SUBMISSION TO THE MEDICARE BENEFITS SCHEDULE REVIEW TASKFORCE

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1 SUBMISSION November 2015 SUBMISSION TO THE MEDICARE BENEFITS SCHEDULE REVIEW TASKFORCE Submission by the Chiropractors Association of Australia Page 1 of 10

2 About the Chiropractors Association of Australia The Chiropractors Association of Australia (CAA) welcomes this opportunity to submit feedback to the Medicare Benefits Schedule Review Taskforce (the Taskforce) Public Consultation Paper, September The CAA is the peak body representing the interests of Australian chiropractors and their patients. The CAA is a national organisation with state and territory branches. The CAA corporate structure is one of a company limited by guarantee. The organisation has over 3,000 members and is governed by a Board of Directors elected by representatives of all stakeholder groups within the Association. About chiropractic Chiropractors diagnose, treat and prevent mechanical disorders of the musculoskeletal system, and the effects of these disorders on the function of the nervous system and general health. There is an emphasis on manual treatments including spinal adjustment and other joint and soft-tissue manipulation. Chiropractors are primary healthcare practitioners who use manual therapies and active care to treat and prevent dysfunction of the musculoskeletal system. Chiropractors consider the biopsychosocial aspects of musculoskeletal pain and work collaboratively with other healthcare providers in the promotion of health and optimum musculoskeletal function. Contact CAA Adjunct Associate Professor Matthew Fisher PhD DHlthSt (honoris causa) Level 1, 75 George Street Parramatta, NSW 2124 PO Box 255 Parramatta, NSW 2124 Tel: Fax: Page 2 of 10

3 Do you think that there are parts of the MBS that are out-of-date and that a review of the MBS is required? Do you have any comments on the proposed MBS Review process? - Should the role of the MBS be simply that of an administrative tool, or should it be used actively to guide quality medical practice? - What can be done to reduce unexpected variation in the MBS items claimed for similar services? - What implementation issues should be considered when amending or removing MBS items? - Are there any other principals that must guide the Review? Better utilisation of Australia s allied health workforce including chiropractors A primary aim of the MBS Review process is to modernise the present system to improve both the overall health of the Australian population and the long-term sustainability of Medicare. Reducing inefficiency in the current MBS is fundamental if the Review hopes to achieve its stated outcome. We understand therefore that the focus of this Review is on existing MBS services, although there is some scope for amended or new MBS items. As a starting point, CAA supports the view that health or medical services that provide little or no clinical benefit or, that might actually do harm to patients, should no longer be publicly funded. MBS expenditure should be directed to effective, evidence-based services that maximise the quality and value of health outcomes delivered whilst improving Medicare s sustainability. We also believe the MBS should encourage the adoption of new health care technologies and practises, even if not presently funded through the MBS, if these are accepted best practice. In this respect, we believe the MBS should play an important role in actively guiding quality medical practice in Australia. In undertaking this Review we strongly encourage the Review Taskforce to focus also on future health care needs of the Australian population and on developing flexible and robust systems so that the MBS can respond to evidence for the effectiveness of new roles, new technologies and new modalities of treatment. In 2004 funding for some allied health services was introduced to the MBS for the first time. This was an extremely positive step however, CAA believes more effort is needed to ensure Australia s allied health workforce, including chiropractors, is used to its fullest potential. There are approximately 120,000 practising allied health professionals providing direct consumer care, including diagnosis, treatment and rehabilitation, autonomously or as part of multidisciplinary teams, across a variety of public, private and not-for-profit settings in Australia today. It is estimated that they deliver over 200 million health services annually. Together with doctors and nurses, allied health professionals are regarded as the third pillar of health care providers in Australia. The CAA believes that Allied Health: has an essential role to play in a high functioning, modern health care system; Page 3 of 10

