MTAA Submissin t the Medicare Benefits Schedule Review Taskfrce Cnsultatin Paper 9 Nvember 2015
www.mtaa.rg.au Level 12, 54 Miller St, Nrth Sydney NSW 2060 Australia PO Bx 2016 Nrth Sydney NSW 2059 Australia P (+612) 9900 0650 F (+612) 9900 0655 E receptin@mtaa.rg.au CONTENTS EXECUTIVE SUMMARY... 3 1. INTRODUCTION... 4 2. MEDICAL TECHNOLOGY INDUSTRY COMPILED FEEDBACK ON THE MBS REVIEW CONSULTATION PAPER... 4 a. MBS Review bjectives and prcess... 5 b. Evaluating the MBS Review... 7 c. Need fr review... 8 d. MBS legislatin and rules /cmpliance... 8 e. Access t MBS data... 10 f. Cnsumer experiences perspective f the medical technlgy industry... 10 3. CONCLUSION... 12 ANNEX 1... 13 ANNEX 2... 15 REFERENCES... 16 MTAA Submissin t the Medicare Benefits Schedule Review Taskfrce Cnsultatin Paper Page 2 f 17
EXECUTIVE SUMMARY As part f the Australian Gvernment s Healthier Medicare initiative, the Medicare Benefits Schedule (MBS) Review Taskfrce is undertaking a review f the entire MBS t ensure it reflects current best clinical practice and prmtes the prvisin f health services that imprve health utcmes. The MBS has mre than 5,700 services listed. The Review is clinician led and is lking at pprtunities fr refrm f the MBS ver the shrt, medium and lnger terms. As well as lking at specific MBS items, the Taskfrce will als review the legislatin and rules which underpin the MBS. The main bjective f the Review is t curb inefficiency in the MBS by ensuring that lwvalue services i.e. services which prvide n r negligible clinical benefit and in sme cases, might actually d harm t patients are nt funded. The Taskfrce has released tw cnsultatin papers, ne fr a brad audience including health prfessinals and anther which is mre clsely directed at cnsumers f health services. These papers set ut the backgrund and cntext fr the Review and fcus n sme key issues including: MBS Review bjectives and prcess, evaluating the MBS Review, the need fr the Review, MBS legislatin and rules /cmpliance, access t MBS data, and cnsumer experiences and the perspective f the medical technlgy industry. In this submissin, MTAA expresses key cncerns regarding the MBS Review, in particular the imprtant rle f the medical technlgy industry in the Review evaluatin and cnsultatin prcesses, particularly t review services that invlve medical technlgies. MTAA has prvided a number f recmmendatins t address these issues f cncern: Review f the MBS shuld ensure its applicatin is current and in alignment with cntemprary best medical practice, and that it achieves value and ecnmic efficiency in the healthcare system, ensuring its sustainability. Review f the MBS shuld ptimise patient care and achieve the best pssible utcmes and value fr mney frm MBS services. The Review aims t mdernise the MBS t help achieve best patient health utcmes fr MBS expenditure; and best evidence-based, clinical practice supprted by the health prfessinal services funded thrugh the MBS. Hwever, it is unlikely the rapid review methdlgy prpsed in the cnsultatin paper wuld adequately meet these aims. The review shuld als ensure services that use medical technlgy can achieve ptimal service delivery, access, utcmes and cst benefits. Relating t the MBS Rules and Regulatins: Befre amendment f any existing rule/s is undertaken, ptential adverse impacts n cnsumers, prviders r gvernment must be cnsidered. Any substantial change will require a transitin perid fr implementatin in rder t ensure that stakehlders are able t adapt their clinical practice and business mdels ver time. Better clarity in rules and prcesses cnsidering the suitability f technlgies and devices that replace r reduce the need fr services. Develpment f rules that incentivise physicians and ther health prfessinals t use high value services e.g. payment (fee) fr participating in remte mnitring services. Imprve the prvisin f better frmal targeted training requirements t dctrs fr specific prcedures. These training requirements shuld be cnsidered fr inclusin as part f the Item descriptr. MTAA Submissin t the Medicare Benefits Schedule Review Taskfrce Cnsultatin Paper Page 3 f 17
Cnsideratin shuld be given t restrictins t patient access where the prcedure is nt supprted by evidence fr particular patient chrts. In areas f clinical uncertainty, there shuld be a requirement t cllect data t facilitate infrmed decisin-making e.g. real wrld evidence linked t risk sharing is ne ptin. Rules need t be revised where they are dated, inefficient and d nt lead t the best quality clinical care and patient utcmes. The cnsultatin prcess shuld be transparent with the invlvement f all relevant stakehlders, including the medical technlgy industry, particularly t determine pririty items, whereby a minr amendment (in the item descriptin) may have a majr impact n patient access t medical technlgy and the intrductin f new technlgies. 