Detailed Review of Funding for Diagnostic Imaging Services

Transcription

1 The Royal Australian and New Zealand College of Radiologists Detailed Review of Funding for Diagnostic Imaging Services RANZCR Submission May 2010

2 Contents Executive Summary... 3 Context of the DI Review... 6 Importance of Diagnostic Imaging... 8 Appropriateness... 9 Health System Reforms and DI Services Current DI Service Delivery Future DI Service Delivery Patient Access to Comprehensive DI Services Improved Patient Access for Rural and Remote Communities Professional Supervision and Accountability Integrated Patient Care Changes to Current DI Service Delivery Arrangements Radiologist Training Training Networks Shortage of Interventional Radiologists DI Funding Arrangements Public Sector Issues DI Rebates Indexation Diagnostic Imaging Services Table (DIST) Access to Quality Assured MRI Services Clinical appropriateness Patient Access Patient Billing Arrangements MBS Rebates Indexation Improving Access to Quality Assured MRI Services GP referral for MRI Substitution for Inappropriate CT Strategies for Improving Access to Quality Assured MRI Services Access to Quality Assured PET Services Restrictive Patient Access to MBS Approved Indications Inequitable Patient Access to Funded PET Services Under funding of MBS PET Services Future Developments PET Rebates Indexation Proposal to Restructure PET Item Descriptors Improving Access to Quality Assured PET Services Summary of Key Points Attachment 1 - Elements of a Comprehensive Diagnostic Imaging Practice RANZCR Submission to DI Review, May 2010 Page 2

3 Executive Summary This submission has been prepared by The Royal Australian and New Zealand College of Radiologists (the College) in response to the Department of Health and Ageing s Discussion Paper on the Detailed Review of Funding for Diagnostic Imaging Services (DI Review). Rather than attempting to respond to the specific questions raised in the Discussion Paper, the College s submission focuses on key areas the College believes the Government needs to take into account in determining the future funding of diagnostic imaging (DI) services. The College views this submission to the DI Review as just the first stage of a process to develop a framework for the future delivery of DI services and the funding of those services. The College will provide further input when the Department releases a second, more focused discussion paper in mid-2010, outlining the results of the current information gathering phase and identifying a range of possible options for further consideration by stakeholders. Changes to the overall healthcare delivery system impact diagnostic imaging DI is an integral component of 21 st Century healthcare and must be factored in to the development of broader healthcare reform policies. Given the potential for these broader health reforms to impact on DI services, the College would like a commitment from the Government to establish an overarching approach to diagnostic imaging that is informed by the advice of experts working in the field. The College recommends a formal structure, such as a DI Advisory Group, be established as the principal advisor to the Government on policy and service delivery implications for DI of the broader health reforms as these evolve, and to manage associated change. Consideration needs to be given to how DI will fit into the delivery of acute services both in and out of hospitals, how DI will be integrated into the management of patients with chronic illness, how DI will help in prevention and how to optimise the integration of DI systems and other information and communications technology (ICT) tools into Australia s ehealth system. Radiologists should have a greater role in overall patient management. Radiologists have expertise to bring to clinical treatment and management but their clinical expertise is not utilised to its full potential. With the wide range of complex imaging modalities available today, radiologists should have a greater role in patient management as key members of multi-disciplinary teams focused on patient treatment and care. A multi-faceted approach is needed to ensure that imaging is appropriate and clinically accountable. Approaches that address the causes of clinically inappropriate or unnecessary imaging will be required to achieve practical and sustainable improvement in the appropriate use of DI. These approaches need to address the lack of basic medical training in diagnostic imaging, the radiologist s role, referrer education, greater access to MRI, more effective use of ICT for decision support and ehealth and issues of reasonable rationing and priority setting. The current MBS fee for service model has worked well to provide reasonable patient access to high quality imaging services and healthy competition between providers. Any proposal to shift to alternative funding mechanisms will need careful policy design to ensure maintenance of quality DI services and appropriate patient access to services, as well as to avoid instability, variations in performance and inequalities. RANZCR Submission to DI Review, May 2010 Page 3