4 can provide the specialised health expertise needed to achieve high quality care and best health outcomes, particularly for patients with chronic conditions and complex care needs; uses guidelines and clinical decision making tools to support evidence based clinical judgement. The CAA is concerned that there are no allied health professionals on the Review Taskforce, although we acknowledge some have been invited to participate on a number of relevant working groups established by the taskforce. We are unaware of any registered chiropractors who have been asked to participate on any relevant working groups. Recommendation 1: the MBS should guide quality medical practice by encouraging the adoption of new roles, new technologies and new modalities of treatment if these are accepted best practice. How can the impact of the MBS Review be measured? - What metrics and measurement approaches should be used? - How should we seek to improve this measurement and monitoring capability over time? When measuring the impact of the MBS Review there needs to be greater involvement of all health professions, including allied health professions. This will be particularly important during the Reviews major undertaking across 2016, the review of MBS items by various Clinical Committees established by the Taskforce and supported by Working Groups focusing on specific MBS items. Finally, when measuring and monitoring the impact of the MBS Review, better data needs to be captured for each allied health discipline, rather than aggregating all allied health data together. Recommendation 2: there must be greater involvement of allied health professions in MBS Review processes and data should be captured for each allied health discipline, rather than aggregating all allied health data together. Which services funded through the MBS represent low-value patient care (including for safety or clinical efficacy concerns) and should be looked at as part of the Review as a priority? - Which services funded through the MBS represent high-value patient care and appear to be under-utilised? - Should cognitive (clinical diagnostic) services receive priority? Allied health participation in the CDM Program Page 4 of 10

5 We have already suggested in this submission that allied health professions have an essential role to play in a high functioning, modern health care system. Furthermore, allied health practitioners can provide the specialised health expertise needed to achieve high quality care and best health outcomes, particularly for patients with chronic conditions and complex care needs. However, for this to occur, a greater share of public funding must be made available for allied health practitioners to treat patients with chronic and complex care needs such as musculoskeletal conditions. At present, chiropractic and most other allied health practitioners largely sit outside of the current public funding model. Under existing arrangements Medicare rebates for services provided by allied health care practitioners such as chiropractors are only available for patients with chronic conditions and/or complex care needs under the Australian Government Chronic Disease Management (CDM) program. Patients must have a GP Management Plan and Team Care Arrangements prepared by their GP, or be residents of a residential aged care facility who are managed under a multidisciplinary care plan. However, under the CDM Program, eligible patients can only access a maximum for five services per calendar year from an allied health provider such as a chiropractor. Additional services are not possible in any circumstances. If all services are not used during the calendar year in which the patient was referred, the unused services can be used in the next calendar year. However, those services will be counted towards the five rebates for allied health services available to the patient during that calendar year. The allied health workforce, which includes chiropractors, is an under-utilised segment of the Australian health workforce, especially under MBS. Chiropractors diagnose, treat and prevent mechanical disorders of the musculoskeletal system, and the effects of these disorders on the function of the nervous system and general health. There is an emphasis on manual treatments including spinal adjustment and other joint and soft-tissue manipulation, as well as lifestyle and posture counselling. Chiropractors are primary healthcare practitioners who use manual therapies and active care to treat and prevent dysfunction of the neuromusculoskeletal system. Chiropractors consider the biopsychosocial aspects of musculoskeletal pain and work collaboratively with other healthcare providers in the promotion of health and optimum musculoskeletal function. Australian chiropractors train and qualify within major universities in NSW (Macquarie University), Victoria (RMIT University), Western Australia (Murdoch University) and Queensland (Central Queensland University). As well as providing limited services under Medicare CDM allied health items, chiropractors also diagnose and manage musculoskeletal injuries under private health insurance arrangements, workers compensation insurance and motor-vehicle accident schemes across Australia and through the Department of Veterans Affairs. We believe a significant opportunity exists under the MBS for allied health practitioners such as chiropractors to participate to a much greater extent in the treatment and management of musculoskeletal disorders such as osteoporosis, arthritis, back pain and fibromyalgia. This Page 5 of 10

