Tuesday May 30th May, 2006.
Case studies (provided by Dr Richard Hallinan, Dr Frank McLeod, Sue Jeffries) with a summary of discussion, and including comments from Brian Baker, Disability Support Officer, Area East Coast, Centrelink. Summary by Richard Hallinan.
Click here for summary of main presentation
The following are eight case studies where things went well, or not so well, for people with substance dependency problems in dealing with Centrelink. They show ways in which doctors can help get the best outcomes for their patients. Each case has comments from Centrelink, including advice on new arrangements after July 1 2006.
Some of the changes in how Centrelink deals with people with medical problems are:
- The Centrelink Disability Officer will now be the Centrelink Senior Customer Service Adviser, and will have more of a roving supervisory role rather than just seeing clients by appointment.
- Documents including medical certificate and care plans are presented, at the front desk, to the Customer Service Adviser. If it is clear from the documents what kind of benefit/activity is appropriate the Customer Service Adviser (with or without the supervision/advice of the Senior Customer Service Adviser) will make those arrangements.
- If further assessment is required, the customer will be referred to a "Job Capacity Assessor", which will be a health professional or service (for example a psychologist, or Health Services Australia, or Commonwealth Rehabilitation Service) under contract to provide this service to Centrelink. There is no provision for a treating doctor to liaise directly with a Job Capacity Assessor but .
- If there is a problem with a customer meeting their participation requirements, the case is passed onto the "Participation Solutions Team", a centralised office in each Centrelink area.
The doctor's avenues for liaising with Centrelink will therefore be:
- through documentation given to the patient to provide to the Customer Service Adviser
- by marking documents to the attention of the Senior Customer Service Adviser, or telephoning them - the old contact numbers for the Centrelink Disability Officers apply.
- by contacting the Participation Solutions Team if problems arise (such as a patient's benefits being stopped due to problems arising out a medical condition)
Case 1: Whose responsibility is the Treating Doctors' Report? Centrelink's policy when doctors refuse to complete TDR; Cost shifting between Medicare and Centrelink.
The first case was a 49yo woman on MMT whose previous medical certificates for Centrelink were provided by a GP who had retired. Other doctors, including the methadone prescriber, refused to fill in a Treating Doctors' Report (TDR). She says she was cut off by Centrelink because she didn't produce the TDR.
Centrelink confirmed that no costs are met by Centrelink for Medical Certificates or Treating Doctors' Reports. The time taken to complete the medical report may be claimed under a Medicare item when included as part of a consultation.
A Treating Doctors' Report may be requested:
- if the certificate showed that the symptoms are likely to persist more than two years
- in ALL cases when applying for Disability Support Pension
- or if a Capacity to Participate/Medical Assessment/Work Capacity Assessment was being organised.
Doctors are under no legal obligation to complete Centrelink paperwork, and although it was agreed a Centrelink client should not be penalised if a doctor refused to do so, it was unclear what mechanism if any was in place for this scenario. It was unlikely that the client had payments stopped for failure to submit this form but they may have failed to submit their own part of this paperwork.
A Medical Certificate (with exemption from the activity test) is normally accepted if a client
- has recently started MMT - considered temporary incapacitated whilst stabilising. (OR if dose change and a short period needed to stabilise).
- is in a rehab program - residential or home - provided well supervised and involving activities such as regular counselling, NA/AA etc
- had a Care Plan recently implemented with a series of strategies- eg investigation or management of other conditions- eg Hep C, psychiatric conditions.
If there was active drug/alcohol use and no interventions were in place, the client was not necessarily considered temporary unfit for work but barriers would be recognised and the Personal Support Programme* would be appropriate. Medical Certificate or Treating Doctors' Report would not be required.
*provided by such groups as Centacare, Salvation, and Mission Australia under contract to help people overcome personal obstacles and prepare for entry into the workforce.
Case 2: The importance of access to Disability Support Officers; Centrelink's policy when doctors refuse to complete the Treating Doctors' Report.
The second case was a 46 yo man who had recently restarted on MMT after a heavy relapse into heroin use. He had been on Newstart and a 3-month Medical Certificate was provided citing heroin dependency and chronic hepatitis C. A TDR form was given to the patient by Centrelink in response to a second 3-month Medical Certificate annotated "care plan in preparation."