4 Patient access to comprehensive DI practices offers the most cost effective use of resources for delivering quality assured imaging services to the majority of Australians. Australians already have very good access to one stop comprehensive DI services. Planning is needed to avoid an unnecessary duplication of services. A viable network of professionally supervised comprehensive practices, supported by increased funding for patient travel and accommodation for people living in rural and more remote areas, is the most cost effective model of delivering high quality DI services that are accessible to patients. With the networking potential afforded by ICT systems, this is the most efficient model and the most effective use of resources for responding to the emerging needs of a more patient centred approach. ICT also has the potential to improve access to specialist supervision and opinions for people in rural and remote communities. A serious investment in training is required to provide the radiologist workforce needed to meet the future demand for imaging services. The College estimates that training positions in Radiology will need to increase to at least 450 by 2012, a 20% increase over There must be further expansion of training places in private comprehensive practices where trainees can obtain the necessary range of experience. It is untenable for the public sector to continue to carry the full burden of Radiologist training. DI funding needs to support the viability of both the public and private DI sectors. The College supports a complementary mix of public and private DI service providers. The College would like to see changes to public sector funding aimed at achieving sustainable and equitable funding for both public hospitals and private radiology practices. Current DI rebates do not cover the cost of providing quality, affordable DI services. Rebates should be closely aligned to the cost of providing services or at least a viable mechanism is needed to encourage providers to provide services without charge to those in the community who are genuinely not able to pay a patient co-payment (eg pensioners and concession card holders). The only way private practices can meet increasing costs and continue to provide quality services is by charging patients a co-payment. Rebates need to be indexed for increasing costs, especially wages. The Diagnostic Imaging Services Table (DIST) is outmoded and needs to be simplified and rewritten. The College supports the establishment of a DIST Committee to provide advice on the composition of the DIST and associated rules and regulations. Priority should be given to improving patient access to quality assured MRI services. Access to MRI is a fundamental component of medical services in the 21 st Century. MRI licensing and funding arrangements have created a range of inequities for both providers and patients. A sustainable framework for equitable and improved access to MRI must be an outcome of this review. Priority should be given to improving access to and affordability of quality assured PET services. Patient access to PET services is restricted by the current MBS approved items and by the unplanned evolution of PET services. The use of PET in Australia is lagging behind that of other developed countries with modern cancer care. RANZCR Submission to DI Review, May 2010 Page 4

5 A sustainable framework is needed for improving access to and the affordability of PET services. The treatment of the capital component for Medicare funded PET services needs to be brought into line with the treatment of the capital component of other DI services. Any patient with a histological proven cancer should have access to timely, life saving and life modifying Medicare funded PET services. Further, arbitrary regulatory requirements should not prevent services being delivered in outer metropolitan and regional areas. RANZCR Submission to DI Review, May 2010 Page 5

6 Context of the DI Review The Review of Funding for Diagnostic Imaging Services (DI Review) is being conducted in the context of the broader health reform agenda including hospital and health reform, primary health reform and preventative health. While the scope of these reforms has not yet been fully disclosed, it is inevitable that they will impact health care delivery as well as the relationships between providers and the locations in which people seek attention. Changes to the overall healthcare delivery system impact diagnostic imaging. Access and availability of imaging are both change management tools. Knowing the destination is a critical first step for the DI Review. Any review of DI must therefore consider the structure of health care delivery. The Government seems to favour a greater role for general practice in the management of chronic disease and prevention with a different funding model, and a reduced role in acute care with a migration to large acute care clinics linked to major hospitals and emergency departments. Such changes to the current primary health care delivery model have the potential to change the dynamics of referral for imaging and where investigations are performed. It is therefore considered somewhat unrealistic to be attempting to develop different funding arrangements for DI before the changes to primary health care delivery have been more clearly articulated and the funding structure clarified. The DI review is also occurring after 10 years of capped MBS funding agreements for DI services and cost shifting of public DI services to the MBS by state/territory governments which, in combination, led to a freeze on most DI rebates and closure of many private practices. Substantial productivity gains during the rebate freeze period allowed minimal out of pocket expense increases to patients, however toward the end of the period, decreased practice sustainability lead to pressure to raise patient gaps for DI services. Ten years of capped funding delivered significant efficiency gains to the Government in the private sector. This review is occurring at a time when there is a significant change occurring in the technology and algorithms of practice which is creating further cost pressures. It is also occurring while imaging providers are installing the most sophisticated data management systems in the country and making a greater contribution towards effective e-health than any other medical group. These investments have largely been driven by the need to manage the increasing workloads in an environment that is seriously under funded. It has not been recognised by government that the platforms and connectivity installed by DI practices are already sustaining the system at a lower cost, higher effectiveness and greater efficiency. The College acknowledges the Government s imperative to ensure that total future health care spending is sustainable and that in the context of the ageing Australian population it will be necessary to manage the increasing demand for DI services as part of the overall effort to contain health spending within affordable limits. On the other hand, the DI sector needs a stable and predictable fiscal environment to maintain Uneconomic rebates do not save money for Government. They result in secret taxes, reduced investment and changes in health care delivery which are unplanned. Technological change is revolutionary and diagnostic imaging is a leader. Technology is changing what is possible clinically. Government policy must be adaptive and flexible and not stifle innovation. investment and deliver high quality imaging services. Despite the introduction of the bulk billing incentive from 1 November 2009, current DI rebate levels are uneconomic and as a consequence the 28% of patients who pay gaps are paying a secret tax on their health care to cross-subsidize those who are bulk billed. If DI rebates are not adjusted to more closely align with the RANZCR Submission to DI Review, May 2010 Page 6