1. INTRODUCTION As part f the Australian Gvernment s Healthier Medicare initiative, the Medicare Benefits Schedule (MBS) Review Taskfrce is undertaking a review f the entire MBS t ensure it reflects current best clinical practice and prmtes the prvisin f health services that imprve health utcmes. The MBS has mre than 5,700 services listed, mst f which have never been subject t evidence-based assessment. The Review is clinician led and is lking at pprtunities fr refrm f the MBS ver the shrt, medium and lnger terms. As well as lking at specific MBS items, the Taskfrce will als review the legislatin and rules which underpin the MBS. The main bjective f the Review is t curb inefficiency in the MBS by ensuring that lwvalue services i.e. services which prvide n r negligible clinical benefit and in sme cases, might actually d harm t patients are nt funded. The Taskfrce has released tw cnsultatin papers, ne fr a brad audience including health prfessinals and anther which is mre clsely directed at cnsumers f health services. MTAA welcmes the pprtunity t respnd t the MBS Review Taskfrce Cnsultatin Paper. 1 The Cnsultatin Paper set ut the backgrund and cntext fr the Review and fcus n sme key issues including: MBS Review bjectives and prcess, evaluating the MBS Review, need fr Review, MBS legislatin and rules /cmpliance, access t MBS data, and cnsumer experiences and the perspective f the medical technlgy industry. In this submissin, MTAA expresses key cncerns regarding the MBS Review, in particular the imprtant rle f the medical technlgy industry in the Review evaluatin and cnsultatin prcesses, particularly t review services that invlve medical technlgies. 2 2. MEDICAL TECHNOLOGY INDUSTRY COMPILED FEEDBACK ON THE MBS REVIEW CONSULTATION PAPER MTAA and its members acknwledge that with the intrductin f the MBS in 1984, many f the MBS services (descriptrs) are n lnger current and in alignment with cntemprary best clinical practice. The Review shuld cnsider healthcare services in the cntext f the entire treatment pathway and patient utcmes. The discussin dcument highlights the current limitatins f the MBS, which includes its ineffectiveness t investigate the cmplete clinical pathway f patient chrts. Therefre, the Review shuld ensure that assessment f MBS services MTAA Submissin t the Medicare Benefits Schedule Review Taskfrce Cnsultatin Paper Page 4 f 17
shuld include nt nly the value criteria, but shuld accurately reflect patient care pathways as a whle. MTAA and its members identified the fllwing areas fr cmments relating t the prpsed MBS Review: MBS Review bjectives and prcess Evaluating the MBS Review Need fr Review MBS legislatin and rules /cmpliance Access t MBS data Cnsumer experiences the perspective f the medical technlgy industry. a. MBS Review bjectives and prcess D yu think that there are parts f the MBS that are ut-f-date and that a review f the MBS is required? D yu have any cmments n the prpsed MBS Review prcess? Additinal issues: Shuld the rle f the MBS be simply that f an administrative tl, r shuld it be used actively t guide quality medical practice? What can be dne t reduce unexpected variatin in the MBS items claimed fr similar services? What implementatin issues shuld be cnsidered when amending r remving MBS items? Are there any ther principles that must guide the Review? MTAA and its members expressed the fllwing cmments relating t the prpsed MBS Review prcess: The Review aims t review mre than 5,700 items this may nt be achievable withut an apprpriate prcess t priritise tests r prcedures that are f specific cncern. Any prcess t priritise these tests and prcedures fr review shuld be transparent. The review prcess shuld als adpt perspectives at the healthcare systems level (rather than sils ). There is a brad diversity f technlgies, and a rapid and iterative innvatin cycle, and current data cllectin limitatins in clinical settings ften present a challenge fr gathering cmparative clinical and health ecnmic data i.e. evidence may nt allw fr definitive differentiatin f utcmes and csts despite the ptential fr these benefits t be present. Therefre, cnsideratin is needed at the frefrnt f decisin making where medical technlgy is cncerned. Invlvement f clinical cmmittees and wrking grups t facilitate access t data frm in-huse uses, experiences and cmparisns. MTAA wuld als like t cmment n the fllwing issues: Rle f the MBS as an administrative tl r t guide quality medical practice The MBS culd be used bth as an administrative tl and t guide quality clinical practice t apprpriately incentivise physicians t practice best and cst-effective clinical care fr their patients. MTAA prpses that the MBS mdel shuld implement mechanisms that actively guide clinical care prvided that there are sufficient mechanisms in place t ensure that the MBS can evlve at the same pace as clinical practice (guidelines), particularly where new medical technlgies are cncerned. Similar prpsed healthcare mdels have been successfully implemented verseas. 3 T reduce unexpected variatin in the MBS items claimed fr similar services MTAA suggests the fllwing steps that may be implemented t reduce unexpected variatin in the MBS items claimed fr similar services: MTAA Submissin t the Medicare Benefits Schedule Review Taskfrce Cnsultatin Paper Page 5 f 17