This case described the doctor's frustrating attempts to speak to a responsible person at the Centrelink Office, where the only telephone access is via Helpline 132717, who refused to provide the phone number for the Centrelink Office but herself could not provide the information required The Helpline staff twice phoned the Centrelink office and relayed unsatisfactory answers back to the doctor. Eventually the Centrelink office called the doctor back, and confirmed that the TDR was not really needed. The doctor was given contact details for the Centrelink Disability Officer, who accepted the medical certificate with care plan appended. This contact number for Centrelink Disability Officer was subsequently used frequently and to good effect, with Care Plans regularly copied to Centrelink with patients' permission.
Centrelink's response: Centrelink has now provided a contact number for the "Participation Solutions Team", a centralised office in each Centrelink area. Contact details are: Tel 95822262. Email participation.solutions.eastcoast@centrelink.gov.au . (for health professional staff only, East Coasts Area only)
The existence of a Care Plan indicates that the conditions have not been fully treated and stabilised. Hence the conditions would be accepted as temporary and Medical Certificate would be sufficient. This case also highlights the need for all relevant information to be provided on Medical Certificate. However a TDR would NOT be required. A phone call to an experienced Centrelink Officer (Centrelink Senior Customer Service, or Participation Solutions Team) may solve a lot of trouble for doctors and their patients.
See introductory notes on how to do this after July 1st 2006.
Case 3: 'Sickness Allowance' for people who have a job to return to.
The next case was a 47 yo man, who had been on MMT 15 years, and working the last 13 years. He currently works 2 jobs as a driver up to 60 hours a week, says not paid overtime. He has Hepatitis C genotype 3 with Stage 3 fibrosis and needs 24 weeks interferon/ribavirin treatment but has only 4 weeks sick pay accumulated. He has a sympathetic employer, but doesn't know how he will pay his mortgage is he cannot work during interferon/ribavirin.
Centrelink's response: he would be entitled to Sickness Allowance after his sick leave expires, but should apply immediately, not when the sick pay expires. He is eligible for Sickness Allowance whilst remains temporarily unfit for his usual job and that job remains open for him - which is a 60 hour week job.
Maximum rate of Sickness Allowance is $416.40 per fortnight. If he had some work capacity he may consider supplementing his Sickness Allowance by doing a few hours at work.
The calculations are as follows:
Income test cut off currently is $671.43 per fortnight.
Under Welfare to Work, if he earns $400 per fortnight
Income free area= $62.
50% taper over 62- 250 per fortnight and 60% taper after $250.
(400-250) x .06 + 94 = $184 per fortnight.
Total Income = wage $400pf + Sickness Allowance $184 = $584 per fortnight
Case 4: The correct sequence of application for benefits and provision of a medical certificate.
The fourth case was a 29 yo woman, a chaotic patient on MMT, with chronic hepatitis C and high risk alcohol use, regular cannabis, periodic injecting of stimulants. She was on Newstart with intermittent work, but said she was "being hassled by Centrelink" for not completing work for dole. After a poor response to one month trial of mirtazepine and acamprosate she announced she was cut off social security benefits a week prior. A Medical Certificate was provided with 4 week retrospectivity and a care plan including:
psychiatrist and liver clinic assessment, possible interferon/ribavirin treatment and further attempt at home-based alcohol detoxification.
The patient returned 3 days later claiming Centrelink staff had rejected the medical certificate saying: "you are not currently a Centrelink client and have to reapply for benefits" and throwing the certificate back at her. The doctor phoned the Centrelink Disability Officer and owing to the patient's poor compliance with Centrelink requirements, DSO would insist she participate in Personal Support Programme.
Centrelink's response: if this was a new claim the medical certificate is currently "pended" until an interview with the Senior Customer Service Adviser to decide regarding exemption/appropriate referral. After 1 July, she would likely to be referred to a "Job Capacity Assessor" who will do likewise. The medical certificate was not rejected as such, though through poor communication the client may have been under the impression it was. Personal Support Programme may not be appropriate considering her recent work history. However she might be referred to the Job Network with a temporarily reduced capacity for work.
It was not inappropriate for the doctor to provide the certificate.
Case 5: Catch 22, Go to gaol
A 30 yo man was released after 11 yrs in gaol. After paying for rent/board, his first week of methadone, clothes, shoes, toiletries, smokes he was advised needs to get on Centrelink benefit. He was entitled to a Centrelink cheque, but first needed a bank account, and the bank did not accept gaol ID or a letter of ID, requiring instead a birth certificate, which costs money and takes six weeks to get. No money for board, food, smokes and done...it's all to hard... go back to gaol
As the submitter of this case said: "please don't say this doesn't happen - it happened to one of my clients yesterday.
