Practice Incentives Program (PIP) payments and calculations
PIP Guidelines
More information on the Practice Incentives Program Guidelines
Practice payments
The majority of payments made through the PIP are made to practices and focus on those aspects of general practice that contribute to quality care.
If a practice's PIP application is successful, the practice will receive its initial PIP payment in the first payment quarter after approval. The practice will receive subsequent quarterly payments, providing it continues to meet the eligibility criteria. Payments are made in February, May, August and November.
Medicare Australia will automatically calculate entitlements for payments based on information received from the practice. This means it is important to inform Medicare Australia of any changes in practice arrangements (more information is provided in Practice Changes).
Payments are made by Electronic Funds Transfer (EFT).
Practices can spend their payment as they want, though the usual taxation rules apply. The PIP payment is intended to support the practice in purchasing additional equipment, upgrading its facilities or offering additional remuneration to doctors working at the practice. If a practice chooses to use the payment as an additional source of income for its doctors, the Australian Government strongly encourages its equitable organisation to distribute among doctors working at the practice. However, the Australian Government cannot be responsible for the business arrangements of individual practices.
| Incentives | Aspect or activity | Payment amount |
|---|---|---|
| Quality stream | ||
| Quality Prescribing | Practice participation in quality use of medicines programs endorsed by the National Prescribing Service. Paid annually in May. | $1 per SWPE |
| Diabetes Incentive | Sign-On Payment: one-off payment for notifying the Australian Government that the practice uses a diabetes register and recall/reminder system. | $1 per SWPE |
| Outcomes Payment: payment to practices that complete an annual cycle of care for a target proportion of their patients with diabetes. | $20 per HbA1c SWPE annually | |
| Service Incentive Payment: payment for each annual cycle of care for a patient with diabetes, payable once per year per patient. | $40 per patient per annum | |
| Cervical Screening Incentive |
Sign-on Payment: one-off payment to practices that engage with the state/territory cervical screening registers. | $0.25 per SWPE |
| Outcomes Payment: payment to practices where a specified proportion of women aged between 20 and 69 years have been screened in the last 30 months. | $3 per female WPE† aged between 20 and 69. | |
| Service Incentive Payment: payment to practitioners for screening women between 20 and 69 years who have not had a cervical smear within the last four years. | $35 per patient per annum | |
| Asthma Incentive |
Sign-on Payment: one-off payment to practices that implement a cycle of care for patients with moderate to severe asthma. | $0.25 per SWPE |
| Service Incentive Payment: payment to practitioners who complete an asthma cycle of care for patients with moderate to severe asthma, payable once per year per patient. | $100 per patient per annum | |
| Indigenous Health Incentive |
Sign-on Payment: one-off payment to practices that agree to undertake specified activities to improve the provision of care to their Aboriginal and/or Torres Strait Islander patients with a chronic disease. | $1000 per practice |
| Patient Registration Payment: A payment to practices for each Aboriginal and/or Torres Strait Islander patient aged 15 years and over, registered with the practice for chronic disease management. | $250 per eligible patient per calendar year | |
| Outcomes Payment Tier 1: Payment to practices for each registered patient for whom a target level of care is provided by the practice in a calendar year. | Tier 1: $100 per eligible patient per calendar year | |
| Outcomes Payment Tier 2: Payment to practices for providing the majority of care for a registered patient in a calendar year. | Tier 2: $150 per eligible patient per calendar year | |
| Capacity stream | ||
| eHealth Incentive |
The PIP eHealth Incentive has three components. Practices must meet the requirements of each of component to qualify for payments through this incentive. | $6.50 per SWPE capped at $12 500 per practice, per quarter |
| After Hours Incentive | Tier 1— The practice makes sure that all regular practice patients have access to 24 hour care from a GP, seven days a week, which may be through formalised cooperative arrangements and must include out of hours visits (at home, in residential aged care facilities and in hospitals), where safe and reasonable. | $2 per SWPE annually |
|
Tier 2—Practice GPs must provide the minimum level of after hours cover (dependent on practice size) for all regular practice patients. At all other times, practice patients must have access to after hours care through formalised cooperative arrangements. Practices with a SWPE* value of 2000 or less Practices with a SWPE* value of more than 2000 |
$2 per SWPE annually | |
|
Tier 3—Practice GPs provide all regular practice patients with 24 hour care, seven days a week. The practice GPs must provide all regular practice patients with 24 hour care, seven days a week, including out of hours visits (at home, in residential aged care facilities and in hospitals), where safe and reasonable. |
$2 per SWPE annually | |
| Teaching Incentive | Teaching of medical students. Maximum of two sessions per GP, per day. | $100 per session |
| Aged Care Access Incentive | Tier 1—GPs must reach the Qualifying Service Level 1 (QSL) by providing at least 60 eligible services in residential aged care facilities (RACFs) in the financial year. | $1500 per financial year |
| Tier 2—GPs must reach the QSL 2 by providing at least 140 eligible services in RACFs in the financial year. | $3500 per financial year | |
| Rural support stream** | ||
| Rural Loading | The practice's main location is outside metropolitan areas (increases with extent of remoteness) based on the Rural, Remote & Metropolitan Area (RRMA) 3–7 Classification. Once all incentive payments are added together the rural loading amount is applied. | RRMA 1–0 per cent loading RRMA 2–0 per cent loading RRMA 3–15 per cent loading RRMA 4–20 per cent loading RRMA 5–40 per cent loading RRMA 6–25 per cent loading RRMA 7–50 per cent loading. |
| Procedural GP Payment | Tier 1— A GP in a rural or remote practice provides at least one procedural service, which meets the definition of a procedural service, in the six month reference period. | $1000 per six month reference period |
| Tier 2— A GP in a rural or remote practice meets the Tier 1 requirement and provides after hours procedural services on a regular or rostered basis (15 hours per week on average) throughout the six month reference period. | $2000 per six month reference period | |
| Tier 3— A GP in a rural or remote practice meets the Tier 2 requirements and provides 25 or more eligible surgical and/or anaesthetic and/or obstetric services in the six month reference period. | $5000 per six month reference period | |
| Tier 4— A GP in a rural or remote practice meets the Tier 2 requirements and delivers 10 or more babies in the six month reference period or meets the obstetric needs of the community. | $8500 per six month reference period. | |
* For practices in rural, remote and metropolitan areas 3-7 only.