Investigate funding mdels that are less reliant n episdic transactins, such as bundled payments fr specific care types r ther blended mdels. Prvide training and educatin t prviders n the apprpriate use f item selectin. Where multiple services are prvided in a single episde f care and thse services are prvided 100% f the time then, where pssible, a single MBS item shuld represent the service. Hwever, at times, what may appear t be similar services are in fact different r additinal services t treat patients with a specific clinical need. Adjustments t the MBS need t factr in such circumstances and nt versimplify. Mre detailed and prescriptive descriptrs t avid/reduce misuse. Implement review/audit mechanisms t mnitr utilisatin. If necessary a timely review shuld be perfrmed t accmmdate updates in clinical practice r inclusin f new technlgies. Implementatin issues that shuld be cnsidered when amending r remving MBS items Supprt and infrmatin shuld be prvided t physicians regarding the amended r remved items (i.e. reasning fr amendment r remval, best-practice alternative MBS items). It is imprtant t cnsider the apprpriateness f additinal transitinal supprt fr physicians wh may need t be re-skilled in rder t deliver the alternative service. Prvide a transparent mechanism fr physicians (and relevant stakehlders) t cllate feedback n system effectiveness. Only items identified by the review as ineffective r dangerus shuld be remved. Items may require amendments t prevent ff-label usage. Impact n patient access including funding r reimbursement. A mechanism t assess patient utcmes fllwing implementatin i.e. t determine the impact f amending r remving f items. Other principles t guide the Review MTAA prpses the fllwing key principles t guide the review: Universal access t healthcare, equity f access, sustainable healthcare A transparent review prcess, that includes: A prcess fr the additin f new MBS items whereby the existing items are being reviewed Identificatin f implicatins fr access t medical technlgies when items are t be amended r remved. The Review shuld cnsider a whle f healthcare systems apprach the impact n ther reviews and their recmmendatins e.g. Primary Health Care review, impact n access t medical technlgies, patient utcmes, particularly chrnic disease treatment and management. The cnsultatin paper makes reference t inefficient and lw value services frm ther cuntries, including the UK, US and Canada. It is imprtant that the review cnsiders these services in the cntext f the Australian ppulatin and healthcare system. Due t the rapid and iterative nature f develpments in the medical technlgy industry, it is difficult t cllate the required clinical and health ecnmic data. It is imprtant t cnsider the need fr supplementary funding arrangements that will allw fr shrt-term access t these technlgies in specific circumstances. This culd impse data cllectin requirements n the prvider that independently aids in determining the clinical and health ecnmic value f such technlgies n behalf f the MBS. MTAA Submissin t the Medicare Benefits Schedule Review Taskfrce Cnsultatin Paper Page 6 f 17
b. Evaluating the MBS Review Hw can the impact f the MBS Review be measured? What metrics and measurement appraches shuld be used? Hw shuld we seek t imprve this measure and mnitring capability ver time? The main bjective f the Taskfrce is t imprve the value that is derived frm MBS expenditure. In rder t evaluate the ability f the Review t achieve this, MTAA suggests the fllwing: Evaluate the impact f the MBS Review: Patient utcmes and a lng term view f the health ecnmic cnsideratins i.e. shrt-term saving shuld nt be a pririty. Regular cllatin and reprting t MBS n patient utcmes and health ecnmic cnsideratins - multi-disciplinary, primary and tertiary clinicians and patient feedback t better infrm decisins abut best practice guidelines. Mechanism is needed t identify the reasns fr utilisatin f items i.e. t determine and measure the trends/reasns fr item use. Impact n patient access including funding r reimbursement. Metrics and measurement appraches that shuld be applied t evaluate the MBS Review: Quality, specifically defined (e.g. best practice criteria) Patient experience Specific indicatin-based milestnes Patient cmplexity Need t ensure it is a prcedure-specific apprach and NOT a ne size fits all apprach. Imprve measurement and mnitring capability ver time: By simplifying current incentive prgrams that are intended t encurage participatin in targeted data cllectin Having a n-blame reprting mechanism fr physicians (healthcare prviders and prfessinals) reprting