Feature, Report

Blind spot: the cost of providing domiciliary care

Optometrists who provide domiciliary services are compensated for travel costs and unpacking and repacking equipment, but they say it’s not enough. Will the Federal Government increase the MBS benefit to support more optometrists to provide these services to older Australians? RHIANNON BOWMAN reports.

Hobart and Perth may not have a lot in common, but they share something unusual: an optometrist who exclusively provides eyecare to residents in aged care. In Hobart, Mr Paul Graveson regularly visits 12 aged care facilities, while Ms Robyn Main visits about 70 annually in Perth.

Graveson and Main are a rare breed; they don’t operate a bricks-and-mortar practice, and they don’t treat the general population (including children). They only treat patients typically over 65 and in an aged care facility, or occasionally at home.

They do differ in one respect; Graveson usually doesn’t bulk-bill, Main does. But they are united in their opinion that the current Medicare Benefits Schedule (MBS) fee payable to optometrists providing domiciliary services is woefully inadequate.

Under the MBS, benefits are payable to optometrists providing domiciliary services under items 10931 to 10933, in the form of a loading, in recompense for “travel costs and packing and unpacking of equipment.”

A domiciliary visit performed on one patient at a single location on one occasion (item 10931) attracts a fee of $24.20 and a benefit of $20.60 (85%). A domiciliary visit performed on two patients at the same location on one occasion (item 10932) attracts a fee of $12.10 and a benefit of $10.30 (85%). And a domiciliary visit performed on three patients at the same location on one occasion (item 10933) attracts a fee of $7.95 and a benefit of $6.80 (85%).

Graveson and Main have been providing domiciliary services for several years and both agree the MBS fees demonstrate how much the Federal Government undervalues eyecare. But they are not lone voices. As part of its federal election platform this year, Optometry Australia (OA) advocated for an increase in the optometric domiciliary loading benefit in residential aged care.

OA modelling has shown the current scheduled full fee amount of $24.20 for a domiciliary loading grossly under-recognises the costs of providing domiciliary care, discouraging optometrists from providing eyecare to those at risk and vulnerable patients.

According to OA, research indicates that a more realistic domiciliary loading would increase provision of these services at minimal budget cost due to their infrequency. The organisation has proposed that the domiciliary loading be increased to $85.00 per visit (paid proportionally for multiple patients) with an assumed 10% increase in services.

However, when the federal budget was delivered on 29 March, there was no mention of a domiciliary loading increase, which OA had estimated would cost the government $500,000 per annum.

In a bind

Graveson, an optometrist and low vision consultant, is the only optometrist who exclusively provides domiciliary care in Hobart. He visits 12 aged care facilities in the Hobart region, seeing four or five patients each visit in a four-week cycle.

Paul Graveson.

“I don’t earn as much income as I would if I worked in a franchise practice, but I do it because I like being my own boss,” he says.

“I see patients in the morning through to lunchtime, then I manage phone calls and paperwork at home. I have kids, and I’ve been doing this since they were toddlers, because I value the autonomy, or freedom, it gives me.”

Graveson became involved in domiciliary care through his work in low vision, where he became aware aged care residents weren’t receiving adequate care.

“This is important work, it’s a service that makes a difference to people. Does the government value it? I don’t think so, given the number of cases of untreated glaucoma, dry eye, and diabetes-related vision loss I have seen,” he explains.

“In the context of an aged care facility, having residents with vision impairment because they don’t have glasses is significant – their quality-of-life is hugely affected. Optometrists are immensely important in providing the basics of refracting and dispensing which are important to aged care residents’ quality-of-life – be it for reading, crossword puzzles, jigsaw puzzles, craft, Bingo, anything.”

Despite Graveson’s altruistic outlook, he is also a realist: “I mostly don’t bulk-bill. That makes me quite different, but it brings its own benefits – and difficulties.”

He says that if the Medicare rebate was higher, he’d be able to bulk-bill a larger proportion of his patients, and his privately billed patients would be less out-of-pocket.

Although he examines as few as four or five patients each visit (or session), each visit entails a large amount of organisation.

“I typically contact the liaison person at the aged care facility a couple of weeks ahead with a list of people to see. There may be patients needing review, or a family may have requested an eye examination for their relative in aged care. I also have to obtain medical and financial consent from an aged care resident’s family.”

