Department of Health Library Services ePublications - Historical Collection
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To apply preservation treatments, including digitisation, to a high value and vulnerable Historical collection of items held in the Darwin and Alice Springs libraries so that the items may be accessed without causing further damage to the original items and provide accessibility for stakeholders.
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Northern Territory Department of Health Library Services Historical Collection
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Julie Searle
Heather Moyle
NT Dept. of Health
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INTRODUCTION
Cross Border Interstate Charging was introduced in the 1993/94 financial year as part of the
Medicare Agreement 1993/98. Under the terms of the Medicare Agreement, all States and Territories are required to meet the cost of public and private inpatient services provided to their residents in a public hospital setting in another State or Territory.
The commencement of Cross Border Interstate Charging for acute inpatient services represents the first introduction of Casemix charging on a national basis.
Cross Border charges are determined on the basis of AN-DRG weighted separations using national cost weights and pricing.
The benchmark prices used are :
1994/95 $2405 for public inpatients and $1100 for private inpatients.
1995/96 $2454 for public inpatients and $1123 for private inpatients.
1996/97 $2502 for public inpatients and $1145 for private inpatients.
The following report represents the most comprehensive analysis undertaken to date on patients treated in South Australian public hospitals. In addition to information presented by Region and Specialty, detailed clinical information (diagnoses, procedures, etc) and detailed travel information is also available at the individual patient level if required.
Total Expenditure and Revenue on Cross Border Patient Flows
Graph 1 Total Cross Border Expenditure and Revenue
10,000,000
9,000,000
8,000,000 7,000,000
<I) 6,000,000
:::, iij >
VI- 5,000,000
4,000,000 3,000,000 2,000,000
1,000,000
1994/95 1995/96 1996/97 (Proj.) 1997/98 (Proj)
-+-Expenditure - Revenue
I
The above graph provides information relating to actual and projected expenditure and revenue based on actual patient flows from the NT to other states and from other states to the NT. This information does not contain any adjustments and does not reflect actual yearly expenditure and revenue budget outcomes which are affected by a 12 month time lag. The graph does however provide a clear indication of overall shifts in service utilisation and the likely future budget impact.
Despite significant increased acute inpatient workload in NT hospitals over the last three years ( 16%) the number of NT residents treated in interstate public hospitals has steadily reduced indicating an increase in self-sufficiency. The total projected expenditure relating to 1996/97 and 1997/98 is relatively constant despite the reduction in patients treated, due to an increase in case complexity and higher benchmark prices.
Overall revenue generated for interstate patients treated in NT hospitals is projected to level off for 1996/97 and 1997/98 after significant increases in 1994/95 and 1995/96. The implementation of the Revenue Optimisation Project should assist in improving identification, classification, registration and billing of interstate patients admitted to NT hospitals as there is still considerable scope for improving these procedures. It is estimated that increases in the order of 10% per annum can be achieved at RDH and ASH respectively, through improvements in admission procedures.
The actual net cost of cross border charging to the NT has been reduced from around $4.8m per annum in 1993/94 to around $2.7m per annum in 1996/97.
oo 2.0 c,
Overview of All NT Residents Treated in South Australian Public Hospitals
South Australian public hospitals treat around 72% of all Northern Territory residents treated in interstate hospitals, for which cross border charges are applicable.
Since the introduction of Cross Border Charging in 1993/94 there has been substantial shifts in the number and complexity of NT cases treated in South Australian public hospitals. Whilst there has been a decline in the overall number of NT residents treated in SA public hospitals, the total
workload as measured by weighted inpatient separations has varied markedly on a year to year basis.
In 1996/97, weighted separations were at the highest level since the inception of cross border charging.
The actual number of NT residents treated in SA hospitals in 1995/96 was similar to 1996/97 however the complexity of patients treated was considerably greater, with the average ANDRG cost weight per separation increasing substantially from 1.88 to 2.15. In 1994/95 the average cost weight per separation was 1.98. This clearly indicates the increasing complexity of cases treated with an overall increase of 14% in the average cost weight between 1995/96 and 1996/97. A more detailed analysis of SA public hospital service utilisation by specialty and region is provided at Appendix 'A'.