f adverse utcmes shuld be encuraged Imprving the understanding f patient experiences and utcmes - successful and nt successful. Encurage and implement the use f the electrnic patient health recrd as an identifier and t track the patient s pathway f care frm the diagnsis, treatment and pst treatment. Other MBS issues - Clinical Quality Registries: Where federal gvernment funding is prvided fr the cnduct f a medical device clinical quality registry, it will be critical that clinician reprting cmpliance is achieved t ensure the quality and reliability f the resulting data. MTAA believes that where a MBS fee is payable with respect t a device related prcedure tracked by a publicly funded registry, then there shuld be a mandatry bligatin n the clinician t prvide the necessary reprt. MTAA Submissin t the Medicare Benefits Schedule Review Taskfrce Cnsultatin Paper Page 7 f 17
c. Need fr review Which services funded thrugh the MBS represent lw-value patient care (including fr safety r clinical efficacy cncerns) and shuld be lked at as part f the Review as a pririty? Which services funded thrugh the MBS represent high-value patient care and appear t be underutilised? MTAA agrees that services that represent lw-value patient care, particularly services with clinical efficacy cncerns, shuld be priritised fr attentin by the Review. Fr example: services tests and prcedures already identified by the clinical craft grups thrugh the Chse Wisely campaign. It is imprtant that the Taskfrce ensures that that decisins abut whether a service is prpsed as lw-value are evidenced-based and that patient health utcmes need t be the main cnsideratin f the review. There are sme services that may seem t be lw-value but in actual fact the cause f lw-value is due t the descriptr f the service/item. Examples include services relating t GP cnsultatins with specified time limits, which may lead t narrw clinical assessments (e.g. episdic, nt inter-disciplinary). MTAA prpses t the Taskfrce the fllwing examples f MBS services that represent high-value patient care but are currently under-utilised: Chrnic disease management review and ther practice incentives 4 Remte mnitring and telemedicine - telehealth and remte mnitring technlgies have the ptential t reduce demand n primary care prviders by enabling patients with chrnic and cmplex health prblems t mnitr and manage their cnditins at hme Device funding issues fr nn-implantable medical technlgies e.g. measurement f fractinal flw reserve (FFR) Radiatin therapy (RT) fr cancer treatment Items whereby the fee is nt reflective f the clinical benefit the playing field" needs t be levelled between prcedures that prvide a similar clinical utcme. See Annex 1 fr examples f MBS services that represent high-value patient care but are currently under-utilised as mentined abve. d. MBS legislatin and rules /cmpliance Are there rules r regulatins which apply t the whle f the MBS which shuld be reviewed r amended? If yes, which rules and why? Are there rules which apply t individual MBS items which shuld be reviewed r amended? If yes, which rules and why? Please utline hw these rules and why? Please utline hw these rules adversely affect patient access t high-quality care. What wuld make it easier fr clinicians and cnsumers t understand r apply the rules r regulatins crrectly? Additinal issues: Are there existing rules which are causing unintended cnsequences r are utmded and shuld be reviewed? Are there alternative slutins t deliver the riginal intent? In amending any existing rule/s, are there any ptential adverse impacts n cnsumers, prviders r gvernment? Are there medical services which shuld nt be funded fr reasns ther than cncerns abut safety and/r clinical efficacy? Hw can these be defined unambiguusly? MTAA Submissin t the Medicare Benefits Schedule Review Taskfrce Cnsultatin Paper Page 8 f 17
The MTAA acknwledges that the MBS rules and legislatin are very imprtant, and that the fllwing shuld be cnsidered as part f the Review: Rules r regulatins which apply t the whle f the MBS Issues relating t MSAC: mre guidance surrunding ideal MSAC applicatin cntent clarity regarding the suitability f technlgies and devices that replace r reduce the need fr services. Review the current directive that a service must be delivered by a physician, in cases where a health prfessinal ther than a physician culd als prvide the service. Review prcess needs t invlve different clinical disciplines wrking tgether (nt in sils) t ensure items/services deliver cntinuity f patient care. Rules which apply t individual MBS items which shuld be reviewed r amended: Items t be reviewed r amended needs whle system and crdinated apprach that fcuses n patient health utcmes. There shuld be incentives t encurage cntinuity f patient care and als where apprpriate data cllectin t assess effectiveness f a prcedure. Rules which are easy fr clinicians and cnsumers t understand - t ensure the rules r regulatins are applied crrectly: The MBS bk needs t be made fully electrnic as this wuld prvide a better search engine functin and capability t link items/descriptrs. Review f items with dated and/r bscure descriptrs - these descriptrs need t be re-wrded t ensure that they are clear fr clinicians and cnsumers t understand. Educatinal/prfessinal develpment campaigns (t explain the clinical guidelines and cnsensus statements develped by craft grups) shuld be prvided t patients and clinicians. Clarity in cnsidering the suitability f technlgies and devices that replace r reduce the need fr services. MTAA agrees that existing rules, which are causing unintended cnsequences r are utmded, shuld be reviewed. In particular, rules relating t delivery f care i.e. current delivery f patient care that relies heavily n face t face cnsultatin, even delivery via videlink may be utdated and des nt maximise the use f technlgies with remte mnitring capabilities that are already available fr healthcare use r are in use verseas. Despite the fact that telehealth and medical technlgies with remte mnitring capabilities have the ptential t achieve cnsiderable health system efficiencies and reduce csts, little prgress has been made twards their widespread adptin. One f the key barriers t the brad adptin f these technlgies has been the lack f funding and the fact that reimbursement pathways are nt in alignment with current clinical practice and guidelines. See Annex 2 fr examples f rules which apply t individual MBS items which shuld be reviewed r amended as these rules currently adversely affect patient access t high-quality care. MTAA Submissin t the Medicare Benefits Schedule Review Taskfrce Cnsultatin Paper Page 9 f 17
e. Access t MBS data What kind f infrmatin d cnsumers need t better participate in decisins abut their health care? Additinal issues Shuld the MBS be used t encurage mre systematic cllectin f data? Are there MBS items which culd have health utcmes data readily linked t prvisin f health care? Shuld MBS items supprt participatin in the creatin r develpment f ther data surces? e.g. myhealth Recrd, clinical trials, funding linked t evidence prductin. MTAA cnsiders that cnsumers will need the fllwing infrmatin t better participate in decisins abut their health care: Incentive t participate in the review, evaluatin and implementatin prcesses - cncrdance with an individualised preventin and/r treatment plan may prvide fr an imprved apprach given that health utcmes are nt always within the patient s cntrl. Prir t their prcedure, cnsumers may be prvided with infrmatin regarding the MBS items their physician will use. This will help raise cnsumer awareness and understanding regarding the MBS. Cnsumers prvided with infrmatin t imprve their understanding and awareness f the chices that are available and any limitatins f evidence available fr medical technlgies. Imprved access t ne central surce f infrmatin regarding their (patient s) medical histry in the submissin t the Review f Primary Healthcare in Australia, MTAA recmmended the need fr supprt fr the wide-spread adptin f patient electrnic health recrds. 5 MTAA agrees that the MBS shuld be used t encurage a mre systematic cllectin f data BUT with the emphasis f the data being, as a matter f standard practice, prvided by the dctrs withut being able t charge extra and ONLY cllectin f data that wuld add value and better infrm clinical decisin making. Telehealth and ehealth tls and applicatins shuld als be cnsidered in the Review - t imprve efficiency, linkage and reduce the cst f data cllectin which are particularly crucial fr apprpriate patient treatment and management. f. Cnsumer experiences perspective f the medical technlgy industry What rles and respnsibilities d cnsumers have in facilitating the best value use f Medicare services? Cnsumers play an imprtant rle in facilitating the best value use f Medicare services. Patient engagement is cited as a key success factr in terms f health utcmes and resurce utilisatin in the literature. 6 Hwever, the health system als plays a critical rle in supprting patient participatin and infrmed healthcare related decisin making. Educatinal supprt shuld be prvided t cnsumers t enable cnsumers t be better infrmed abut Medicare services. The Review shuld als cnsider the rle f digital technlgies in facilitating self-management and imprvement in patient health utcmes and quality f life. MTAA Submissin t the Medicare Benefits Schedule Review Taskfrce Cnsultatin Paper Page 10 f 17