7 cost of providing the services, and if indexation is not introduced to account for the increasing costs of providing these expensive services, patients will face increasing gap payments. We note the recent comments by the Professional Services Review (PSR) director, Dr Tony Webber, that he was concerned about the cavalier fashion in which doctors are making CT To be a gate keeper requires delegated authority which for radiologists means substitutionof-test powers; this authority is equivalent to that already entrusted to specialist clinicians. referrals for complaints of back ache 1. Further he indicated that the PSR would be undertaking a crackdown on CT scans. If CT scans are found to be inappropriate or if the investigation is deemed to be not clinically relevant, the practitioner will be required to reimburse the Medicare benefits paid. This has serious implications for the role of the radiologist as a gatekeeper and adviser for the relevance and appropriateness of imaging, yet radiologists are required to be a gatekeeper without powers of test substitution and in a framework where relevance is established retrospectively and with the use ofother data that are not known to the DI service provider at the time of doing the test. The College is equally concerned that policy for the future funding and delivery of quality DI services be determined not primarily by an imperative to cut spending, but strategically and recognising DI s Imaging is a benefit not just a increasing role in modern medical management. In cost. Cost effectiveness of particular DI determines the need for and specificity of imaging must be measured in the surgical intervention, and is improving patient broad context of improved patient outcomes and decreasing costs associated with outcomes. This means a new exploratory and extensive surgery. In addressing the approach to rebates. Thwarting challenges of escalating health costs and increasing expenditure at the DIST level demand for DI services, it is important to acknowledge may create a greater cost burden that every policy and reform strategy will confront the elsewhere. need to reconcile benefit, access and affordability. It is also unreasonable to expect that costs can be contained while the benefits in terms of patient outcomes are improving, patient expectations are rising, and medico-legal pressures persist in a system that has created a large number of referrers who have little training in the appropriateness of imaging. All countries are dealing with the increasing costs of health and a variety of different funding and policy approaches are being considered, but there are very few funding alternatives that increase the pressure on clinicians to reduce imaging requests and on patients to reduce their expectations. The College wants to work with the Government for sustainable change as long as the goals are defined in the broad context of access, affordability, sustainability, quality services and patient outcomes. This will take time. What is needed is a DI policy committee that seeks and respects advice that is focussed and measured against these yard sticks and that acts on such advice. Frequent policy changes are disruptive to investment, orderliness and sustainability. The College views its submission to the DI Review as the first stage of a process to develop a framework for the future delivery of diagnostic imaging (DI) services and the funding of those services. The College will provide further input when the Department releases a second, more focused discussion paper in mid-2010, outlining the results of the current information gathering phase and identifying a range of possible options for further consideration by stakeholders. Given the potential for the broader health reform agenda to impact on DI services, the College would like a commitment from the Government to establish an overarching approach to diagnostic imaging that is 1 Doctors cavalier on use of CT scans, Adam Creswell, Health Editor, Australian. Aug 7,2009 RANZCR Submission to DI Review, May 2010 Page 7

8 informed by the advice of experts working in the field. The College recommends a formal structure, such as a DI Advisory Group, be established as the principal advisor to the Government on policy and service delivery implications for DI of the broader health reforms as these evolve, and to manage associated change. It is important to build on the positive aspect of DI management to date and the collaborative input of the profession under the previous MOUs is viewed by the College as one of its major achievements. Importance of Diagnostic Imaging Diagnostic imaging has expanded dramatically in recent years as has its sophistication. This has been matched by increasing complexity in medical practice and increasing reliance on imaging to manage patients. Today, in 2010, diagnostic imaging is perceived by both clinicians and consumers as an integral part of medical care. DI services are a critical part of all aspects of healthcare delivery: prevention, diagnosis, treatment and monitoring. The advent of sophisticated computers has allowed development over the past thirty years of several types of body scanning, utilising x-rays (CT scans), ultrasound, radioisotopes (nuclear medicine scans), and magnetic and radio waves (MRI scans). Conventional x-ray has also become digital, no longer requiring film to capture the image. The ability to image any part of the body, and the increasing expectations of timely and accurate diagnosis, have placed diagnostic imaging at the forefront of patient care. Diagnostic imaging is now requested by practitioners and their patients to confirm, exclude, stage, or monitor almost all serious illness. Figure 1: Medicare Funded DI Services, 10 year trend to 2009 No Services ('000) 20,000 18,000 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 Medicare funded DI Services ('000) 1999/ /09 CAGR (10yrs) - 4.3% CAGR (5yrs) - 5.2% Source: Medicare Australia, MBS Statistics Figure 1 shows the steady growth in Medicare funded DI services over the past 10 years, with 17.3 million services provided in 2008/09. This equates to approximately four services for every five persons in the population. RANZCR Submission to DI Review, May 2010 Page 8

