003–04.Canberra: Australian Government, 2004.

3 The Australian Government Department of Health and Ageing.Medicare Benefits Schedule—Allied Health Services—1 November2008. Canberra: Australian Government; 2008.

4 Senate Select Committee on Medicare Secretariat. MedicarePlus: The Future for Medicare? Canberra: Commonwealth ofAustralia, 2004. (Available from: http://www.aph.gov.au/senate/committee/medicare_ctte/medicareplus/report/report.pdf,accessed 19 July 2006).

5 Productivity Commission. Australia’s Health Workforce.Canberra: Commonwealth of Australia, 2005.

6 DAA. Dietitians Association of Australia (DAA) Response to‘The Health Workforce’ Issues Paper. Canberra: Dietitians Associa-tion of Australia, 2005.

7 Cant R, Aroni R. Melbourne dietitians’ experience of Medicarepolicy on allied health services (Strengthening Medicare;Enhanced Primary Care) in the first 12 months. Nutr Diet 2007;64: 43–19.

8 Shortus TD, McKenzie SH, Kemp LA, Proudfoot JG, Harris MF.Multidisciplinary care plans for diabetes: how are they used?Med J Aust 2007; 187: 78–81.

9 Foster MM, Mitchell G, Haines T, Tweedy S, Cornwell P,Fleming J. Does Enhanced Primary Care enhance primary care?Policy-induced dilemmas for allied health professionals. Med JAust 2008; 188: 29–32.

10 Medicare Australia. Medicare Item Reports. Canberra; 2007.(Available from: http://www.medicareaustralia.gov.au/statistics/mbs_item.shtml, accessed 1 October 2007).

11 StataCorp. Stata Statistical Software: Release 9.0. College Station:Texas, 2005.

12 Australian Diabetes Educators Association. Private practice—anew horizon for credentialed diabetes educators. Aust DiabetesEduc 2007; 10: 1–6.



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Structural change in Medicare funding: Impact on the dietetics workforce