Following is an AACP update on the Federal Government reviews that are currently underway. Three are particularly relevant to consultant physicians:

(i)    the MBS Review, which is being overseen by a Taskforce, chaired by Prof Bruce Robinson, Dean of Medicine at the Sydney University Medical School;

(ii)    the Primary Health Care Advisory Group (PHCAG), chaired by Dr Steve Hambleton, which is undertaking a review inter alia to “investigate options to provide better care for people with chronic and complex illness and innovative care and funding models”, and

(iii)   a review of Medicare compliance rules and benchmarks which will also commence shortly. (The other reviews include a national approach to mental health, e-health, a review of practice incentive payments for GPs, the role of private health insurers and the reform of Federation discussions.)

Each of these Reviews is likely to have a significant impact on clinical practice, both in terms of the ongoing review of MBS items, but also the proposition that funding arrangements may change away from the traditional fee for service to different funding models. The AACP is concerned that the ability of consultant physicians and consultant paediatricians to provide the best quality care for their patients is maintained.

AACP involvement in these Reviews

Overall, it will be important for the AACP to have close involvement in both the MBS Review and the PHCAG’s consultations. There are a number of issues that potentially affect consultant physician and consultant paediatrician (CPP) practice, not the least of which is the proposition that MBS items may be “bundled” and the concept of the “health care home” for those with chronic and complex conditions that would see greater oversight for GPs in the delivery of services to those patients whose care needs are more complex and may be more appropriately managed by a consultant physician or paediatrician.

The AACP strongly supports the concept of team care arrangements where they can assist in improving patient care. However, they are but one option in the appropriate management of patient care.

In relation to the “discipline group” process, the AACP has already put forward a number of names of possible “discipline group” members at the Adelaide MBS Review Forum and will seek further discussions with the Taskforce about its consideration of the wide range of items that relate to services provided by consultant physicians and paediatricians.

The AACP would welcome input from the consultant physician / consultant paediatrician specialty societies about specific issues that need to be addressed.

Please keep in touch with the AACP about the MBS Review: email the AACP at secretariat@aacp.org.au to contact the Secretariat or Dr Bill Heddle, the Chair of the AACP’s MBS Review Committee.

Following on from a series of MBS Review Forums, the AMA convened its own Forum on 19 August 2015 to provide an opportunity for discussion about concerns about the Review and also for the Taskforce Chair, Professor Bruce Robinson, to provide an update and answer questions. The Australian Association of Consultant Physicians was represented by a senior member of AACP Board, Dr Richard Whiting, a consultant geriatrician.

The following summary from the meeting on the 19th sets out a number of the concerns about the Review and includes points from the presentation by Professor Bruce Robinson.

The AACP will be making submissions to both the MBS Review and the Primary Health Care Advisory Group’s consultations and will be seeking ongoing involvement in relevant discipline groups concerning consultant physician and consultant paediatrician services.

We invite you to contact the AACP on matter concerning the Review.

Key points and concerns raised in presentations and by specialty society / college participants about the MBS Review, its rationale and the process to date, included:

• the lack of detailed explanation for the Review and the exclusion of matters that could usefully be included such as the relationship between the public and private sectors and the interaction with primary care providers (see Table 1 at the end of this document which sets out what is “in scope” and what is “not in scope” for the MBS Review)
• as has been widely discussed, Government is concerned about increased Medicare outlays and the sustainability of health costs (although it was noted that Australia’s expenditure is average compared with OECD countries)
• whether there will be adequate resources within the Department of Health to conduct this Review in an efficient and effective manner
• the fact that the lack of new and amended MBS items in recent years (and the difficulty of the current process of achieving change in item descriptors or securing funding for new services) that has exacerbated the problem of the Schedule being out of date
• the significant role of up to 100 discipline group reviews of all MBS items and many aspects of that process, including the involvement of individuals in the discipline group reviews at the expense of input from specialty societies and associations (although Prof Robinson sought to allay these concerns by indicating that discipline group members could consult with their organisations where they found difficulty in the material being considered, and also when there are draft recommendations for consideration), and whether discipline group membership will be sufficiently representative of practising specialists
• the promotion of the Ontario Rapid Review Model for use by the discipline group reviews which will rely on the availability of high level evidence that is not routinely available – and further, where there is no appropriate literature, the review process can shift away from a “clinical review” model to a “policy” or “compliance” review (see summary of the Health Quality Ontario Model for Rapid Reviews at the end of this document that is to form the basis for the “quick reviews” of the entire MBS)
• some of the possible mechanisms for putting a limit on Medicare outlays that will be investigated and possibly implemented, such as:
  • limits on services and Medicare rebates where they are provided more than once within a designated time period and the potential impact on the end provider (i.e. the DI or pathology provider where they deliver a service but then discover that it is a repeat service when the patient’s claim for a rebate is rejected)
  • billing for follow up specialist consultations
  • where GPs perform the same surgical procedure as specialists, should the rebate be lower, or should it be the same
  • whether referrals between medical professionals should continue
  • whether assistance in surgery will continue to be eligible for Medicare rebate
• a push to task substitution (primarily GPs taking on specialist roles) and pitting one specialty against another will be divisive and needs to be avoided
• an increased focus on specialisation as opposed to generalism that will detrimentally affect rural practice
• the lack of a clear methodology for quantifying potential savings, and the lack of a clear indication of how any such savings might be applied
• the lack of a clear indication of how the Review’s output will be implemented and what, if any, role MSAC will have in relation to the Review (coupled with the concern that if MSAC then has to review recommendations, the timeframe will extend well beyond two years, and finally
• that much of what has been discussed concerns “taking away” and not about modernising or adding items the Schedule.