9 DI services accounted for approximately 14% of all MBS outlays in 2008/09. As a funder of medical services, the Government must recognise that by investing in DI, it is purchasing a key component of 21st century healthcare. Radiologists are highly trained medical specialists who have expertise to bring to clinical and treatment decision making across all disciplines but their clinical expertise is not utilized to its full potential. With the wide range of complex imaging modalities available today, the College considers diagnostic Radiologists as central and indispensable specialist consultants who should have an increasing role in overall patient management. The clinical model in which diagnostic Radiologists are doctors doctors. Their educational role, their disease management and staging role and their teaching role are often over looked. Radiologists are integral to all these components of every examination. They create accountability for clinicians. and interventional radiologists are key members of multi-disciplinary teams focused on patient treatment and care, is how modern day radiologists should act. In addition, the time that diagnostic and interventional radiologists spend on such activities as multi-disciplinary care meetings, providing second opinions and providing before and after clinical care to patients should be remunerated in the same way as other clinicians. A key focus of the College s new diagnostic radiology curriculum is directed to this clinical role and the importance of collaboration and supporting other medical practitioners in the multi-disciplinary care team. Developments in the Internet and image storage have led to full digital imaging, where images are captured and stored in digital format, and distributed electronically to the radiologist for reporting and the requesting practitioner for viewing. In the future these images, together with the radiologist s report, will become part of the patient s ehealth record. Appropriateness One of the first challenges in addressing imaging growth is to ensure that imaging is appropriate and clinically accountable. If changes are to be made to health care delivery, the re-distribution of responsibilities must be aligned with outlay expectations. There is no point in suggesting that there should be nurse practitioners with rights to request imaging and then expecting specialist radiologists to accept responsibility for the appropriateness of these requests. The College is very concerned that best practice and evidence based criteria are linked to Appropriateness requires experience and training by referrers. That young doctors do not have sufficient training in anatomy, pathology and the use of diagnostic imaging is a cause for concern but increasing access to less well trained people is likely to create higher referrals. imaging services and yet chiropractic referrals and other non evidence based referrals are funded in an unregulated environment that is neither without risk to patients nor medico-legal risk to providers. More than 90% of DI services are arms length referred services, about 60% of these deriving from requests by GPs and the rate of GP referral for imaging has been increasing (BEACH data 2 ). It is generally acknowledged that a proportion of these imaging requests are clinically inappropriate or unnecessary. However, a multifaceted approach that addresses the causes of clinically inappropriate or unnecessary imaging will be required to achieve practical and sustainable improvement in the appropriateness of DI requests: 2 Australian Institute of Health and Welfare. General Practice Series No.26, General Practice Activity in Australia to : 10 year data tables, BEACH, December 2009 RANZCR Submission to DI Review, May 2010 Page 9

10 Medical Student Training: a significant cause of inappropriate referral is related to the lack of basic training of medical students and junior doctors in anatomy and pathology and the use of diagnostic imaging. This failure of training is a weakness of academic medicine and in part the result of problem oriented learning and in part a product of current clinical systems which make decisions based on imaging and other investigations before relying on clinical judgement. The College shares the concerns of other specialist colleges about the variation in anatomical training across Australia s medical schools. In this There has been a failure of academia regard, the RANZCR has made representations to and medical curricula to teach Medical Deans Australia and New Zealand, the clinical diagnosis and decision peak body for the Deans of eighteen Australian and making, which has resulted in a two New Zealand medical schools and faculties; and greater reliance on imaging as a to the Confederation of Postgraduate Medical substitute for diagnostic reasoning. Education Councils which through its member councils is responsible for developing and implementing the education and training of junior doctors during their prevocational (PGY 1 and 2) years. In each case the College has emphasised that diagnostic imaging has been significantly under represented in medical school training and in the prevocational years, resulting in young doctors developing habits of unnecessary and inappropriate imaging and, in some cases reluctance to seek the advice of radiologists in determining what the most appropriate approach to imaging their patients is. The value add to patient care from imaging studies is also severely reduced and compromised as a consequence, because even radiology reports need to be explained in simpler terminology when new graduates do not understand the anatomical or pathological abnormality being diagnosed. The College has offered to work with medical schools and postgraduate medical councils to address these educational deficiencies, so far with very limited response. It is important to emphasise that with the trend towards shorter medical courses, there is a move away from didactic anatomy education, which forms the basis of radiology. In the current medical school environment it is therefore crucial that undergraduates are educated on how to RANZCR wants to migrate away from modality expertise to a greater training emphasis on disease specificity. This is very hard to achieve when the dependence on general imaging has increased because of the issues of medico-legal liability and referral uncertainty. utilise DI appropriately. This should not be confused with teaching medical graduates how to perform detailed radiological interpretation, which is beyond the scope of their courses. Radiologist Role: Radiologists have an in depth knowledge of anatomy, pathology, clinical medicine and diagnostic imaging that comes from many years of experience and training, firstly as doctors and then as a doctors specializing in imaging and image guided intervention. More direct involvement of radiologists in the clinical decision making process would reduce unnecessary and inappropriate requests for imaging, but with current workload pressures there is less and less time to review requests and to educate referrers and the concept of requiring radiologists to ring referrers and ask questions to define appropriateness of each request is simply unrealistic and costly. Referrer Education: current referrers need education and better information and the College is looking to work closely with the National Prescribing Service (NPS) to develop appropriate strategies to deliver more evidence based requesting. Greater Access to MRI: MRI is the modality of choice in an increasing number of clinical conditions and does not use ionising radiation. The current licensing arrangements and related policy settings for MRI, particularly specialist only referral and the lack of powers for test substitution by specialist radiologists, contribute to inappropriate imaging. These artificial RANZCR considers appropriate access state-of-the-art imaging to be a fundamental component of medical services in the 21 st Century, and that MRI access issues must be resolved in the current review. RANZCR Submission to DI Review, May 2010 Page 10

