Tag: rural

In terms of land area, Australia is a large country, the 6th largest in the world. About 7,700,000 square kilometres. It’s a big country and as such has a lot of “country” or rural areas. Australia is also one of the most urban countries in the world, with about 85% of the population living within 50km of the coast. Just like other big countries. When doctors attempt to migrate to Australia from overseas some of the first questions they often will have are: “Whereabouts will I be able to work?” And “will I have to work as a rural doctor?” They will have normally already heard how big Australia is as a country and often heard rumours that international doctors can only work in rural parts of Australia.

If you are reading this blog as a doctor from another country, I think it’s important to understand the facts and I’d like you to not feel too put off by the thought of potentially working in a rural part of Australia. There are far more important and difficult parts of the process of coming to work here. Don’t be put off by potential work locations.

The quick facts about whether an international doctor has to work as a rural doctor in Australia are as follows:

• Both international medical graduates, as well as medical students studying in Australia from other countries, are both subject to a ten-year restriction on being able to access Medicare billings as a service provider which can prevent you from being able to work in certain locations. This is commonly referred to as a 19AB restriction or the 10-year-moratorium.
• There are many urban, regional and semi-rural areas (as well as more rural and remote areas) where you can still work in under Medicare.
• But you generally won’t need to access Medicare for all of this ten year period. And if you are working as a trainee doctor or consultant in a public hospital you can potentially work in any part of Australia without having to worry about this restriction.

The 19AB Medicare restrictions are the most significant policy that impacts international doctors working in Australia. But there is a range of other rules, restrictions as well as incentives that might affect you, including visa restrictions. So let’s look at these a bit more. As well as taking a deeper dive looking at the 19AB 10-year-moratorium.

Government rules generally require IMG doctors to spend a period of time as a rural doctor. But not always.

Australia is a vast country with large population centres concentrated in cities on the coastal fringes and much smaller populations throughout its landmass. This creates a problem whereby people who live in smaller population areas tend to miss out on access to a range of services in comparison to those based in the cities. This includes access to health care.

Doctors themselves as an overall group tend to want to live and work in larger centres. The Federal Government, therefore, provides a range of incentives to entice doctors to work as rural doctors. As well as creating a number of restrictions for IMGs to make working in rural areas the only viable option.

There are a couple of ways in which the Federal Government attempts to control the distribution of IMG doctors in Australia. The first is through Medicare billings. The second is through visa restrictions.

Medicare and the 19AB Restriction Explained In More Detail.

What is 19AB?

International medical graduates are restricted in where they can work in Australia and access Medicare benefits as health care providers.

What is Medicare?

Medicare is Australia’s universal health insurance scheme. It guarantees all Australians (and some overseas visitors) access to a wide range of health and hospital services at low or no cost.

Australians make more than 150 million visits to a GP every year. Medicare helps pay for the majority of the cost of these visits.

Patients who have a Medicare card can access a range of health care services for free or at a lower cost, including:

• medical services by doctors, specialists and other health professionals
• hospital treatment
• prescription medicines
• diagnostic and imaging services
• psychological services

The Medical Benefits Schedule (MBS) lists the medical services covered by Medicare.

The schedule includes an MBS fee for each service. This is the amount (or benefit) the Australian Government believes that the service should cost.

Whilst it is possible to work as a doctor outside of the Medicare system. On a practical level, without access to the Medicare Benefits Schedule, it is pretty tough for a doctor to make a living. Doctors would have to either significantly reduce their fees to a level which matches the out of pocket costs that other doctors charge on top of Medicare or set up in an area where there was very little competition. Even then it is likely that patients would not be happy as the Australian population is used to being able to access Medicare for their health care.

Section 19AB of Australia’s Health Insurance Act 1973 sets out the rules for international medical graduates and these restrictions.

Medicare Provider Numbers.

In order to bill Medicare for services, a doctor needs to have a Medicare provider number. Most doctors have more than one Medicare provider number. The reason being that you are required to have a provider number for each unique location where you might work.

By tieing provider numbers to geographical locations, the Federal Government is able to restrict where doctors are able to practice.

Who does 19AB apply to?

