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Australian Day Surgery Council

Categorisation of Day Facility Procedures

Commonwealth Discussion Document

MARK 4 – Day Surgery Arrangements

Categorisation of Day Facility Procedures

October 2000

Contents
Background
Reason for review
Industry comments on prior proposal for categorisation
Outline for revised proposal
Dedicated day surgery unit in hospital/day hospital facility
Patient classification
Benefit payable (proposed)
Current requirements to remain
Current requirements to be removed
New requirements
Issues to be addressed
Implementation

Background

Presently, for procedures undertaken on a day only basis for admitted patients in public or private hospital or a licensed free standing day hospital facility a health insurance facility benefit is available. These declared minimum benefits are known as Default Table Benefits (paragraph (bj), of Schedule 1 of the National Health Act 1953).

The Default Table Benefits identify three types of categories of professional attention:

• Type A: Professional attention normally requiring admitted overnight hospital stays
• Type B: Professional attention normally requiring admitted hospital treatment, that does not include part of an overnight stay
• Type C: Professional attention that does not normally require hospital treatment.

The day arrangements focus on Type B and Type C procedures.

A day facility benefit is set by the Commonwealth for the private sector. States and Territories set their benefits for day procedures (Type B procedures) according to a banding system based upon level of anaesthesia and theatre time. Usually based on recommendations by the Commonwealth.

Four bands and non-band specific list classify procedures undertaken on a Type B day only basis for day facility benefit purposes:

• Band 1 is a definitive list of procedures with no flexibility for re-classification to another band
• Band 2, 3 and 4 are determined by anaesthetic type and theatre time
• The non-band specific Type B list can be banded according to anaesthetic type and theatre time. In the absence of anaesthetic and theatre, a Band 1 classification is applicable.

The Type C exclusion list is a list of services for which default benefits will not normally be paid. However, there will be occasions when admission is warranted and completion of a Day Only Procedure Certification will enable the payment of a Band 1 accommodation benefit. A Band 1 benefit only is payable, regardless of anaesthetic type or theatre time.

Current banding levels as of July 2000 are:

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Reason for review

The Commonwealth Government is keen to broaden the scope of private health insurance to cover out of hospital care including day procedures in doctors' room, extending the application of hospital in the home services for patients and examining the feasibility of using 'limited care accommodation' services for step-down recovery from the acute sector.

The incidence of day surgery has increased dramatically over the years and statistics show the complexity of procedures capable of being performed as day surgery in the public and private sector is increasing.

Given these trends the Department initially sought comments from the industry on the options of categorising facilities to encourage a 'step down' of procedures to more cost effective settings and further support the use of day surgery services as efficient and sag alternatives to overnight hospital care. Comments were taken into account and a revised proposal describing categorisation of procedures (as per current overnight arrangements) was then circulated for comments.

Following on from this, a third version incorporating stakeholder comments and suggestions is below. This version integrates the features of both prior proposals that stakeholders suggested would facilitate growth in day surgery.

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Industry comments on prior proposals for categorisation

In determining the best option to encourage and promote the use of day surgery, the Department has taken into account all comments and suggestions relating to the proposal to introduce a system of categorisation. The main issues that were highlighted in the consultation process included:

Facility Categorisation (five-star system)

• Too many categories – limiting boundaries between levels and may create additional administrative burden.
• The procedure should be classified not the centre – average items are not indicative of centres activities, minor and major procedures may be undertaken in a single centre
• The basis of the default principle should be applied to day facilities.

Procedure Categorisation

• Brings day procedures under the same arrangements as overnight procedures thus facilitating the potential expansion of day only procedures.
• Recognises anaesthesia and theatre time banding, utilising MBS values as a basis for determining procedure complexity.

In summary, acknowledgment of both procedure complexity and types of facilities will allow for the expansion of day procedures including allowances for this extension through office-based surgery and extended recovery services.

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Outline of revised proposal

The Department is proposing a benefit be payable for a day procedure according to patient classification and approved level of facility. It is proposed that the facility benefits be based on similar payment arrangements to current overnight default benefits (Attachment 1).

Current patient classification arrangements takes into account both anaesthesia and theatre time banding (and surgeon skill) in a similar manner to the current banding arrangements for day procedures.

The proposal refers to concepts such as extended recovery. Definitions relating to such concepts are identified and defined in the 1997, revised edition of the Report and Recommendations of the Australian Day Surgery Council titled Day Surgery. An extract of the definition is at Attachment 2.

It is envisaged that the following diagram will reflect the new arrangements to come extent.

