06 September 2016

MBS Review Interim Report

The interim report of the Medicare Benefits Schedule (MBS) review taskforce is described as having "successfully reached what might best be described as ‘the end of the beginning’".
The major Taskforce recommendations regarding changes to individual MBS items will be made in the latter part of 2016 and 2017. This Interim Report however describes preliminary outcomes from the work of the early Clinical Committees, including items for which the consensus view was that these services do not have a place in contemporary practice and should not be MBS funded. Those items identified as potentially obsolete are currently being considered by relevant stakeholder groups.
The report states -
The Medicare Benefits Schedule Review Taskforce was established in June 2015 by the Minister for Health, the Hon Sussan Ley MP, following feedback from clinicians and the broader community that certain items on the MBS did not reflect clinical best practice and that the Schedule included anomalies that in some cases were creating distortions in services provided. There was also the broader issue that, some 30 years after its inception, the first thorough review of the MBS was well overdue. The MBS Review commenced in July 2015 with the first meeting of the Taskforce and an initial round of stakeholder consultations, and will continue through to mid-2017. The rationale for this Review is very clear. The MBS is a key driver of the way health services are delivered into the community. Despite its importance to health outcomes and the sizeable public investment ($20 billion in 2015–16, around 30 per cent of total Commonwealth health expenditure), the MBS has never been subject to a comprehensive review. Yet over this period there have been significant changes in best medical practice. This means there are specific MBS service items which were once appropriate but are now obsolete or of less value, overtaken by more effective treatments solidly backed by evidence. At the same time, many tests and procedures benefit patients but only when provided in the right clinical circumstances. Internationally, there is concern that many interventions provide little of no benefit to very many patients. This low-value care is displacing high-value care.
Furthermore, modern healthcare practice increasingly involves more multidisciplinary care delivered by teams of health professionals, and this service model does not sit neatly with the existing MBS structure.
In the early part of this Review, an extensive analysis of existing research and evidence, national and international was combined with widespread consultation. This involved doctors and other health professionals, public and private health service providers, regulators, data and systems experts, policy makers and commentators, and consumers and patient groups. There has already been a great deal of input from health professionals and from other stakeholders, and this has been invaluable in developing a plan for the next phase of the project. There has been significant engagement with clinicians who have brought their expertise and goodwill to the first reviews of specific MBS items.
Key outcomes to date
• The design of the process by which the Review will be undertaken.
• The Taskforce has held five stakeholder forums, with more than 100 organisations represented. In addition, more than 80 other meetings with stakeholders have been held.
• More than 1,500 surveys and more than 240 written submissions were received in response the consultation paper released in September 2015. Approximately 300 health professionals provided specific examples of low-value and high-value usage through the online survey, as well as examples of potential obsolete items or misuse.
• The establishment of the first five Clinical Committees - Gastroenterology, Ear Nose and Throat, Obstetrics, Diagnostic Imaging, and Thoracic Medicine. These first Committees have trialled the Review methodology.
• Approximately 100 individuals have agreed to participate in the first tranche of Clinical Committees.
• An initial 23 MBS items referred for stakeholder consultation.
• The establishment of a Principles and Rules Committee to review the regulations that underpin the MBS. • Development of a timeline for establishing Clinical Committees in other disciplines through 2016.
The Review methodology, the processes adopted to support the Review and the guidance given to Committees will be monitored and refined based on the real-world experience of undertaking this complex and highly collaborative project.
The focus of this, the Taskforce’s Interim Report, is on the following key areas:
• The need for review—outlining the critical reasons why the MBS is in need of evidence-based review.
• Methods—outlining the processes the Taskforce is adopting for conducting the Review, which have been tested through stakeholder consultation and early priority reviews.
• Preliminary results and considerations—reflecting on the outcomes of the Taskforce’s initial activities, in stakeholder consultations and other early Review activities.
• Discussion and next steps—identifying a number of areas where there is a need for further consideration of issues raised in the Terms of Reference and the Taskforce’s early activities.