Graph 2
3000
T
I2900
~ 2800
.: ~ ... 0: 2700
~ .,
'fl 2600
,::
~ ~ 2500
·~ ~
2400 2300
Total Northern Territory Residents treated in South Australian hospitals.
2595
1993/94
2890
Increase of 11 %
1994/95
Decrease of 12%
2535
199 5/96
mNT Residents treated in SA Hospitals
Increase of 17%
19 96/97
Total NT Residents Treated in South Australian Hospitals
Actual Inpatient Expenditure
Table 1 compares the expenditure on inpatient costs of Northern Territory residents treated in South Australian hospitals during the period 1994/95, 1995/96 and 1996/97. This table represents both referred and self-referred patients.
Table 1 Expenditure on Total NT Residents treated in South Australian Hospitals South Australian Cross Border Flows
1994/95 1995/96 1996/97
All Inpatient Expenditure Variation$
Variation% Total Separations
$6,366,928
1459
$5,872,890
-$494,038 -7.75% 1343
$7,094,972 +$1,222,082 +20.80%
1380
The above expenditure analysis reveals that the overall costs of treating NT residents in SA hospitals has increased substantially in 1996/97 despite the number of patients treated remaining at similar levels. This reflects an increase in the complexity of cases treated in SA public hospitals and increases in benchmark prices.
Graph 3 Expenditure on Total NT Residents Treated in South Australian Hospitals
"
s.000,000
T
7,000,000
6,000,000
~ 5,000,000
;..,
,,,
'i= 4,000,0001
3.000,000<::'
~ 2.000,000
1,000,000
O+ -- -
$6.37 m
l 994/95
Decrease of 7.8%
$5.87 m
1995/96
Increase of 20.8%
II NT Residents lreat.ed jn SA Ho~-pita.ls
$7.09 m
1996/97
() '·2-...;, )
Analysis of NT Residents Referred by NT Hospitals
Referred Patient Expenditure
Table 2 compares the expenditure of Northern Territory residents, including corresponding travel expenses, treated in South Australian hospitals during the period 1994/95, 1995/96 and 1996/97.
This table represents only referred patients.
Table 2 Expenditure on NT Residents Referred by all NT Hospitals
South Australian Cross Border Flows - NT Total
Referred Inpatient Expenditure Only Travel Expenditure
Total Expenditure Variation$
Variation%
Total Referred Separations
Referred as % of Total Separations
1994/95
$4,409,721
$991,161
$5,400,882
880 60.31 %
1995/96 1996/97
$4,190,723 $4,615,275
$941,491 $1,068,034
$5,132,214 $5,683,309 -$268,668 +$551,095
-5% +10.74%
863 839
64.25% 60.79%
The above table indicates that the total number of patients referred by NT hospitals is showing a downward trend, with an overall decrease of 5% between 1994/95 and 1996/97. This indicates an increase in self-sufficiency, although overall treatment and travel costs have increased by $551,095 (10.74%) between 1995/96 and 1996/97. This reflects a combination of increased complexity and higher patient travel costs.
Activity by Region
Table 3 Expenditure on NT Residents Referred by Top End Hospitals
South Australian Cross Border Flows - Top End Region
Referred Patient Expenditure Travel Expenditure
Total Expenditure Variation$
Variation%
Total Referred Separations
Region as % of Total Referred Separations
1994/95
$2,201,177
$413,693
$2,614,870
398 45.2%
1995/96 1996/97
$2,262,420 $2,393,550
$436,429 $533,917
$2,698,849 $2,927,467 +$83,979 +$228,618
+3.2% +8.4%
416 415
48.2% 49.5%
The above table indicates that despite increased demand for acute inpatient services at Royal Darwin Hospital (14.5% increase over last two years), the number of patient referrals has remained constant.