6 opportunity is being driven by a number of factors including the escalating inflationary costs of health care and healthcare technology and the growing evidence base suggesting that other mainstream treatments for musculoskeletal disorders, particularly chronic problems, have met with limited success to date. Many musculoskeletal disorders, particularly those affecting patients with chronic or complex care needs such as spinal pain, require effective treatment strategies that go beyond medication for pain relief or surgery. We are not advocating in this submission that there should be no place for medication or surgery in the treatment and management of musculoskeletal disorders. Rather, we believe existing and emerging research evidence supports a view that manual and manipulative therapy, particularly spinal manipulative therapy (SMT) can be an effective first-line treatment for acute non-malignant spinal pain, with significant potential cost savings compared to usual medical care. Evidence supports early referral and assessment of spinal pain patients by an appropriately qualified musculoskeletal clinician such as a chiropractor, musculoskeletal physician, osteopath or musculoskeletal physiotherapist. These clinicians are appropriately trained to not only treat spinal pain patients but to also facilitate health promotion, rehabilitation and patient education. Increasingly, clinicians and policy makers are realising that attention should be focused not only on the most effective, evidence-based management of a particular condition but also on other factors such as lifestyle, exercise and patient education which emphasizes self-help management and disease prevention. Musculoskeletal conditions such as low back pain and neck pain are a significant cause of disability and lost productivity and accounts for a significant portion of healthcare expenditure in Australia. The Global Burden of Disease 2010 Project ranks low back pain and neck pain first and third respectively in Australasia as the cause of years lived with disability. The prevalence of these conditions increases up to the age of 60 and the demand for health care services associated with managing them is likely to increase significantly over the next three decades. Early referral and assessment of spinal pain patients by a musculoskeletal clinician, such as a chiropractor, has the potential to deliver significant cost savings to the public health system and the MBS by avoiding unnecessary imaging and investigations, hospitalisations, medical procedures and surgery. These cost savings could be as high as 20 per cent on current expenditure for low back pain within mainstream health care. Recommendation 3: there should be greater participation of allied health practitioners, including chiropractors, in the CDM Program. Recommendation 4: evidence supports early referral and assessment of spinal pain patients by an appropriately qualified musculoskeletal clinician such as a chiropractor. Are there rules and regulations which apply to the whole of the MBS, or to individual MBS items, which should be reviewed or amended? If yes, which rules and why? Please outline how these rules adversely affect patient access to high quality care. Page 6 of 10

7 - What would make it easier for clinicians and consumers to understand or apply these correctly? - Are there existing rules which are causing unintended consequences or are outmoded and should be reviewed? - Are there alternative solutions to deliver the original intent? - In amending any existing rule/s, are there any potential adverse impacts on consumers, providers or governments? - Are there any new rules which should be introduced? Allied health participation in the CDM Program As noted already, under the CDM Program, eligible patients can only access a maximum for five services per calendar year from an allied health provider such as a chiropractor. After this, additional services funded via the MBS are not possible in any circumstances. This arbitrary limit takes little or no account of evidence based, best practice guidelines or the clinical requirements of individual patients. It also imposes restrictions on allied health practitioners that are not imposed on services provided by other health practitioners (i.e. general practitioners). As a consequence, patients (especially those with chronic and complex conditions) often have little real choice when it comes to accessing and funding the most appropriate health care for their individual circumstances. Unfortunately, decisions are often made based on cost (particularly out-ofpocket costs) or expediency alone rather than the most effective solution for their particular medical condition. This can also contribute to, or exacerbate, existing chronic diseases or conditions. We would argue the current system does not well serve the needs of patients and health care consumers in Australia. A significant opportunity now exists under the MBS for allied health practitioners such as chiropractors to participate to a much greater extent in the treatment and management of musculoskeletal disorders such as osteoporosis, arthritis, back pain and fibromyalgia. However, if this is to occur there needs to be established referral pathways between general practitioners and specialists and allied health practitioners such as chiropractors. The current MBS Review should consider better use of early intervention strategies and an extension of current programs to better integrate allied health care within them, particularly for patients with chronic and complex conditions. In addition to this, MBS rebates for allied health services provided under the CDM Program should be reviewed and a uniform approach, built on evidence based, best practice care should be applied across all health care practitioners including allied health practitioners. Allied health referrals Under the current CDM Program, when a patient is referred by a consultant medical practitioner to an allied health practitioner, the patient must first attend a GP in order to obtain a second referral, in order to claim a rebate for the allied health services. Page 7 of 10

