Calculating the GPII outcomes payment
Overview
The outcomes payment is based on the Whole Patient Equivalent (WPE) value of children seen at a practice during a 12 month reference period and on the proportion who were fully immunised. To calculate the payment, the WPE and the proportion of fully immunised children must be determined.
Whole Patient Equivalent (WPE)
The WPE is a numerical representation of the proportion of care provided to a patient (child under seven) at a practice during a 12 month reference period, compared to the overall care provided to that patient by all practices during the same period.
The WPE is calculated from the Medical Benefits Schedule (MBS) fee value of non-referred services for a child under the age of seven at a single practice within a 12 month reference period. The value of these consultations is then divided by the total schedule fee value of all non-referred attendances at all practices for that child in the same period.
The schedule fee value is used to incorporate an element of quality and time, rather than using the number of visits. Practices cannot calculate their own WPE value, as they do not have access to information about other practices each child may have visited.
Example: child attends two practices during the reference period.
| Practice A | Practice B |
|---|---|
|
1 x level B consultation ($30) Total $30 |
1 x level B consultation ($30) Total $90 = Grand Total $120 |
| $30 divided by $120 = 0.25 WPE | $90 divided by $120 = 0.75 WPE |
Note: the above are examples only and do not reflect the current MBS fees.
12 month reference period
Outcomes payments are made on a quarterly basis in February, May, August and November. Each quarter has a 12 month reference period that begins 16 months before the calculation. This allows time for consultations conducted within the reference period to be recorded on the Medicare system.
The table below shows the reference periods used to calculate the practice population, as applicable to each payment quarter.
| Payment quarter | Reference period used for WPE calculation |
|---|---|
| February | 1 October–30 September |
| May | 1 January–31 December |
| August | 1 April–31 March |
| November | 1 July–30 June |
Proportion of children fully immunised
A practice's immunisation coverage is determined by the proportion of children under seven years of age who attended the practice during the 12 month reference period and who were up to date with immunisation at the time of the calculation.
Immunisations recorded on the ACIR before the calculation are included in the assessment of the practice’s immunisation coverage. Immunisation data provided to the ACIR after the calculation is included in the payment recalculation process.
The proportion of fully immunised children is calculated as follows:
- Medicare claims records are used to determine which children under seven attended a practice in the 12 month reference period for a non-referred Medicare consultation (the practice population).
- The WPE value is calculated for each child within the practice population. The WPE total is split into those children who were seen only once at the practice (single visits) and those who were seen two or more times.
- The immunisation status for each child in the practice population is taken directly from the ACIR immediately before the date of the outcome payment calculation, providing real time immunisation status assessment.
- A practice’s immunisation coverage is calculated by dividing the WPE value of children who are fully immunised by the WPE value of children seen at the practice (for two or more non-referred Medicare consultations during the reference period) and multiplying this number by 100.
Single visit children are excluded from the calculation of immunisation coverage. This is because some practices (such as those in holiday areas and those that provide after hours services) would have their figures affected by a large number of single encounters. Excluding single visit patients from the coverage calculation makes sure the figures for the regular population carry more weight. Single visits are included in the WPE value used for calculating the practice’s total outcomes payment.
Querying calculations and payments
If a practice is concerned their reported immunisation coverage rate is lower than expected, the practice can request a GPII practice report (GPII020A). The GPII020A practice report provides details on the children who were assessed as not fully immunised at time of the calculation. Practices can use this information to verify their patient records against the data held on the ACIR and advise the ACIR of any missing information.
If a practice is still unsatisfied, they can ask Medicare Australia to review its calculations. The request must be made by the practice proprietors or their authorised representative (nominated as the contact person in the application form) and include:
- the name and address of the person lodging the request for review
- the name of the practice
- the calculation quarter that should be reviewed
- the grounds for requesting the review.
Requests for a review based on data issues may be resolved through the routine recalculation of payments process. Where errors have occurred in the membership of the practice, these amendments need to be brought to the attention of Medicare Australia in time for inclusion in the recalculation process.
Last updated: 19 March, 2010