This indicates a significant increase in overall self-sufficiency. There has been an increase in total
0,..,..,. ,) ....:,
costs of treating referred patients from the Top End Region ($228,618 or 8.4%) between 1995/96 and 1996/97. There has been a substantial increase (22%) in travel costs alone, which accounts for 43% of the total increase in expenditure.
Table 4 Expenditure on NT Residents Referred by Central Region Hospitals
South Australian Cross Border Flows -Central Region
1994/95 1995/96 1996/97
Referred Patient Expenditure Travel Expenditure
$2,208,543
$577,469
$2,786,012
$1,928,303 $2,221,726
$505,061 $534,118
Total Expenditure Variation$
$2,433,364 $2,755,844 -$352,648 +$322,480
Variation% -12.6% +13.2%
Total Referred Separations 482
54.8%
447 424
Region as % of Total Referred Separations 51.8% 50.5%
The demand for acute inpatient services at Alice Springs Hospital increased by 5.8% between 1995/96 and 1996/97 (9.2% over two years) which represents a substantial increase in workload. Despite this increase in workload the number of patients referred to SA public hospitals has continued to decline (12% reduction) in total patient referrals between 1994/95 and 1996/97. This clearly indicates a substantial increase in self-sufficiency.
It is however apparent that the cost of treating referred patients in SA public hospitals has increased appreciably between 1995/96 and 1996/97, with a overall increase of $675,000 in total treatment costs.
Analysis of NT Referrals Based on Population
The Central Australian Region has a population catchment of around 45,000 people, while the Top End Region has a population catchment of 140,000. Royal Darwin Hospital and Darwin Private Hospital provide a much greater range of specialist services and as such the overall referral rate to SA public hospitals in 1996/97 was 2.9 per 1,000 compared to a rate of 9.4 per 1,000 for the Central Region.
It is apparent that Central Australia continues to use SA public hospitals as its principal specialist referral base for patients requiring up-transfers despite the fact that a large proportion of these services are now available at Royal Darwin Hospital or Darwin Private Hospital and there is no cost difference in transporting patients to Darwin compared to Adelaide. Given that the Territory currently pays SA public hospitals based on average costs (1996/97 benchmark prices of $2502 for public patients and $1145 for private patients) and could provide many specialist services at Royal Darwin Hospital at marginal costs, Territory Health Services is currently paying a premium price for treatment costs relating to specialist referrals from Central Australia. Since the inception of cross border charging in 1993/94 there has been a notable increase in self-sufficiency in Central Australia however there has been little change in referral practices by specialists employed in Central Australia in relation to utilisation of Top End Hospital services.
More indepth analysis needs to be undertaken on a specialty and sub-specialty basis involving ASH and RDH specialists to confirm the opportunities that do exist, to examine service capacity issues, to determine cost benefits and to implement changes in specialist referral practices based on agreed NT clinical protocols.
The next section of the report identifies a number of specialty areas that should be investigated based on current patient referral numbers and the ability of Top End Hospitals to provide these specialist services for NT residents.
Analysis of NT Referrals by Specialty and Region
Cardiology
Referral of cardiology patients from both ASH and RDH to SA public hospitals represents a substantial workload and cost, with an increase of over 100% in weighted separations between 1994/95 and 1995/96. The NT expended a total of $1.13m for cardiology treatment services and travel costs for NT residents treated in SA public hospitals in 1996/97 and also incurred an estimated additional $180,000 for cardiology specialist services provided in other states.
Consultants engaged by the Darwin Private Hospital are currently investigating the feasibility of establishing a Cardiac Catheterisation Laboratory at DPH and detailed information from this analysis has been provided to Dr James Agnew of Newchurch Consultants. If established, the service would be available to treat all public and private patients in the NT requiring invasive cardiac procedures and diagnostic services. RDH has also recently recruited a specialist cardiologist.