8 Similarly, if an allied health practitioner cross-refers a consumer to another allied health practitioner, the consumer must also obtain a GP referral in order to claim a rebate for the services provided by the second allied health practitioner. This duplication of referrals is time consuming and inconvenient for the consumer, and creates inefficiencies and increased costs to the health system. We believe the rules governing allied health referrals should be amended to permit medical consultants to refer directly to allied health practitioners and suitably credentialed allied health practitioners are able to cross-refer patients, without the need for a GP referral. Diagnostic imaging services In late 2012 the Health Insurance (Diagnostic Imaging Services Table) Regulation 2012 made significant changes to the way radiology services were funded under the MBS. The amendments introduced a new requirement so that only medical practitioners, dental practitioners (for specified items) and medical radiation practitioners could provide radiology services, except when the service is performed in specified regional, rural or remote areas. Prior to this, chiropractors were eligible to perform Medicare-funded diagnostic imaging procedures. There was little or no consultation with the chiropractic profession prior to these change being implemented despite the fact that chiropractors have more extensive training in radiography and radiology than dentists and medical practitioners. This decision has negatively affected thousands of healthcare consumers across Australia as well as adversely effecting hundreds of chiropractic x-ray sites across the country. We believe the exclusion of the chiropractic profession from the performance of Medicare related diagnostic radiographic procedures in 2012 was unnecessary. Prior to this, chiropractors were following all necessary compliance steps as required under the Diagnostic Imaging Accreditation Scheme. The adverse impact this decision has had on patients includes: 1. patients can no longer access a Medicare Funded Radiologist Report, which is afforded to patients of Dentists and Medical Practitioners, when the imaging was performed by a chiropractor. This restriction is at odds with the principle of providing the Right care in the Right place at the Right time ; 2. patients who are clinically assessed by a chiropractor as requiring a further Radiologist Report to review images in some clinical circumstances, must now be referred to a local radiology company a second time to repeat the same images. This is because the images captured by the chiropractor are now no longer eligible for a Medicare funded report. The patient will pay privately for the radiology report or, as happens more often, is compelled to have a repeat exposure of the same radiographic study under Medicare arrangements with another provider. The end result is more radiation exposure and more costs with no additional benefit to the patient; 3. patients are forced to wait for a consultation at a Diagnostic Imaging Facility and then wait for the return of images and related reports to the chiropractor. This can result in lost productivity, Page 8 of 10

9 time off work and delays when receiving appropriate care. This is often compounded by a further delay waiting for a follow-up appointment with the chiropractor prior to commencing care or a referral to another health care provider if required. We believe the Health Insurance (Diagnostic Imaging Services Table) Regulation should be amended so that registered chiropractors are eligible to perform Medicare-funded diagnostic imaging procedures under the same provisions as those afforded to medical practitioners and dentists, and within the existing scope of diagnostic imaging training and practice. Recommendation 5: MBS rebates for allied health services provided under the CDM Program should be reviewed so that a uniform approach, built on evidence based, best practice care can be applied across all health care practitioners. Recommendation 6: the rules governing allied health referrals should be amended to permit medical consultants to refer directly to allied health practitioners and suitably credentialed allied health practitioners are able to cross-refer patients, without the need for a GP referral. Recommendation 7: registered chiropractors should be eligible to perform Medicare-funded diagnostic imaging procedures under the same provisions as those afforded to medical practitioners and dentists, and within the existing scope of diagnostic imaging training and practice. Page 9 of 10

10 Recommendations 1. the MBS should guide quality medical practice by encouraging the adoption of new roles, new technologies and new modalities of treatment if these are accepted best practice; 2. there must be greater involvement of allied health professions in MBS Review processes and data should be captured for each allied health discipline, rather than aggregating all allied health data together 3. there should be greater participation of allied health practitioners, including chiropractors, in the CDM Program; 4. evidence supports early referral and assessment of spinal pain patients by an appropriately qualified musculoskeletal clinician such as a chiropractor; 5. MBS rebates for allied health services provided under the CDM Program should be reviewed so that a uniform approach, built on evidence based, best practice care can be applied across all health care practitioners. 6. the rules governing allied health referrals should be amended to permit medical consultants to refer directly to allied health practitioners and suitably credentialed allied health practitioners are able to cross-refer patients, without the need for a GP referral. 7. registered chiropractors should be eligible to perform Medicare-funded diagnostic imaging procedures under the same provisions as those afforded to medical practitioners and dentists, and within the existing scope of diagnostic imaging training and practice. Page 10 of 10

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