11 restrictions result in exposure of patients to unnecessary radiation from CT procedures requested as a substitute for MRI when MRI would be a safer and better procedure. Clinical Decision Guidelines and ICT: At the same time, ensuring the right patient receives the right service at the right time will not be significantly enhanced without more effective use of information and communications technology (ICT) tools such as decision support and ehealth. Clinical decision guidelines or appropriateness criteria would assist referring practitioners to decide if imaging is medically justified. The College welcomes the Government s efforts to introduce a national, integrated ehealth system by The DI sector already has a strong base to enable the sharing of images and other relevant information, through its significant investment in Radiological Information Systems/Picture Archiving and Communication Systems (RIS/PACS) systems as a means of managing increased workloads arising from the rapid expansion of digital imaging. The linking of such systems to decision support at the point of DI request has the greatest potential to result in significant reduction in unnecessary or inappropriate imaging in addition to streamlining patient care. It is Government s role to inform the public that it will only fund certain imaging in certain circumstances. Evolution to rationing based on proven benefit is also the responsibility of the Government. It must be articulated openly and not turned into a blame game between doctors and patients. Reasonable Rationing and Priority Setting: Overall healthcare policy needs to consider issues of prioritisation of services. As DI plays such a fundamental role is healthcare, any such policies should also be applied to it. Rationing of care is currently ad hoc, variable and based on little systematic cost effectiveness analysis. DIST item descriptors may need to be used to a greater extent to restrict access and reduce unnecessary imaging or even be removed if publicly funded services need to be rationed. The College is expecting that this will be addressed under the new MBS Quality Framework s process for systematic monitoring and review of all MBS items on an ongoing basis to ensure that: all items are effective and safe, likely to lead to improved health outcomes for patients, and represent value of money; and item descriptors, fees or usage that are not consistent with best practice or contemporary evidence are identified and either removed or appropriately amended. Processes need to be established to monitor, review and evaluate the outcomes of initiatives adopted to address inappropriate and unnecessary imaging. RANZCR Submission to DI Review, May 2010 Page 11

12 Health System Reforms and DI Services The Government s desire to restructure the health system around a more patient centred delivery of health care services through greater integration of health care services, a multi-disciplinary approach to patient management and a shift from managing illness to preventing illness requires a clear vision for the future delivery of diagnostic imaging services. Some of the proposed reforms under consideration have the potential to be disruptive and produce fragmentation of what is an efficient, well integrated, comprehensive DI service in Australia (see current DI service delivery below). The installed base of comprehensive imaging practices represents a huge investment; it is fixed in The role of Government is to location and has very limited re-location potential. facilitate connectivity and patient Change must factor this in. It would be a wilful waste confidentiality. The capability of expensive resources to start reproducing this already exists to deliver service installed base in acute care centres or other health integration in decision making facilities in order to offer patients co-ordinated and colocated care for specific conditions when there are and ought not to be reproduced in any way that makes existing adjacent, or nearby, appropriate facilities. Determining facilities obsolete. how this integration would occur cannot take place until there is more precise detail as to how such clinics will operate and how they will be linked to major hospitals and emergency departments. A recent OECD report 3 examined the use of market mechanisms in health care. It considered that the perils associated with competition are likely to be relatively immaterial for some acute aspects of care with homogenous patient groups, for which there are good outcome measures and well understood technologies. However it was considered difficult to envisage circumstances in which a truly competitive market could be created for many common (and costly) chronic conditions with heterogeneous patient groups for which there are few if any measures of outcome and complex patient pathways. Any proposals to shift to alternative funding mechanisms will therefore need careful policy design to ensure the maintenance of quality DI services and appropriate access to services as well as to avoid instability, variations in performance and inequalities. For example, in theory, there may be some scope for DI services to be included in an episode based payment approach for certain conditions, eg a hip replacement, but a number of issues would need to be addressed in developing such payments: Inclusion of DI in bundled payments has been successful in private hospitals where the bundled payments have served to create known gaps, have shifted the debate about charges to the private hospital management and the doctor so that there is a mutual responsibility to have facilities available, to have personnel available and to limit bed stays. But this Changes in health care delivery and types of services impact demand for DI, not the reverse. Consequently these drivers of demand will not be influenced by changes to the schedule or to controls on DI services. The DI schedule is a schedule for sickness not for health and prevention. If this is a new direction it will need new funding. The current MBS fee-for-service model is an efficient and effective means of funding DI services. It has worked well to provide reasonable patient access to high quality imaging services and healthy competition between providers. is not without difficulties, for example with coronary angiography, which is just an imaging test in a hospital environment and has defined costs, its complexity and difficulty changes with comorbidities such as immobility, other vascular disease, diabetes etc. these and other issues 3 Achieving Better Value for Money in Health Care. OECD 2009 RANZCR Submission to DI Review, May 2010 Page 12