ENT
The total weighted separations of patients referred within this specialty was significant, with RDH exhibiting a 49.66% increase between 1995/96 and 1996/97. RDH has upgraded specialty services in this area and it is expected that the range of services provided locally will increase substantially during 1997/98. There is scope for reviewing the referrals from ASH to SA public hospitals in the light of this upgrade. Several high cost DRGs which are included in this specialty (eg tracheostomy) have a substantial resource impact, involving a small number patients with very complex
requirements.
General Surgery
General Surgery represents a specialty area in which there is scope for increased workload to be performed in the Northern Territory. Increases in weighted separations of 92.44% and 44.75% were exhibited in 1996/97 at RDH and ASH respectively. ASH refers a significant number of patients to SA public hospitals for procedures that can be performed at RDH.
Haematology
There is evidence of increasing self-sufficiency and additional specialist services at both RDH and ASH within this specialty, with substantially decreased referral patterns evident since 1994/95. ASH refers significantly more patients to SA public hospitals for treatment that could be provided at RDH.
Neonatology
While referral for neonatology services from RDH have decreased over the last two years, this is not evident at ASH, which exhibited a 61 % increase in 1996/97 over the previous year. It is apparent that ASH is referring patients interstate when excess capacity exists at RDH. There is significant potential for cost savings in this specialty.
Neurosurgery
There are steady numbers of weighted separations being referred to South Australia in the area of neurosurgery, however current service utilisation would not appear to support the introduction of a
' I ... ~ V _.
Obstetrics
There is some scope within obstetrics for additional patients from ASH to be referred to RDH in preference to SA public hospitals. A small decline in referred weighted separations however was exhibited by ASH in 1996/97.
Orthopaedics
Referral of orthopaedic patients declined in 1995/96 but increased again in 1996/97. There is further scope for increased utilisation of services within the Northern Territory.
Urology
There is evidence of increasing self-sufficiency at RDH and ASH within this specialty, with total weighted separations declining by 87.8% at RDH and 33.5% at ASH between 1994/95 and 1995/96.
There is scope for increasing referrals from ASH to RDH which has now become largely self- sufficient in this specialty.
Further Analyses
More detailed analyses of referred services by region, specialty and DRG can be found in Appendix 'A' and 'C'. If required, more detailed information at the individual patient level (including