Restrictions under 19AB apply to two groups of doctors. The federal government calls both of these groups of doctors international medical graduates. This is a bit confusing as really only one of these categories of doctors is really an international medical graduate as most people understand this term to mean. You are deemed to be an international medical graduate if you:

• got your degree outside of Australia or New Zealand
• enrolled in a degree in Australia or New Zealand as a temporary resident

So the second group is basically doctors who graduated from an Australian or New Zealand medical school but did so as a student paying fees from overseas.

So Australian Doctors Can Just Work Anywhere Then?

Yes and No.

In order to charge for Medicare services all doctors, including Australian graduates and those under 19AB restrictions, have to meet certain other qualifications.

For most doctors, this means being what is called “vocationally-registered” or what many might call recognised as a specialist. General Practice is recognised as a specialty in Australia.

There are also some restrictions for what is called Bonded Medical Place Scheme.

Doctors who are Australian Citizens or Permanent Residents are subject to another section of the same legislation Section 19AA.

What is 19AA?

Doctors who are permanent residents or citizens of Australia must become vocationally recognised. Doctors become vocationally recognised by getting a Fellowship qualification in a specialty that is recognised in Australia.

Under 19AA, you can’t get a Medicare provider number if you are a permanent resident or citizen of Australia, and you are not:

• recognised as a Fellow by the Royal Australian College of General Practitioners
• recognised as a Fellow by the Australian College of Rural and Remote Medicine
• recognised as a Fellow by another Australian specialist college
• on an approved 3GA program

3GA Explained. Sorry I Promise I Am Going to Finish With the Meaningless Letters and Numbers Soon.

If you do not hold Fellowship, you can provide services covered by Medicare if you are on a section 3GA approved training or workforce program. As of the time of writing this post, there were a number of open 3GA programs:

• Approved Medical Deputising Services Program
• Approved Private Emergency Department Program
• Australian College of Rural and Remote Medicine Independent Pathway
• Australian General Practice Training Program
• More Doctors for Rural Australia Program
• Remote Vocational Training Scheme
• Royal Australian College of General Practitioners Practice Experience Program

As well as some programs which are closed to new applicants.

• Rural Locum Relief Program
• Special Approved Placements Program
• Temporary Residents Other Medical Practitioners Program

Most of these programs relate to supporting doctors on a training pathway to general practice, e.g. the Australian General Practice Training Program.

DPA and DWS (Sorry 🙂 )

Under 19AB, you must work in a Distribution Priority Area (DPA) if you’re a GP, or a District of Workforce Shortage (DWS) if you’re a non-GP specialist, for at least 10 years.

Distribution Priority Areas are a new concept. They have been developed because the previous concept, which is and was District of Workforce Shortage wasn’t making a whole lot of sense.

To explain this I am going to use a few images from the Health Workforce Locator tool, which is a very handy and useful tool that you yourself can use to find out more about where doctors in Australia are needed and can work if they are under restrictions.

Let’s take Melbourne, Victoria as our example. Melbourne is Australia’s second-largest city by population.

The first image depicts the most current classification scheme for locations in Australia, the Modified Monash Model. It is named the Monash Model as it is based on some work done by researchers at Monash University.

The Modified Monash Model (MMM) is used to define whether a location is a city, rural, remote or very remote.

The model measures remoteness and population size on a scale of Modified Monash (MM) category MM 1 to MM 7. MM 1 is a major city and MM 7 is very remote.

Using the MMM classification system can in theory help distribute the health workforce better in rural and remote areas.

MMM classifications are based on the previous Australian Statistical Geography Standard – Remoteness Areas (ASGS-RA) framework.

The Distribution Priority Area classification uses MMM boundaries.

Some government programs use the MMM to define their eligibility requirements.

From January 2020, Department of Health programs are transitioning to use the MMM classification.

The next image again centred around Melbourne depicts the current status of General Practice using the DPA system.

The DPA system takes into account gender and age demographics, and the socio-economic status of patients living in an area.

An area is automatically classified as DPA when it is: 

• classified under the Modified Monash Model as MM 5 to 7 
• in the Northern Territory

Other areas can be classified as DPA when the level of health services for the population does not meet a service benchmark.

The average level of health services under MM 2 is the benchmark for international medical graduates to work in DPA areas.

This benchmark is compared to the needs of an area, taking into account gender and age demographics, and the socio-economic status of patients living in an area.

The next image, again around Melbourne, depicts the previous ASGS Remoteness Area classification system. It is still used to determine a range of programs including District Workforce Shortage. As well as determine how doctors can speed up their 10-year moratorium.