13 would need to be dissected for DI if bundled payment models are to be pursued. The key issues identified are: Defining the episodes of care Establishing episode based payment rates Identifying providers to receive episode based payments, and how DI providers are remunerated within the episodic payment Compatibility with other payment mechanisms Staging implementation, eg to focus on a narrow set of priority conditions, patients and providers, and addressing potential legal barriers. Such alternative funding mechanisms seek to transfer, or at least share, responsibility for how money is spent with clinicians and to make clinicians more accountable. Clinicians however often have their commitment thwarted by lack of beds, delays in theatre access, staff shortages etc. They will quickly see their contribution to this new cost containment as spiralling out of control and out of their control. To ensure high quality but more efficient DI services, Specialist Radiologists will need to be more directly involved in the patient management team. It would be critically important for the profession to be engaged in the development of such a payment mechanism. A clearer understanding of the current system might help in developing strategies to meet the DI review and broader health service reform objectives. DI is an over arching layer that provides certainty of diagnosis, defines intervention parameters, reduces unnecessary surgery, and stages disease accurately so that unnecessary and expensive therapies are not embarked upon. It is one of the pillars of efficient medicine, not a liability. However, the College recognises that there is a need to optimise the use of DI, particularly the tests that involve ionising radiation, and a more prominent role for Radiologists is needed to achieve this. Going forward, it is imperative that consideration be given to how: DI will fit into the delivery of acute services both in and out of hospital; DI will be integrated into the management of chronic illness; DI will help in prevention; to realise and optimise the potential productivity gains and quality improvements from the integration of DI systems and other ICT tools into Australia s E-health system. A shift to delivering care along service lines or within discrete episodes of care may have a significant effect on radiology training programs, which would be expected to train sub specialists for other organisations service lines, while such training requires deep sub-specialty silos. Radiology needs to be integrated with clinical disease-specific teams. It would be unfortunate if other specialists started competing for services, doing the areas of greater intellectual and financial reward in-hours and expecting a depleted radiological service to provide the services at other times. The College is mindful of the need to achieve greater respect for, and integration of, radiologist services and has introduced a new curriculum which will shift the focus to integrate appropriate services in a wider clinical context. This already occurs in large tertiary centres, but Radiologists should have an increasing role in overall patient management. DI is an integral component of 21 st Century healthcare and must be factored into the development of broader health reform policies. Change needs a plan, one that looks at investment efficiency and avoids duplication and instability. this is not where the majority of services occur. There are many ways this can be achieved and without this discussion the viability of an under RANZCR Submission to DI Review, May 2010 Page 13

14 funded DI service meeting the expectations of expertise and quality will not survive. Current DI Service Delivery Diagnostic imaging (DI) services in Australia are currently provided by public hospitals (35-40% of total services) and private imaging practices (60-65%). It is estimated that approximately 70% of DI services are now funded through Medicare and this is rising at least in part due to public outpatient services being increasingly billed to Medicare. Table 1 shows that almost three quarters of MBS DI services in 2009 were provided to the Australian people in comprehensive practices with some 64% being provided by private specialist radiologist providers in community based practices and 9 % being provided within public hospital settings. In some of the larger private practice groups, a hub and spoke model enables greater penetration into smaller communities with larger central sites serviced by smaller feeder sites, while most after hours services are provided 24/7 in public or private hospital emergency departments. This model of complementary public and private sectors has ensured the widespread availability of quality and timely services to the Australian population. Table 1: Providers of Medicare Funded DI Services, 2009 Provider Type of Practice No Practices % MBS DI services Jan-Jun 2009 Private Specialist Comprehensive practices with at least 3 modalities (eg x-ray, ultrasound, CT) % Radiologists Public Hospitals Non Radiologist Providers Smaller non comprehensive practices % Comprehensive imaging departments 113 9% with at least 3 modalities Non-comprehensive or specialist clinics 424 3% Specialist, GP and other practices 1,677 10% Source: Unpublished data, Department of Health and Ageing. Public and private radiology providers also provide services to Veterans Affairs, workers compensation, third-party, public hospital and private patients, although collectively these services represent a small proportion of total services provided. Map 1 shows the distribution of comprehensive practices across Australia, distinguishing private specialist radiologist and public hospital practices. Australians are extremely well Map 2 shows the location of comprehensive practices, served in terms of access to DI distinguishing basic comprehensive services and those services - 90% live less than that provide further services such as MRI or Nuclear 25km from a one stop Medicine overlayed on population areas up to 100,000 comprehensive DI practice. persons. The map shows that the current geographic dispersion of comprehensive practices, by their very need to be accessible to patients, already supports the broader trend now occurring in patient care to a more patient centred approach. Further analysis reveals that almost 90% of the population (2006 Census) live within 25km of a comprehensive practice, increasing to 94.5% living within 50km and 97.5% living within 100km. RANZCR Submission to DI Review, May 2010 Page 14

15 Diagnostic imaging is a large industry in Australia. Organisations providing DI services are expected to generate revenue of approximately $2.5bn from providing DI services under Medicare in RANZCR Submission to DI Review, May 2010 Page 15