• A provisional work programme for 2016—identifying the key priorities for the Taskforce in 2016.
The report notes
The Taskforce is committed to providing recommendations to the Minister that will allow the MBS to deliver on each of these four key goals:
1. Affordable and universal access—The evidence demonstrates that the MBS supports very good access to primary care services for most Australians, particularly in urban Australia. However, despite increases in the specialist workforce over the last decade, access to many specialist services remains problematic with some rural patients being particularly under-serviced.
2. Best practice health services—One of the core objectives of the Review is to modernise the MBS, ensuring that individual items and their descriptors are consistent with contemporary best practice and the evidence base where possible. Although MSAC plays a crucial role in thoroughly evaluating new services, the vast majority of existing MBS items pre-date this process and have never been reviewed.
3. Value for the individual patient—Another core objective of the Review is to have a MBS that supports the delivery of services that are appropriate to the patient’s needs, provide real clinical value and do not expose the patient to unnecessary risk or expense.
4. Value for the health system—Achieving the above elements of the vision will go a long way to achieving improved value for the health system overall. Reducing the volume of services that provide little or no clinical benefit will enable resources to be redirected to new and existing services that have proven benefit and are underused, particularly for patients who cannot readily access those services currently.
Broadly, the Taskforce’s focus is on reviewing the existing MBS items, with an initial emphasis on ensuring that individual items and usage meet the definition of best practice. Within the Taskforce’s brief there is considerable scope to review and advise on all aspects which would contribute to a modern, transparent and responsive system. This includes not only making recommendations about new items or services being added to the MBS, but also about a MBS structure that could better accommodate changing health service models.
The Taskforce has made a conscious decision to be ambitious in its approach and seize this unique opportunity to recommend changes to modernise the MBS on all levels, from the clinical detail of individual items, to administrative rules and mechanisms, to structural, whole-of-MBS issues. ... Like all parts of the health system, the use of MBS services is growing and at a rate that exceeds population growth. Overall, service volumes increased by almost 20 percent between 2009–10 and 2014–15—from 307.9 million services to 368.5 million—and by over 50 percent since 2004–05. More significantly, per capita use of services has also increased over time, growing from 11.7 services in 2004–05 to 15.4 services in 2014–15, with 89 per cent of the population accessing MBS services. As expected, the number of services per capita is much higher in the oldest age groups compared to younger cohorts .... The per capita use of MBS services in older people is also growing at a faster rate than for younger people. In the over 75 year age cohort, per capita use of services increased from 25.9 to 41.3 between 2003–04 and 2014–15. Figure 1 also shows that even for younger age groups the average number of services per capita is rising.
The Bettering the Evaluation and Care of Health (BEACH) report A decade of general practice: 2004–05 to 2013–14 shows the following breakdown of actions taken by GPs in managing their patients’ problems. In 2013–14, for every 100 patient encounters, there were:
• 49.1 referrals for pathology (an increase from 36.7 in 2004–05)
• 10.9 referrals for diagnostic imaging (an increase from 8.3 in 2004–05)
• 4.9 referrals to allied health (an increase from 2.7 in 2004–05)
• 9.5 referrals to medical specialists (an increase from 7.7 in 2004–05)
This shows not only that referral and requesting behaviour has increased across all these categories, but that one or more of these actions are taken in around 75 per cent of attendances (up from around 55 per cent in 2004–05).
There has been an increase in the proportion of the population that receives a Medicare pathology test annually, up from 46 per cent in 2003–04 to 54 per cent in 2013–14, with the number of pathology services per capita increasing from 3.7 to 5.4 in the same period. The proportion of the population that has a diagnostic imaging service has also increased to 37 per cent from 30 per cent in 2003–04, with the number of services per capita increasing from 2.2 to 2.6.
MBS data can be a useful tool for raising questions about services being provided. Growing utilisation, in the absence of changes in patient need, can be a prompt to consider whether clinically useful items or services are being provided.