Centrelink's response: Centrelink has field officers in the prison system to try to facilitate payments. However, this service has not yet reached rural areas (and it can break down when prisoners are released at night or on weekends).
Case 6: Convenience is not a medical issue
This was the case of a man who had no transport owing to the sickness of his mother (who drove him everywhere) and requested a Medical Certificate so he didn't have to make the long trip to town to fulfil Centrelink requirements. This was denied on the grounds that convenience is not a medical issue
Centrelink's response: when a medical condition doesn't prevent participation the patient/job seeker should be encouraged to discuss with a Senior Customer Service Adviser or Social Worker. There are other ways of addressing these issues than via medical certificates. Although exemptions are discouraged there is provision for short term exemptions due to a major personal crisis or caring requirements.
Question on Notice: 'buck passing' when Centrelink officers tell individuals to see their doctor and get a Medical Certificate (for no good reason).
Centrelink's response: if a job seeker failed to comply with requirements and is "breached", they often say they have a medical condition or were sick on the day.
If they are not currently sick and certificates cannot be back-dated, preferable would be a note from the Doctor confirming existence of an illness that can from time to time prevent attendance. Centrelink can ensure the job seeker is not penalised, but directed to the best pathway
Case 7 : The borderline personality coping with bureaucracy, and how to deal with intermittent fitness for work.
Kassandre Katastroff a 45yo of fluctuating gender, on MMT, with chronic hepatitis C seeks a medical certificate for pension, saying she was on Disability Support Pension before and was 'tricked' out of it. File notes read: "he was able to hold down 40 hour job only recently and now feels totally and permanently incapacitated. Is she for real?"
Kassandre is seldom long enough between jobs to get Newstart and he is keen to work but lurches from one unstable period of employment to another, with always some new drama (flatmate does a runner with the rent money, flat broken into, wallet stolen and all ID lost, skin breaking down and chronic itch, teeth falling out and recurrent dental infections). KK can't sleep and seeks valium, every time she has problems "I take drugs or drink".
Frustrated by being still hassled from all sides, especially Centrelink, she was given Newstart Jobsearch exemption on the basis of Medical Certificate and a care plan involving liver and dental clinics, psychiatrist and dermatology review. KK arrives hung over after drinking a bottle of bourbon to cope after receiving letter from Job Ventures telling him he was breached for non-compliance. She was drunk for psychiatrist appointment, but admits she didn't tell psychiatrist that she was drunk: "if he couldn't tell I was pissed, how could he tell if I was koo-koo". Interferon treatment was in doubt because of this episode.
The doctor discussed the matter with the Centrelink Disability Officer. There had been an error of notification at Centrelink with paperwork lost: all was easily solved.
Centrelink's response: Newstart with exemption from participation requirements may be more appropriate than Disability Support Pension as the listed conditions have not yet been fully treated and stabilised.
Disability Support Pension eligibility: the condition(s) must be fully diagnosed, treated and stabilised.
- a physical , intellectual or psychiatric impairment of at least 20 points under the impairment tables; and
- at least 16 years of age; and
- continuing inability to work for at least two years; and
- an Australian resident at the time of the inability to work occurred; or
- qualifying Australian residence.
Impairment Tables: Alcohol or Other Drug (AOD) use does not in itself indicate permanent impairment.
5 pts AOD use sufficient to cause intermittent or temporary absence from work.
20 pts AOD dependence well established over time, sufficient to cause prolonged absences from work. ? reversible end organ damage
30 pts AOD Dependence well entrenched over many years, minimal residual work capacity. ? irreversible end organ damage
40 pts AOD use with severe functional disability and irreversible end organ damage.
Case 8: Helpful and less helpful partners in care planning.
The last case was a 29 yo woman on MMT, cannabis and alcohol dependent with hepatitis C. There had been repeated attempts at ambulatory alcohol detoxification.
During one such, a medical certificate was provided for Centrelink for 6 weeks. Care planning was discussed with the Job Network Member* who asked for a copy to her but shied at idea of participating in a care plan, saying she would send her back to Centrelink if she is unwell.
* Providers such as Job Futures/Work Ventures, Jobfind, Employment Plus under contract to provide people with assistance in getting employment.
Centrelink's suggestion: refer to the Participation Solutions Team:
"I have seen Care Plans that incorporate an interview with a Centrelink Senior Customer Service Adviser (CDO) - which is a good way of flagging the barrier to Centrelink. Need to do so via Participation Solutions team. The Job Network Member JNM would follow Centrelink's direction - ie accept she is totally unfit and leave her alone or comply with the reduced work capacity direction and assistance recommendations."