16 In population terms there are about 65 Radiologists per million of population in Australia. This figure is significantly lower than the USA (100 per million) and some European nations (the highest being 120 per million). In order to increase this figure by just 10 per million, Australia would require another 220 Radiologists more than the estimated 1,380 practicing radiologists 4 In addition to the Radiologist workforce, the DI sector employs more than 10,000 medical imaging workers. In population terms in 2006, the latest data available from the Australian Institute of Health and Welfare 5, there were 510 medical imaging workers per million of population and they were the second fastest growing health occupation group, increasing by 28.2% over five years. Future DI Service Delivery A range of forces including the digital revolution, globalisation, consumerism and pressure to contain the escalating healthcare costs is causing radiologists to reflect on how they can most effectively contribute to the future health care system. Patient Access to Comprehensive DI Services From a business perspective, the time, effort and skill required in managing large scale imaging operations (high cost, high maintenance and high operating costs) that face rapid technology changes, continues to favour at least some clustering of imaging equipment. An outline of the many elements of a Radiology practice is at Attachment 1. Professionally supervised comprehensive practices with their high level information and communications technologies offer the most effective use of resources for delivering imaging services. A viable network of comprehensive practices, supported by increased funding for patient travel and accommodation for people living in rural and more remote areas, is the most cost effective model for delivering high quality DI services that are accessible to patients. With a radiologist on site to professionally supervise the imaging services and personally attend the patient when required, together with the networking potential afforded by information and communications technology and RIS/PACS systems for image transmission to specialists, to hospitals and to GPs, the geographically centralised one stop comprehensive practice model, is the most efficient model and the most effective use of resources for responding to the emerging requirements of a more patient centred approach. Improved Patient Access for Rural and Remote Communities The College supports the range of recommendations of the National Health and Hospital Reform Commission 6 to improve health care access for people living in rural and remote areas, including: calls for increased funding for patient travel and accommodation to enable better and more cost effective access for patients in remote and rural areas to comprehensive DI practices; development of mechanisms to support a range of initiatives including expansion of specialist networks, telehealth services including teleradiology, on-call 24 hour telephone and internet consultations and advice; and strategies to improve health workforce supply and clinical training opportunities in remote and rural areas. 4 AMPCo August Health and Community Services Labour Force AIHW 6 Chapter 3, A Healthier Future for All Australians, Final Report June RANZCR Submission to DI Review, May 2010 Page 16

17 Innovative teleradiology strategies can improve access to specialist supervision and opinions for people in rural and remote communities. Information and communications technologies have enormous potential to provide real time access to specialist clinical opinions. Despite the challenges of scarce resources and the high costs of diagnostic imaging equipment, these technologies are already being used in some rural and remote parts of Australia to provide innovative teleradiology access to specialist radiologists to the people of those communities. For example, in the Goldfields region of Western Australia, the X-Ray West practice operated by Imaging the South (ITS) has made an active contribution to the betterment of indigenous health care and its work has been recognised internationally in a presentation of research studies centred on cardiac and renal disease management innovations for remote communities 7. Funding and incentives are needed for further development and implementation of such strategies to better meet the imaging needs of rural and remote communities. Professional Supervision and Accountability The College s Standards of Practice have established the Radiologist as the single point of accountability for each imaging examination with each component of a diagnostic imaging service required to be carried out under the professional supervision of a Radiologist. This is also required by radiation regulations across Australia for those examinations involving the use of ionizing radiation. There are specific rules in the Standards, determined on a clinical risk management basis, around what tasks can be delegated, and under what circumstances. Where there are not specific rules set out in the Standards, it is up to the individual Radiologist to ensure that appropriate protocols are in place for delegation of tasks to individual imaging team members with the required professional expertise to undertake these tasks independently, but still under the radiologist's professional supervision. Integrated Patient Care The interpretation of visual data is a core competency of specialist radiologists but for imaging data to be useful for clinical decision making and patient management today requires the imaging data to be provided in a broad array of imaging formats and to be combined with an increasingly broad range of knowledge relevant to the management of the patient s overall health. More direct involvement in patient care and clinical decision making will also enable radiologists to acquire and integrate additional knowledge during the image interpretation phase. Radiologists have invested heavily in digital technologies, including RIS/PACS and are well placed to integrate imaging studies with other relevant information and to provide accurate, accessible, fast and timely information, including after hours. The introduction of ehealth, with electronic referral and transfer of test results and the sharing of patient records will provide the platform for Specialist Radiologists to become vital members of the patient s diagnostic and treatment team. The infrastructure is already being developed to support ehealth in a large proportion of Radiology practices and the potential efficiencies and benefits to the broader health care system should not be underestimated. These include productivity improvements, increased remote access and better reporting together with reductions in duplicate tests, lost results, communication errors. ehealth will also provide the platform for electronic decision support tools which have the potential to Provision of images without a report removes the single point of accountability for the total service, including the interpretation of the images. ehealth will enable a quantum leap towards integrated patient care and enable better use of the clinical expertise of radiologists. 7 RANZCR Submission to DI Review, May 2010 Page 17