The final image around Melbourne using the same tool shows you the state of general surgery around Melbourne. Notice a difference between this image and the one for General Practice? There are large areas of Melbourne available to work in for an IMG general surgeon. Yet big parts of rural Victoria are seemingly off-limits.

Under the DWS system, you would also see quite bizarre patterns for general practice. This is why there has been a switch to DPA.

The problem is that the DWS system is a cruder system. It basically looks at Medicare billings for a particular specialty in a certain location and determines if that area is above or below the average of billings.

For this reason, one would and should expect that all specialties will eventually be switched over to DPA over time.

Bonded Medical Place Scheme

Under the BMP Scheme, the Government provides a Commonwealth Supported Place (CSP) at a medical school at an Australian university.

In exchange for a medical place, once they have graduated, bonded participants agree to work in an area of workforce shortage for one to six years. The length of time depends on your agreement and is called the return of service period.

The 10-Year Moratorium

The 10 year moratorium period starts from the first day of medical registration. This is called the 10 Year Moratorium. 

All international medical graduates are subject to the moratorium. There are no exceptions.

The moratorium and 19AB restrictions will end for you after 10 years if you are a permanent resident or citizen by this time. Most IMGs, if they have gotten this far, will be eligible for permanent residency.

If however, a doctor does remain a temporary resident, their moratorium continues until the time they become a permanent resident or citizen.

But if you do not have a Fellowship qualification when you become a permanent resident, you will subject to the other rules under 19AA.

Speeding Up Your Ten Year Wait.

So are there any options for reducing the amount of time under which you are restricted in your Medicare Provider Number?

Yes, there are some options. But as we have highlighted above you may not necessarily wish to consider these options if you do not have a clear path to permanent residency or citizenship.

Moratorium Scaling

Moratorium scaling allows you to reduce the amount of time you must work in an area classified as DPA or DWS.

Working in eligible locations lets you collect ‘scaling credits’. The more credits you have, the sooner you can work in any location across Australia you want. That is provided you satisfy all the other requirements.

The more remote a location is, the more scaling credits you will get for working there. In theory, this directs the workforce to the areas that need it the most.

The moratorium is always 10 years, minimum. However, once you have enough scaling credits, you will have a class exemption for the remainder of your moratorium.

You can then apply to practise in an area that is not classified as DPA or DWS.

How Moratorium Scaling Works

You can scale the moratorium if all of the following apply:

• you are an international medical graduate working in an eligible regional or remote area under 19AB
• you are claiming Medicare Benefits Schedule items for services as part of your employment
• your monthly billing threshold is $5,000

So for example, you can’t just fly out to Bourke once a month for a day and run a clinic and count this for scaling. Unless you are good enough to collect $5,000 on that particular day.

Also, if you have worked in multiple areas in a month, Medicare will be able to work this out and your credit will be based on the area where you billed the most, as long as you reached the $5,000 threshold.

Scaling locations are based on the Australian Standard Geographic Classification – Remoteness Area system.

Classification	RA Category	Monthly scaling benefit (where billing threshold is met)	Potential reduction of DPA period under the moratorium
RA 1	Major cities	Nil	Not reduced
RA 2	Inner regional	3.37 days	9 years
RA 3	Outer regional	13 days	7 years
RA 4	Remote	20.3 days	6 years
RA 5	Very remote	30.4 days	5 years

Is Sitting It Out An Option?

I hesitate to write an answer to this question because I truly do believe that working in regional and rural Australia offers significant benefits to doctors. But if you are truly not inclined to work in one of the more rural regions of Australia then sitting it out may be an option for you.

Let’s take the situation of an IMG who comes to Australia and works their way into a Resident Medical Officer role in a city hospital as part of the Standard Pathway. So this doctor will work off one of their ten years just doing their provisional registration year to gain general registration.

Lets then say that they take a further couple of years of Senior Resident roles whilst working themselves towards a specialty training program. So we now have 3 of the ten years done.

And then let’s say they enrol in Adult Physician training take 3 years to complete Basic training. Take a further 3 years to complete an Advanced Training program and a year off to complete a PhD.

That’s a fairly common path even for an Australian trainee. And its ten years in total.

Sitting It Out Is Not An Option For General Practice Training Or Specialist IMGs.

