FAQ for Primary Care on new funding model for COVID-19 Updated 150922

Updated FAQ for primary care on new funding model for COVID-19 assessments and care 15 September 2022 Q: What is changing with primary care funding for COVID-19 clinical care?

A: The main change is to claims for proactive outreach by primary care to people who have tested positive to COVID-19.

Previously, we funded proactive initial clinical assessments for all COVID-19 positive people if their primary care provider determined it was needed.

From 14 September, we will only fund proactive initial clinical assessments for people who meet the Pharmac access criteria for COVID-19 antivirals or those who are not enrolled with a primary care provider.

Another change is claims to see people with COVID-19 who have been self-managing, but become unwell, regardless of whether they meet Pharmac’s criteria/are not enrolled with a primary care provider.

From 14 September, we will fund for clinical escalation for people who have been self-managing, but have self-referred to their health provider because they have become unwell. These could be people who had been self-managing since testing positive, or people who had been self-managing after receiving an initial clinical assessment.

Also, funding for in-clinic reviews has changed.

Previously we funded claims for in-clinic reviews of people who had COVID-19, regardless of whether it was for a condition related or unrelated to COVID-19.

From 14 September, funding for in-clinic reviews is retained for COVID-19 related consults only.

And discharging a person from isolation is no longer required, as patients are automatically notified of when they are due to finish their isolation period. The discharge payment is no longer available.

Other claiming remains unchanged, including for regular reviews with timing and frequency clinically determined at the initial assessment consult or at the clinical escalation consult, post-hospital discharge review (also called a transfer-of-care review), in-home care for care related to someone with COVID-19, and in-person care in a clinic for a COVID-19 related presentation, and the postCOVID follow-up review.

Q: What is the difference between claiming for a clinical escalation consult and a one-off follow-up consult?

A: A claim for a clinical escalation consult relates to people needing care for their acute illness during their isolation phase.

The one-off post-COVID follow-up review is for people who still feel unwell from COVID-19 (up to six weeks from their day 0), but after their acute episode of COVID-19 is over. These people can access a single free consult with their primary care provider. Following that, they will need to co-pay, even if it is related to COVID-19 illness and is within 6 weeks period.

Q: Can Urgent care facility claim under Initial assessment for therapeutics if the patient meets pharmac eligibility criteria when patients presents directly to Urgent care?

A: Yes, Urgent care facilities can claim Initial assessment where appropriate, if this has not already happened through their primary healthcare provider. They need to ensure that if the patient is eligible and consenting, the antivirals are prescribed in a safe manner, rather than referred back to their Primary healthcare provider for prescribing.

Q: Why is primary care funding for COVID-19 clinical care now linked to Pharmac’s widened eligibility criteria for COVID-19 antiviral medicines?

A: After consultation with primary care sector leaders, it was agreed that there should be national consistency of the funding provided to primary care for COVID-19 related clinical care.

Our funding should enable an equitable approach and resources should be targeted towards those with the greatest risk.

Eligibility to COVID-19 medicines was identified as a mechanism to prioritise people who need initial assessment as it identifies those who would be most at risk of severe disease.

Q. What is the difference between clinical escalation and a single follow-up patient-initiated consult?

A. A claim for clinical escalation can be made for a person who becomes acutely ill from COVID-19 and needs care during their 7-day isolation period.

A follow-up consult is funded for an eligible person who has recovered from their acute illness, but requires a follow-up check before the end of the 6 weeks of becoming ill.

For example, a patient who is feeling short of breath during their isolation period who contacts their provider can be claimed for under clinical escalation. If the same patient calls after 3 weeks to followup on their ongoing cough or minor symptoms (not new symptoms unrelated to the original COVID19 infection), this can be claimed under patient-initiated follow-up consult.

Please see content from the Ministry website that outlines the funding framework. COVID-19: Infection and care | Ministry of Health NZ Q. How do I claim for COVID-19 care that took place prior to this new funding model?

A. The new funding model is effective from 14 September 2022 and does not affect funding for COVID-19 related activities prior to that date. All previous COVID-19 related activities will be funded according to the timelines and funding framework that were current at the time.

Q. How does chart review claiming apply when, for example, the patient is 2 years old and is otherwise well, so will not receive therapeutics? Do we need to do chart review on every patient?

A. A chart review is not needed for every patient, which is why we have used the term “where necessary”. If you know the patient, and are confident they are low risk, you may not need to review their notes. However, if a GP needs to do a chart review, then a claim can be made for it if the person meets the clinical eligibility criteria, regardless of age.

Q. How do high needs patients who don’t fit the funding criteria receive the care they might need from us?

A. A practice can utilise the chart review and send the person a text or email with self-management advice and if they are concerned or get unwell to contact their practice. If they do make contact, the clinical escalation pathway can be claimed. If on chart review you find the patient would be eligible for therapeutics, you can undertake initial assessment and if that patient is determined to be not eligible at that stage (for example, they are asymptomatic), you can still make a claim under initial assessment.

Q. What funding applies if the patient is enrolled outside the hub region or district?

A. The process in place initially enabled a hub to manage all cases in the region no matter where the person lived. This meant there was a lot of work for the hub to undertake a consultation with little information in their system. However, now that most consultations are remote, the patient should be managed by their primary healthcare provider. If a COVID-19 positive patient is outside of their usual domicile area and requires an in-person consult at general practice or urgent care facility, this encounter can be claimed under in-person consult.

Q. How is ‘after hours’ defined?

A. Because most care can now take place in normal hours, the weekend and after-hours rates remain unchanged. Most regular reviews are intended to be undertaken during standard work hours (weekdays) with weekend reviews based on clinical need. After-hours on weekday is between 8pm8am Monday – Thursday. Weekend rate covers 5pm Friday- 8am Monday and any public holidays.

Q. How do you define high needs vs standard/unenrolled?

A. Not all of those who meet Pharmac’s eligibility criteria for COVID-19 antiviral medicines will fit into the ‘high needs’ definition for the population. High needs for healthcare is defined as Māori, Pacific peoples, people living in New Zealand deprivation quintile 4 and 5 areas, refugees and people 75 years old and over.

Because unenrolled people are not under a regular healthcare provider, they will require some initial assessment by a hub or other provider (which could include General practice or Urgent care).

Q. Can we only claim an initial assessment if the patient meets eligibility criteria for antivirals after desktop review?

A. Currently, the provision is that if a patient meets the eligibility criteria on desktop review, their actual status will need to be checked (for example, whether they have symptoms to be able to qualify for COVID-19 medicines) so that qualifies for initial assessment funding. On contacting the patient, if we find that they do not meet the criteria, the initial assessment funding still stands.

Clinical escalation is available to those patients who need to raise their concerns with the provider to ensure there is timely and funded access for care. If the desktop review on the same day leads to clinical escalation, then only claim under clinical escalation.

Q. Does this new funding model affect assessment and testing for people presenting to the practice with COVID-like symptoms?

A. No. At this stage, there is no change in funding for the assessment and testing for people presenting with COVID-19 symptoms.