Organising a visit doesn’t end there; there is also the logistics of transporting, loading and unloading equipment.

“You need to pack up the relevant equipment from your practice and carry it to your vehicle, (Graveson has most of his equipment permanently in a car he uses specifically for domiciliary visits), travel to the aged care facility, sign-in, complete a Rapid Antigen Test, wait for the result, then carry your equipment into the exam room, set it up, before you’re then ready to examine your first patient, who might not be ready – for instance, they may be showering or sleeping – despite a liaison person knowing you’re coming to see residents.

Medicare MBS Review Taskforce
A domiciliary visit under item 10931 attracts a fee of $24.20 and a benefit of $20.60 (85%).

“There is some sitting around, waiting for patients. After examining patients, you then need to pack up your equipment, load it into your vehicle once again, drive back to your practice or workplace, carry your equipment back into the practice, unpack and set it back up. You’re looking at a minimum of an hour in total split between before and after the session. Still, it’s a significant chunk of non-income-generating time though – most practices would see two or three patients in 60-90 minutes, so the ‘opportunity cost’ is high. “

You then need to start calling family members to give them a report. You need to organise a referral if required, which is more common in aged care than in the general population. If glasses are required, you need to prepare a quote, send it out, follow-up payment and delivery.”

Graveson has $40,000 worth of portable equipment and purchased a vehicle, plus insurance cover, specifically for work purposes.

“All of that (equipment, vehicle, preparation, travel, packing and unpacking) is supposed to be covered by $24.20. Although it has increased by 1% per year, it is lower than CPI. In real terms the Medicare rebate goes down a little more every year,” he says.

“The dispensing rate in aged care facilities is lower than in private practice. Essentially, you need the consultation to pay in its own right. The consultation fee not only has to cover your time spent in the consultation, but the preparation time before the session.”

One of the main ‘sticking points’ preventing optometrists from offering domiciliary services like Graveson is that the opportunity cost is too high.

“To visit one resident in aged care, you need to book out at least two hours. It’s hard to make a business case on that basis for bricks-and-mortar practices.”

Graveson says OA’s proposal to increase the domiciliary loading to $85 per visit is “still very modest”.

“We’re in a bind. The current domiciliary loading fee is a joke. But the fact that it’s there is a double-edged sword. I wrote to the Health Minister a few years ago on this issue, and the Health Minister wrote back that the MBS loading item is there to support us, so that was enough,” Graveson says.

By contrast, GPs who treat residents in aged care facilities receive a higher rebate as part of General Practitioner Aged Care Access, a government incentive designed to encourage GPs to provide increased and continuing services in Australian Government funded residential aged care facilities.

Under the program, GPs receive $2,000 if they provide between 60 to 99 eligible MBS services in residential aged care facilities in a financial year; an additional $2,500 if they provide 100 to 139 services; another $2,500 if they provide 140 to 179; and an additional $3,000 if they provide 180 or more services. Eligible GPs can get four payments totalling $10,000 for the financial year, in addition to the consultation fee.

No such incentive exists for optometrists.

“The optometry MBS rebate is the patient’s rebate. It is halved if you see two patients, then it drops to a third of the value if you see three patients. If you see four or five patients, they don’t get any domiciliary rebate. If you’re not bulk-billing, the fourth and fifth patients receive less total rebate. It’s an equity problem,” Graveson says.

In the decade between January 2010 and December 2019, before COVID, Graveson says the total number of domiciliary consults was 140,790, which loosely translates to 14,000 per year, for a population of over 180,000 aged care facility residents.

He says compared to the population living in aged care facilities – which was 184,000 people in 2017 – that’s less than one domiciliary exam per 10 people per year.

“It highlights the problem with item 10933 – it is impossible to capture how many consults are done after the third patient but it’s unlikely to be more than another 20 to 30%,” Graveson says.

“I support OA’s proposal for a higher loading fee. But I also think optometrists should be able to charge item 10933 on third and subsequent consultations. If every patient who received a domiciliary service received a domiciliary item number, the Medicare data would give us a more accurate indication of how many residents are receiving optometry services in aged care.

“Optometry also needs its own incentive program, similar to GPs. I can’t see why optometrists can’t have equivalent incentives to GPs. Do they – the government – support eyecare in aged care facilities or don’t they?”