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Dedicated day surgery unit in hospital/day hospital facility

It is proposed that in respect of hospital treatment, provided to patients undergoing day procedures, the suggested following benefits would be payable for patients requiring treatment that includes an extended recovery period or an overnight stay and falling within the following classes:

Facility type

Level 1: Dedicated free-functioning facility in a public or private hospital and licensed day hospital facilities able to provide all types of professional attention including arrangement for extended overnight recovery and limited care accommodation
Level 2: Facility able to provide all types of professional attention including extended overnight recovery or limited care accommodation
Level 3: Facility able to provide only:

• same day Type B procedures: and/or
• same day Type C procedures (office-based surgery) performed under local anaesthesia or local anaesthesia and sedation

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Patient classification

As specified in part 1 of Schedule 1, paragraph (bj) of the National Health Act 1953:

• an advanced surgical patient is derived from the Medicare Benefits Schedule (MBS) and apply to those MBS items that have a MBS fee that is greater than $656.20
• a surgical patient is derived from the MBS and apply to those MBS items that have a MBS fee within the range of $195.40 to $656.20
• other patients are deemed to be any patient in a hospital other than an advanced surgical, surgical, obstetric, psychiatric, rehabilitation or nursing home type patients).

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Benefit payable (proposed)

• A benefit would be payable for up to three (3) overnight stays following advanced surgery or up to two (2) overnight stays following surgery, in limited care accommodation, would be a negotiated rate for Level 1 facilities only

• These values are based on the current overnight patient classification arrangements in the default schedule and would mirror these arrangements into the future (ie indexation)

• Utilising extended overnight recovery accommodation facilities will need to meet current requirements for overnight certification.

Revised Same Day Accommodation Default Benefits Table (current same day default benefits are at Attachment 3) would look as follows:

*this benefit is payable if the same day procedure requires an extended (overnight) recovery or limited care accommodation arrangement for one (1) night and replaces the same day procedure benefit payable.

**this benefit is payable for a subsequent limited care accommodation night in addition to the benefit for same day or extended recovery.

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Current requirements to remain

• Licensing/approval of day facilities by the States will be required as under present requirements
• Provider numbers from the Commonwealth will be distributed as currently – State approval/licensing must be demonstrated
• Current definitions of Advanced Surgical/Surgical/Other to remain
• Current requirements for Same Day Procedures (overnight certification and patient transfer requirements) to remain

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Current requirements to be removed

• It would be proposed that the current banding system (1 through 4) be removed. Patient classifications take into account the current requirements for anaesthesia and theatre time.

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New requirements

• Commonwealth standards for care and recognition will need to be implemented for limited care accommodations, extended (overnight) recovery and office-based surgery facilities unless State and Territories are able to license these under their current requirements.
• All day procedure facilities will require licensing (as in NSW for all small freestanding day facilities) and hence a provider number from the Commonwealth.
• Accreditation will be required by all day procedure facilities.

  It is envisaged that facility level would be distinguished by the requirement to meet standards (Attachment 4) of day procedure overnight accommodation

  Level 1: dedicated free-functioning facility in a public or private hospital able to provide all types of professional attention including arrangements for extended overnight recovery and limited care accommodation

  Level 2: facility able to provide all types of professional attention including extended overnight recovery or limited care accommodation

  Level 3: facility able to provide only:

  • same day Type B procedures; and/or
  • same day Type C procedures (office-based surgery) performed under local anaesthesia or local anaesthesia and sedation

• Completion of the private patient claim form same day certification required for all day procedures to ascertain benefit payable.

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Issues to be addressed

• Ability to recognise limited care accommodation, extended (overnight) recovery facilities and categorise as licensing requirements varies across States/Territories.
• How accreditation requirements will apply to limited care accommodation and Type B only facilities – would current recognised accrediting programs in use need modification or suggest that facilities require hospital accreditation level to be able to provide overnight accommodation.
• Standards for each level of facility to be developed (ADSC has developed Guidelines for Office Based Surgery).
• Options to decide level of facility:
  • guidelines further developed by ADSC (if interested)
  • introduce into provider number requirements (how?)
  • States/Territories to allocate facility level or Commonwealth could do until appropriate arrangements are in place.
• Changing Private Patient Claim Form to enable patient classification benefits payable (example Attachment 5, current form at Attachment 6).

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Implementation

The Proposal would be enabled through modification to Schedule 3 of the Default Benefits Table. The Department holds the delegation for modifications to this Schedule.
Timeframe:

• support from ADSC/Industry
• Minutes to the Minister
• July 2001 in Portfolio Budget Statement.

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