18 reduce inappropriate and unnecessary requests for imaging. Changes to Current DI Service Delivery Arrangements As outlined above the current installed base of comprehensive imaging practices provides very cost effective access to services for the vast majority of the Australian population. It is fixed in location and has very limited re-location potential. Change must factor this in. It would be a wilful waste of expensive resources to start reproducing this installed base in acute care centres or other health facilities in order to offer patients co-ordinated and co-located care for specific conditions when there are adjacent, or nearby, appropriate facilities. Comprehensive practices would be/are of sufficient size and workload to require the presence of an on-site radiologist, enhancing the quality of the service with on-site clinical supervision and providing appropriate clinical input to coordinate imaging and clinical parameters, by being able to interview and clinically assess the patient and provide the integrated imaging required to answer the clinical question. This would avoid the current situation where patients are referred for imaging that the radiologist knows is inappropriate for the clinical condition and in the report recommends another test, necessitating another patient attendance with associated wasted time and resources and possibly increased radiation exposure. The establishment of 37 GP Superclinics and the concept of one stop shops require an assessment of; the current accessibility of imaging services for patients that will use these clinics; and the need for and cost effectiveness of additional imaging services, possibly co-located with the superclinic, in order to meet the community expectations for the delivery of imaging services to the local community. By way of illustration only, the first GP superclinic to open was at Ballan, a small town about 80km from Melbourne and 34km from Ballarat. It has a population of less than 2000 and is in the Shire of Moorabool which has a population of around 27,000 people. Map 3 shows the diagnostic imaging services, including comprehensive practices (red dots), accessible by driving from Ballan: comprehensive practices are Changes to primary health care delivery may impact the delivery of diagnostic imaging services - planning is needed to avoid unnecessary duplication of services. located within 30 minutes drive in Ballarat and within 45 minutes drive in Melton. There is a chiropractic clinic providing limited x-ray services in Ballan. In the case of Ballan, the existing comprehensive services are considered to be reasonably accessible for patients and the population base does not support the investment in a co-located comprehensive DI service. As the population expands, a feeder practice providing US and x-ray services may be a viable consideration. RANZCR Submission to DI Review, May 2010 Page 18

19 Radiologist Training The Radiology profession and industry recognize the need for a substantial increase in the number of training positions in order to provide the workforce required to meet the future demand for DI services. If access to training opportunities in Radiology is to be maintained relative to the number of medical graduates forecast, the College estimates that training positions in Radiology will need to increase significantly to at least 450 by 2012, a 20% increase over There are currently approx 335 training positions in Radiology in Australia of which around 94% are in the public sector. Even though approx 70% of trainees, on completion of training, will work primarily in the private sector, the opportunities for the private sector to contribute to training in Radiology have been fairly limited and there have been few financial incentives other than the longer term one of investment in its future workforce. This is in part because the requirements for accreditation of training sites (particularly with regard to workloads which permit protected time for trainees and supervisors, provision of teaching resources etc) have been more geared to larger public sector sites where training has been regarded as an important part of service provision. The College has welcomed the $100,000 per trainee contribution by the Federal Government as an incentive for private practices to invest in training. There must be further expansion of training places in private comprehensive practices where trainees can obtain the necessary range of experience. It is untenable for the public sector to continue to carry the full burden of Radiologist training. Specialist training typically requires five years and a long term funding commitment is needed for Radiologist training overall and to promote training beyond the traditional tertiary training A serious investment in training is required to provide the Radiologist workforce needed to meet the future demand for imaging services. hospital setting so that trainees can gain valuable experience in areas of radiology that are more commonly practised in the private sector. It should be noted that as a consequence of the shift in many types of elective surgery to the private sector and RANZCR Submission to DI Review, May 2010 Page 19

20 the increased performance of endoscopic procedures by a wide range of specialists in public hospitals, many kinds of previously routine diagnostic imaging tests are no longer (or very rarely) performed in public teaching hospitals, whereas they are still widely and frequently performed in private practice. The continued value of these studies is not in doubt, but the casemix environment in public hospitals means that most trainees today will get very little exposure to studies they will be expected to perform and interpret if they work in the private sector. Training Networks Increases in private sector training places must not be at the expense of the public sector. The establishment of training networks based on major public hospitals, but with structured rotations to outer metropolitan, regional and private sector hospitals/practices recognizes the important role of registrars in public sector service provision and the importance of public sector teaching sites in delivering high quality training and at the same time significantly increases potential participation of the private sector in training by managing the risks over the lengthy training period. Training networks have been established for some time in South Australia and Western Australia and similar arrangements are being developed in Queensland and NSW. There are several other examples in Australia and New Zealand where ad hoc arrangements have been established between individual hospitals and private sector sites. It is also desirable for radiology training to expand into BreastScreen and other sites that are neither private sector nor public tertiary teaching hospitals, in order to provide the required range of training opportunities. This expansion will not be possible without government support. Shortage of Interventional Radiologists Interventional radiology has critical and direct links to patient care and the importance of image guided therapy is increasing. In recent years MBS under funding of interventional procedures and different funding arrangements between the public and private sectors has lead to a decline in the performance of many interventional procedures in the private sector. This situation has resulted in a reduction in the number of radiologists seeking and gaining post graduate fellowship in interventional radiology. This has contributed to a skills shortage and reduced access to services particularly in outer and regional centres. DI Funding Arrangements Two of the stated objectives of the DI review are to: establish appropriate fee relativities for MBS items across and within different diagnostic imaging modalities; and develop alternatives to fee-for-service and establish whether there are areas of diagnostic imaging that would be more appropriately funded through a different mechanism. The College has already commented on the difficulties associated with considering different funding mechanisms for DI services while it is unclear how these services will be impacted by broader healthcare and hospital reforms. While consideration of fee relativities might be more sensibly done following a streamlining of the current DIST (see below), there are a number of more general comments that the College would like to make about the current funding arrangements and DI rebates. The objectives of the review suggest the Government believes that current DI relativities are inappropriate and that fee-forservice funding should be replaced by a different funding mechanism. RANZCR Submission to DI Review, May 2010 Page 20