Presentation on the MBS Review by Professor Bruce Robinson, Taskforce Chair

N.B. This presentation included material about the Review that is already in the public domain and can be found at Review’s website, together with information about membership of the Taskforce and the Primary Health Care Advisory Group and its consultations.

http://www.health.gov.au/internet/main/publishing.nsf/Content/healthiermedicare

The following points raised by Professor Robinson expand on some of the information already available.

Review Working Group Principles

Review Working Group teams will comprise

• Chair (selected by Taskforce)
• No one with “major conflict of interest”
• <50% of members from main in-scope discipline
• Remaining members from adjacent or other clinical fields
• Decisions will be made using a 60% majority of the group (consensus not required
• All decisions and dissenting positions to be minuted
• Meetings by teleconference

(The Committees will use a review mechanism developed in Ontario – the Health Quality Ontario model for rapid reviews a description of which is set out at the end of this update – to rapidly review the items.)

“Priority Review Items”

A number of specialty groups have already proposed possible priority review items, which include:  bone densitometry, imaging for pulmonary embolism and acute DVT, knee imaging;  adenoidectomy, tonsillectomy and grommets; blood transfusion services, iron studies and coagulation studies; obstetrics; sleep studies, respiratory function tests; upper and lower GI endoscopy and colonoscopy; and Rules and Regulations.

The Taskforce is currently seeking nominations for membership of the clinical committees and review working groups, to nominate items for review and prioritise them for early review; provide feedback and suggestions on planned approach; provide feedback and suggestions on draft recommendations as generated.  He also highlighted the importance of the specialty societies and other organisations in commenting on the material generated during the Review.

In other areas of the Review, e.g. where literature reviews are carried out, if there is disagreement the reviews can be critiqued by the relevant specialty group and where flaws are identified, then an “appeal” can be lodged by the specialty group.

It was noted that issues will arise during the Review that need to resolved, e.g. where one specialty group’s item groups are used by different specialists (procedures involving hand surgery were particularly highlighted as an issue).  It has been accepted that there will need to be a defined process to deal with cross specialty issues.

Cleary there will be ongoing issues to be addressed for the duration of this Review and the AACP will take a close interest in all aspects of the Review in order to best represent consultant physicians and paediatricians.

Table 1
The Taskforce / Government have defined what is “in scope” in the MBS Review and what is not, as shown in the following table:

The Taskforce has indicated that the following are likely to initiate a review of existing MBS items:

• obsolescence
• indication creep
• inappropriate frequency intensity
• pricing failure
• bundling unbundling

Rapid Review Methodology that will be used by the Discipline / Clinical Review Groups

Review groups will look at the macro issues, using the Health Quality Ontario model for rapid reviews. This model is described thus:

• rapid reviews are completed in 2–4-week time frames
• clinical questions are developed by the Evidence Development and Standards branch at Health Quality Ontario, in consultation with experts, end users, and/or applicants in the topic area
• a systematic literature search is then conducted to identify relevant systematic reviews, health technology assessments, and meta-analyses
• the methods prioritise systematic reviews, which, if found, are rated by AMSTAR to determine the methodological quality of the review. If the systematic review has evaluated the included primary studies using the GRADE Working Group criteria.
• http://www.gradeworkinggroup.org/index.html, the results are reported and the rapid review process is complete
• if the systematic review has not evaluated the primary studies using GRADE, the primary studies in the systematic review are retrieved and the GRADE criteria are applied to two outcomes
• if no systematic review is found, then RCTs or observational studies are included, and their risk of bias is assessed. All rapid reviews are developed and finalised in consultation with experts.