It’s a question that has grass-roots ramifications in Hobart, where Graveson often receives requests to visit residents in aged care facilities in addition to the 12 he currently services.

“I have to say no to requests from other aged care facilities because I’m already at capacity. The same goes for home visits – I have to say no.”

Daily challenges mounting

Ms Robyn Main has been providing optometry services to most of Perth’s aged care facilities since 2005 through her business Moving Eyes Mobile Optometry Outreach.

She has confronted a long list of issues in that time, which she started documenting in 2015, and hasn’t seen much change.

“I started noting down some daily challenges and barriers I have, ranging from administrative problems, incorrect medical records, patient logistics, occupational health and safety, to inadequate consulting room space and patient communication.”

Recently widowed, Main lost Richard, her husband of 35 years, to Creutzfeldt-Jakob disease, also known as CJD, a rare degenerative disease of the brain, in December 2021.

“I am still grieving and only just returning to work. I’m now a widow and most of those in aged care facilities are widows so I have more compassion to give them as I walk the same journey,” she says.

Prior to COVID and her late husband’s illness, Main was visiting 180 aged care facilities a year; now she visits 70. When she spoke with Insight in April, Perth’s aged care facility staff were on strike over a pay increase, which was preventing her from working too.

Optometrist Robyn Main in an aged care facility in Perth on Optometry Giving Sight Day 2017.

Apart from the Medicare fee for an eye exam, Main doesn’t get any financial benefit from attending to aged care residents. Like Graveson, she is aware that GPs receive a bonus, rated per number of patients they see in addition to their Medicare exam rebate, and like Graveson, she questions if optometry could be included in this financial arrangement.

Main says she has personally encountered many of the issues and challenges facing optometrists in providing care to older Australians outside of established practice. But before she elaborates, she shares why she started providing optometry services in aged care facilities.

“My personal experience of working in this area came from three sources. Firstly, I heard Peter Herse speaking at an optometry conference in WA using Medicare stats showing a drop in optometry services in the over-70’s. Secondly, my 74-year-old father needed domiciliary optometry care due to lung cancer medication affecting his eyesight. And thirdly, the corporate optometry group I was working in strongly disapproved of domiciliary care as it took too much time for too little profit to be sustainable,” she says.

Disappointingly for Main, the current domiciliary MBS item numbers lack appropriateness and relevance.

“I often travel more than 70 km to aged care facilities in Perth. That means more than 140 km in peak traffic, sometimes three hours a day spent in the car just getting to and from aged care facilities. I don’t think $24.20 is enough for the domiciliary loading. It needs to be more or at least include the addition of a kilometre allowance.”

One of the problems Main encounters almost daily when providing optometry services to residents in aged care is lack of consent.

“Consent from next-of-kin is needlessly difficult. Often, ageing parents are going blind because their next-of-kin haven’t signed a consent form. Some aged care facilities only have 10% response rate to written consent forms sent out. Consent should not be required – it is an aged care facilities duty of care that should enable all residents to be able to access optometry.”

Main also finds organising visits to be wrought with difficulties.

“Aged care facilities are meant to have designated staff for optometry and dental visits, called Clinical Nurse Managers, but some are not educated to the importance of optometry – residents should still be entitled to good eyesight despite the rest of their health problems – or unaware how to organise a visit.”

Main sends reminder notices to all the aged care facilities she visits, but usually 15-20% fail to organise an optometry visit annually.

“In the past, I would chase these up by phone and email. Now, I send a card in December reminding them they missed the annual optometry visit and please consider … I haven’t got time to chase them up, yet their residents are missing out on their eye exams and could be in danger of jeopardising their eye health due to staff neglect,” she says.

“When I have broached the subject with some Clinical Nurse Managers, they just sound weary and sceptical; ‘We don’t have the time’ or ‘It’s all too hard’.”

Main has also frequently encountered flawed medical records, including incorrect date-of-birth, incorrect Medicare numbers, and incorrect Department of Veterans’ Affairs numbers.

“Medical diagnosis and medication charts are not always accessible, and I may require staff assistance to gain access, but they are often too busy or not available, so it’s a labour issue.”

Patient logistics can cause headaches too.

“Bringing patients in a timely manner works in theory, but not always in practice. I can have 10 patients waiting for me in a corridor and this can cause frustration for everyone. This is usually due to lack of staff in aged care facilities on duty to help on the optometry day. Again, it’s a labour issue. At other times, I have had to get the resident out of bed and to the consulting room for the exam.