diagnoses, procedures, complications and comorbidities) can be obtained for each individual specialty and sub-specialty for clinical review.
Appendix 'B' provides information on all NT residents treated in SA public hospitals by DRG.
C.J rJ :,.!_.LJ 1....1
APPENDIX A
3 YEAR COMPARISON OF WEIGHTED SEPARATIONS
NT RESIDENTS REFERRED
BY NT HOSPITALS
BY REGION & SPECIALTY
Spec
Appendix 'A'
Referred Patient Travel Data in Weighted Separations
94/95 134.43 56.53 0 1.99 0 1.98 3.97 194.93
95/96 260.17 113.28 11.62 14.47 4.64 8.09 38.82 412.27
Var% 93.54% 100.39% 627.14% 308.59% 877.83% 111.50%
96/97 224.94 121.48 8.2 9.84 0 9.80 27.84 374.26
Var% -13.54% 7.24% -29.43% -32.00% -100.00% 21.14% -28.28% -9.22%
94/95 133.45 67.45 6.8 6.44 6.44 11.42 31.1 232
95/96 53.78 47.44 0 0 3.86 10.63 14.49 115. 71
Var% -59.70% -29.67% -100.00% -100.00% -40.06% -6.92% -53.41% -50.13%
96/97 39.58 59.11 5.15 6.25 0 9.23 20.63 119.32
Var% -26.40% 24.60% -100.00% -13.17% 42.37% 3.12%
94/95 0.62 1.00 0 0 0 0 0 1.62
95/96 0 0.72 0 0 0 0 0 0.72
Var% -100.00% -28.00% -55.56%
96/97 1.18 1.84 0 0 0 0 0 3.02
Var% 155.56% 319.44%
94/95 3.82 4.65 0 1.15 0 0 1.15 9.62
95/96 5.02 3.57 0 0 0 0 0 8.59
Var% 31.41% -23.23% -100.00% -100.00% -10.71%
96/97 12.50 2.98 0 0.88 0 0 0.88 16.36
Var% 149.00% -16.53% 90.45%
94/95 128.53 161.04 19.22 2.64 0 0 21.86 311.43
95/96 131 96.34 2.68 8.17 0 0 10.85 238.19
Var% 1.92% -40.18% -86.06% 209.47% -50.37% -23.52%
96/97 196.06 92.70 27.3 27.35 0 1.1 55.75 344.51
Var% 49.66% -3.78% 918.66% 234.76% 413.82% 44.64%
94/95 10.52 21.6 2.22 0 0 0 2.22 34.34
95/96 6.55 8.59 0 0 0 0 0 15.14
Var% -37.74% -60.23% -100.00% -100.00% -55.91%
96/97 5.63 12.19 0 0 0 0.77 0.77 18.59
Var% -14.05% 41.91%
94/95 6.57 29.07 1.93 0 0 0 1.93 37.57
95/96 4.07 22.49 0.57 2.24 0 0 2.81 29.37
Var% -38.05% -22.64% -70.47% 45.60% -21.83%
96/97 15.70 16.75 5.88 0.57 0.63 0.99 8.07 40.52
Var% 285.75% 931.58% -74.55% 187.19% 37.96%
94/95 48.34 112.35 7.17 0.94 0 0 8.11 168.8
95/96 49.72 59.48 1.37 0.53 0 0 1.9 111.1
Var% 2.85% -47.06% -80.89% -43.62% -76.57% -34.18%
96/97 95.68 86.10 4.89 0 2.95 0 7.84 189.62
Var% 92.44% 44.75% 256.93% -100.00% 312.63% 70.68%
Spec
94/95 3.48 13.92 1.24 0 0 0 1.24 18.64
95/96 3.88 9.99 1.84 0.45 0 0 2.29 16.16
Var% 11.49% -28.23% 48.39% 84.68% -13.30%
96/97 9.66 8.48 0 1.43 0 0 1.43 19.57
Var% 148.97% -15.12% -100.00% 217.78% -37.55% 21.10%
94/95 110.75 57.08 0 0.83 0 0 0.83 168.66
95/96 27.03 38.16 0.5 0 0 0 0.5 65.69
Var% -75.59% -33.15% -100.00% -39.76% -61.05%
96/97 30.26 56.53 0 0 0 0 0 86.79
Var% 11.95% 48.14% -100.00% -100.00% 32.12%
45.59 125.89 0 0 0 0 0 171.48
95/96 33.63 69.62 0 0 0 0 0 103.25
Var% -26.23% -44.70% -39.79%
96/97 0.92 112.15 3.61 0 0 0 3.61 116.68
Var% -97.26% 61.09% 13.01%
94/95 17.55 9.51 0 0 0 0 0 27.06
95/96 27.59 22.85 1.13 0 0 0.98 2.11 52.55
Var% 57.21% 140.27% 94.20%
96/97 9.57 14.62 1.18 0 0 0 1.18 25.37
Var% -65.31% -36.02% 4.42% -100.00% -44.08% -51.72%