†Whole Patient Equivalent (WPE)
Calculation of payments
PIP payments are generally based on a measure of the practice size known as the Standardised Whole Patient Equivalent (SWPE) value. The SWPE value is calculated using Medicare Benefits Schedule (MBS) claims by patients attending the practice during a historical 12 month period known as the reference period. The reference period is a rolling 12 month period that commences 16 months prior to the payment quarter. See Table 2.
Payments are calculated using Medicare Australia and Department of Veterans' Affairs (DVA) data that are linked to the provider numbers specified on the practice's application form and any subsequent amendments provided to Medicare Australia. If for example, you do not provide Medicare Australia with details of new GPs, you will not receive payment associated with the services provided by the new GPs. More information is provided in the Practice Changes section.
Data will be excluded if any of the GPs in a practice refuse consent to the use of their data for the purposes of calculating the practice's payment when completing the Individual GP details form. If GPs would like their data to be included at a later stage, they must advise Medicare Australia in writing.
Calculating the SWPE value
The Standardised Whole Patient Equivalent (SWPE) value of a practice is the sum of the fractions of care provided to practice patients, weighted for the age and gender of each patient. As a guide, the average full-time GP has a SWPE value of around 1000 SWPEs annually. For more information on the calculation of payments and the SWPE value, refer to the PIP guidelines [PDF, 190Kb]
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The total care for each patient equals one (1.0) and is known as the Whole Patient Equivalent (WPE). The WPE is based on GP and other non-referred consultation items in the MBS and uses the value rather than the number of consultations per patient.
Table 1 gives the values used in weighting WPEs for age and gender for May 2013. (Weightings are subject to quarterly adjustments).
Table 1
| Weighting factors for age and gender of patients | ||||||||
|---|---|---|---|---|---|---|---|---|
| Sex | Patient age (years) | |||||||
| <1 | 1 - 4 | 5 - 14 | 15 - 24 | 25 - 44 | 45 - 64 | 65 - 74 | 75 + | |
| Female | 0.5290 | 0.8406 | 0.5145 | 0.8225 | 1.0072 | 1.1087 | 1.5217 | 2.2500 |
| Male | 0.5725 | 0.9094 | 0.5217 | 0.5326 | 0.6703 | 0.9094 | 1.3696 | 2.0870 |
The values in the table above are calculated from consultations by age and gender, using Medicare Australia and Department of Veterans' Affairs (DVA) data and are updated as required.
These weighted fractions of patient care are then added together, giving the SWPE value for the practice.
When payments are made
To qualify for payments, practices must be participating in the PIP and meet the eligibility requirements of the incentives at a ‘point in time’ date. The ‘point in time’ date is the last day of the month prior to the next PIP quarterly payment. The quarterly payment months, ‘point in time’ dates and reference periods are provided in table 2. For more information on when payments are made, refer to the PIP guidelines [PDF, 190Kb].
Table 2
| Quarterly Payment Month | ‘Point in time’ assessment of eligibility | SWPE value reference period |
|---|---|---|
| February | 31 January | 1 October to 30 September |
| May | 30 April | 1 January to 31 December |
| August | 31 July | 1 April to 31 March |
| November | 31 October | 1 July to 30 June |
Appealing a Medicare Australia decision
The PIP has an established appeals process. To request a review of a decision, your practice’s authorised contact person or the owners of the practice must write to Medicare Australia within 28 calendar days of the date on the notice of the decision they would like reviewed.
The request must include the following details:
- the name and address of the person requesting the review
- the name and PIP practice identification number of the practice
- the decision to be reviewed
- the grounds for requesting the review.
Medicare Australia will reassess its decision in accordance with the PIP eligibility requirements and/or payment formula used to make the original decision and advise the practice in writing of the outcome of the review.
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Last updated: 15 May, 2013