“Sometimes patients don’t bring their spectacles to their appointment because they may be lost, locked away or taken home by family. I have often had to rummage through a patient’s personal belongings to find their specs.”

Visiting up to 180 aged care facilities has also exposed Main to a variety of consulting rooms, not all of which are fit for purpose.

She says temporary consulting rooms are sometimes inappropriate but there is nowhere else to examine patients in an aged care facility.

“I usually use the hairdresser’s room or sometimes, the doctors consulting room, but there are less of these available now as GPs walk around with laptops and consult at bedsides and the space is used for something else, such as occupational therapy,” Main explains.

Optometrist Robyn Main with Harry Abrahams, a retired optometrist who now lives in aged care. (Consent from son and optometrist, Paul Abrahams).

Communicating with patients is not plain sailing either. For example, some dementia patients can only be screened for basic eye conditions, others require a full exam as they are still able to read and enjoy much of life visually.

“Dementia patients can be impulsive and unpredictable. I have been hit, punched, spat on and head-butted by dementia patients, but not during tonometry, which is my worst fear. Staff normally warn me of this behaviour. Often, I find these patients are blind so it may actually be a cause/effect of their blindness coupled with their dementia,” Main says.

“Frail elderly patients cannot be hurried in body or mind. Their family are not usually present at the eye exam, so I have to quiz these patients with failing memory regarding their ocular history and discuss outcomes which they often don’t remember.”

And the paperwork?

“A full report is required by the aged care facility. This report is not covered by Medicare. I do it free-of-charge. If specs are required, I prepare a quote which is meant to go to next-of-kin for perusal and payment. Only 30% of quotes for new specs are filled. I am not sure if this is due to family finances or because the patient is palliative. I can only speculate.”

Main also provides referrals for ophthalmology and says most (about 90%) are followed through.

“Of the 10% that aren’t, I follow up at the next visit. Often referral is for cataract and reasons given for not attending are due to poor health or long hospital waiting lists. Many of these patients have to be seen at teaching hospitals due to mobility (full hoists) and they have very long waiting lists.”

Loading fee ‘less than a third’ of what is required

Optometry Australia (OA) has been advocating for an increase in the optometric domiciliary loading benefit in residential aged care for a number of years, to no avail.

Ms Skye Cappuccio

In 2014, results from an OA member survey to assess the true cost of providing domiciliary eyecare helped form a revised MBS domiciliary loading benefit, which the organisation says remains relevant today.

General manager of advocacy, Ms Skye Cappuccio, explains what motivated OA to nominate this issue as part of its its 2022 federal election platform.

“In 2015, the government announced the MBS Review which has effectively, and rather disappointingly, meant the government has been unwilling to consider change to existing MBS items outside of the review,” Cappuccio says.

“However, we believe change on this issue is well overdue and, as a result, we have elevated this as a priority for Optometry Australia. Further, the Aged Care Royal Commission has served to shine a light on the need to support better healthcare access for aged care residents, which we are hopeful will see the government more attuned to the need to increase the benefit and support more optometrists to provide more domiciliary services to older Australians.”

Cappuccio says current indications suggest there is insufficient servicing of older, immobile Australians by optometrists.

“We believe that this is due mainly to the low loading fee which continues to be well below the true cost of providing domiciliary care providing a major financial disincentive for optometrist. Some of our more vulnerable community members are unfortunately impacted by this ongoing set of circumstances,” she says.

In support of OA’s argument, Cappuccio points to modelling which shows the current scheduled full fee amount grossly underrecognises the cost of providing domiciliary care.

“Optometry Australia worked with members to determine the additional time inputs required on average to provide domiciliary care, and used this as the basis for costing the provision of domiciliary services. This modelling suggests that the loading fee is less than a third of what would be reasonably required to cover the costs of providing such care,” she says.

Hence, OA is proposing the domiciliary loading be increased from $24.40 to $85.00.

“We believe a fairer fee will help ensure those optometrists who provide domiciliary care can continue to do so, and enable more optometrists to be able to provide domiciliary services in their communities alleviating concerns of being out of pocket. It’s an important step in making sure older and immobile members of our community can have ready access to the primary eye and vision care they need,” Cappuccio concludes.

More reading

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