24.91 30.71 3.91 0 0 0 3.91 59.53
95/96 12.31 8.33 3.02 0 0 0 3.02 23.66
Var% -50.58% -72.88% -22.76% -22.76% -60.26%
96/97 12.62 21.53 3.66 0 0 0 3.66 37.81
Var% 2.52% 21.19% 59.81%
68.83 23.34 0 0 0 0 0 92.17
95/96 104.91 75.31 2.39 11.47 0 0 13.86 194.08
Var% 52.42% 222.66% 110.57%
96/97 85.42 65.96 3.64 0 0 0 3.64 155.02
Var% -18.58% -12.42% 52.30% -73.74% -20.13%
94/95 3.53 22.5 0.48 0 0 0 0.48 26.51
95/96 2.74 29.76 0 0 0 0 0 32.5
Var% -22.38% 32.27% -100.00% -100.00% 22.60%
96/97 10.42 18.04 0 0 0 0 0 28.46
Var% 280.29% -39.38% -12.43%
94/95 49.16 23.47 1.39 0 0 0 1.39 74.02
95/96 11.21 11.03 0 0 0 0 0 22.24
Var% -77.20% -53.00% -100.00% -100.00% -69.95%
96/97 7.04 5.44 0 0 0 0.32 0.32 12.8
Var% -37.20% -50.68% -42.45%
94/95 9.55 12.9 2.06 0 0 0 , 2.06 24.51
95/96 18.34 19.89 3.72 0 0 1.77 5.49 43.72
Spec
94/95 20.96 39.4 3.97 1.01 0 0 4.98 65.34
95/96 8.98 23.11 5.96 0 0 0 5.96 38.05
Var% -57.16% -41.35% 50.13% -100.00% 19.68% -41.77%
96/97 22.98 25.00 4.68 4.64 0 0 9.32 57.3
Var% 155.90% 8.18% -21.48% 56.38% 50.59%
94/95 41.51 17.77 1.16 1.66 0 0 2.82 62.1
95/96 86.57 50.17 1.73 0 0 0 1.73 138.47
Var% 108.55% 182.33% 49.14% -100.00% -38.65% 122.98%
96/97 49.00 20.51 0 0 0 0 0 69.51
Var% -43.40% -59.12% -100.00% -49.80%
0 1.5 0 0 0 0 1.5
95/96 0 5.87 0 0 0 0 0 5.87
Var% 291.33% 291.33%
96/97 0 1.14 0 0 0 0 0 1.14
Var% -80.58% -80.58%
29.08 20.35 0 0 0 0 0
95/96 4.3 0 0 0 0 0 0 4.3
Var% -85.21% -100.00% -91.30%
96/97 8.6 17.2 0 0 0 0 0 25.8
Var% 100.00% 500.00%
94/95 1.95 0.73 0 0 0 0 0 2.68
95/96 5.25 3 0 0 0 0 0 8.25
Var% 169.23% 310.96% 207.84%
96/97 0 0.5 0 0 0 0 0 0.5
Var% -100.00% -83.33% -93.94%
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94/95 4.78 1.41 0 0 0 0 0 6.19
95/96 7.62 16.24 0 0 0 0 0 23.86
Var% 59.41% 1051.77% 285.46%
96/97 19.19 10.11 1.87 0 0 0 1.87 31.17
Var% 151.84% -37.75% 30.64%
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.94/95 4.18 0.75 0 0 0 0 0 4.93
95/96 0.92 4.13 0 0 0 0 0 5.05
Var% -77.99% 450.67% 2.43%
96/97 0 0 0 0 0 0 0 0
Var% -100.00% -100.00% -100.00%
94/95 28.14 43.99 1.93 3.51 0 0 5.44 77.57
95/96 3.43 29.22 1.88 0 0 0 1.88 34.53
Var% -87.81% -33.58% -2.59% -100.00% -65.44% -55.49%
96/97 9.73 52.14 2.63 0 0 0 2.63 64.5
Var% 183.67% 78.44% 39.89% 39.89% 86.79%
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,: 0' ·~!,)'1~. a r.:94/95 20.71 28.91 0 0
' 0 0 0 49.62
95/96 36.07 22.81 0 0 0 0 0 58.88
Var% 74.17% -21.10% 18.66%
96/97 9.23 11.9 0 2.83 0 0 2.83 23.96
Var% -74.41% -47.83% -59.31%
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94/95 951.05 927.95 46.63 20.21 6.44 13.41 86.69 1965.69
95/96 905.1 791 .40 38.41 37.33 8.5 21.47 105.71 1802.21
Var% -4.83% -14.72% -17.63% 84.71% 31.99% 60.10% 21.94% -8.32%
96/97 909.17 848.38 73.78 55.65 4.07 22.21 155.71 1913.26
Var% 0.45% 7.20% 92.09% 49.08% -52.12% 3.45% 47.30% 6.16%