The situation would be much more different obviously for a trained specialist IMG who comes to Australia. If you are lucky enough to be assessed as either partially or substantially comparable then you will need to find a position where you can work supervised to complete the rest of your assessment. Whilst this post could be potentially anywhere in Australia, we will see below how its likely not to be in a major metropolitan centre.

You won’t necessarily need to worry about Medicare initially as its most likely you will be working in the public hospital system. But after a while, if you wish to work privately you are definitely going to be subject to 19AB restrictions.

Similarly, for any international medical graduate who comes to Australia via the Standard Pathway and wishes to enter general practice training. In order to enter the largest General Practice training program, the AGPT program you will be required to training under the rural pathway and not be able to train under the general pathway.

Once you finish GP training there are very few options for GPs to work salaried in a hospital or medical centre and urban GP practices will be unlikely to offer you a post if you cannot bill Medicare, so you will definitely need to work in a DPA area.

Visa Restrictions.

Up until this point we have pretty much solely focused on Medicare Provider number restrictions. But it is also important to point out that the Federal Government is able to and does attempt to control the supply of various professionals working in Australia through visa restrictions.

Firstly, in order to be able to gain a work visa there needs to be a recognition that there is an undersupply of the work category that you are in. Luckily for doctors, most medical categories are seen as being in undersupply in most parts of Australia.

If you are lucky enough to gain a post in Australia and are not already a permanent resident or citizen then the most likely visa that you will be able to gain is a Subclass 482 or Temporary Skill Shortage visa.

482 Temporary Skills Visas

These visas let an employer sponsor a suitably skilled worker to fill a position they can’t find a suitably skilled Australian to fill.

They run from about 2 to 4 years depending on whether you are on the short-term or medium-term or labour agreement stream. Your medical area will need to be on one of several lists that the federal government keeps to identify strategic workforce needs.

In most cases, you are not necessarily restricted to working in a certain location on a 482 Visa. But some may have restrictions (for example Anaesthetics is currently listed as needing to be in a regional area).

However, you are generally tied to your employer on a 482 Visa and its not very easy to transfer between one employer and another without gaining another visa.

If you are interested in more information about visa options you should definitely discuss with a qualified migration agent. I am only providing the above information as general information and not specific advice.

The Labour Market Also Dictates That IMGs Are More Likely To Find Work in Regional and Rural Areas.

Up until now we really haven’t discussed much about the role of the State and Territory governments or the employers in the whole process.

Public hospitals in Australia are run by the State and Territory governments and these governments also often pick up a lot of the slack around primary care in the rural regions.

So unsurprisingly, these governments also attempt to exert some control over where international medical graduates work. Mostly they do this through marketing and the use of incentives. But they can also restrict whether a hospital can advertise a certain position to an international medical graduate and set rules around these circumstances.

But there’s another big factor that weighs upon where IMG doctors do end up working and that is the labour market itself. Generally speaking, medical positions fill up towards the major capital centres and vacancies will draw doctors in from regional and rural areas.

So its therefore not surprising that there are simply more opportunities for IMG doctors in regional, rural and remote areas as there are must more vacancies to fill in these places.

On the flip side, a number of these locations have focussed on the IMG market as a workforce solution and become really good at supporting IMGs to get their headstart in Australia.

I often hear comments about how IMGs are not wanted by Australian employers. There are always good and bad employers around. If you are applying for jobs as an IMG in Australia you are probably going to find that the big city hospitals are the more inhospitable and that the regional and rural hospitals much more receptive.

Summary.

So to summarise. There are many reasons why as an international doctor you may find yourself working in rural Australia. At least for a period of time. But this does not necessarily mean working a long distance from an urban centre. And the experiences of many international doctors who have trod this path before you have often been positive. Compared to things like actually finding a job or putting yourself through the AMC or college assessment process. I frankly think that there are more important matters to be worried about if Australia is your destination.

Related Questions.

Question. How Do I Get Registered To Work In Australia?

Answer. As an International Doctor, you first need an employment offer to gain registration. After that, there are two main pathways to registration: the standard pathway (if you are not a specialist) and the specialist pathway.

Question. Where Can I Get Further Information About the Specialty Colleges?

Answer. We have a post written about that very topic.

Question. Where Can I Find Information About Jobs?

Answer. Head over to our IMG resources page.