MTAA recmmends raising awareness and imprving the understanding f the benefits that telehealth and technlgies with remte mnitring capabilities can bring t the wider cmmunity, including targeted prgrams fr cnsumers/grups mst likely t benefit, such as individuals with chrnic and cmplex health cnditins (e.g. diabetes), the elderly, r thse living in rural r remte areas. RECOMMENDATIONS MBS Objectives, Prcess and Evaluatin: Review f the MBS shuld ensure its applicatin is current and in alignment with cntemprary best medical practice, and that it achieves value and ecnmic efficiency in the healthcare system, ensuring its sustainability. Review f the MBS shuld ptimise patient care and achieve the best pssible utcmes and value fr mney frm MBS services. The Review aims t mdernise the MBS t help achieve best patient health utcmes fr MBS expenditure; and best evidence-based, clinical practice supprted by the health prfessinal services funded thrugh the MBS. Hwever, it is unlikely the rapid review methdlgy prpsed in the cnsultatin paper wuld adequately meet these aims. The review shuld als ensure services that use medical technlgy can achieve ptimal service delivery, access, utcmes and cst benefits. MBS Rules and Regulatins Befre amendment f any existing rule/s is undertaken, ptential adverse impacts n cnsumers, prviders r gvernment must be cnsidered. Any substantial change will require a transitin perid fr implementatin in rder t ensure that stakehlders are able t adapt their clinical practice and business mdels ver time. Better clarity in rules and prcesses cnsidering the suitability f technlgies and devices that replace r reduce the need fr services. Develpment f rules that incentivise physicians and ther health prfessinals t use high value services e.g. payment (fee) fr participating in remte mnitring services. Imprve the prvisin f frmal targeted training requirements t dctrs fr specific prcedures. These training requirements shuld be cnsidered fr inclusin as part f the Item descriptr. Cnsideratin shuld be given t restrictins t patient access where the prcedure is nt supprted by evidence fr particular patient chrts. In areas f clinical uncertainty, there shuld be a requirement t cllect data t facilitate infrmed decisin-making e.g. real wrld evidence linked t risk sharing is ne ptin. Rules need t be revised where they are dated, inefficient and d nt lead t the best quality clinical care and patient utcmes. Need fr the Review The cnsultatin prcess shuld be transparent with the invlvement f all relevant stakehlders, including the medical technlgy industry, particularly t determine pririty items, whereby a minr amendment (in the item descriptin) may have majr impact n patient access t medical technlgy and the intrductin f new technlgies. MTAA Submissin t the Medicare Benefits Schedule Review Taskfrce Cnsultatin Paper Page 11 f 17
3. CONCLUSION Medical devices shuld be cnsidered in the scpe f the MBS review where medical technlgy plays a crucial rle in patient care, diagnsis, treatment and management pathways. Many MBS services cannt be prvided withut use f diagnstic, mnitring r interventinal technlgies. Medical technlgies can prvide cst savings t the healthcare system gained thrugh reductin in preventable hspitalisatins and imprved patient utcmes resulting in a mre efficient healthcare system. Further, the rle f the medical technlgy industry shuld be recgnised, and be invlved in the cnsultatin cmmittees, particularly t review services that invlve medical technlgies. Overall, the review utcmes shuld emphasise the imprtance f maintaining an affrdable and sustainable healthcare system in Australia that is in alignment with cntemprary best clinical practice and with a whle-healthcare system apprach. The review shuld als ensure that issues relating t inequitable access are identified and addressed i.e. the develpment f new items t address an unmet clinical need and prevent delays t access cmprising patient utcmes. MTAA and its members are supprtive f the Australian Gvernment s cmmitment t the MBS Review, with the aim t ensure that a transparent whle-system evidence-based apprach is applied and that implementatin f MBS services reflect cntemprary clinical practice, imprve patient utcmes and represent value-fr-mney fr a mre efficient, effective and sustainable healthcare system. MTAA Submissin t the Medicare Benefits Schedule Review Taskfrce Cnsultatin Paper Page 12 f 17
ANNEX 1 Case examples where MBS fails t supprt delivery f best value and quality healthcare Case examples Which services funded thrugh the MBS represent highvalue patient care and appear t be under-utilised? Recmmendatins Nn-implantable technlgy that enables prvisin f minimally invasive diagnstic r therapeutic services Develpment f new medical services utilising innvative nn-implantable technlgy require Medical Services Advisry Cmmittee (MSAC) evaluatins t infrm decisins relating t public funding f the new service. MSAC may find these new services are cst-effective, with psitive MSAC advice leading t the creatin f new MBS items. Hwever, this may nt lead t ptimal adptin f new therapies r diagnstic prcedures i.e. current Cmmnwealth arrangements fr assessing devices fr private health insurer reimbursement are limited t permanently implanted medical devices. There is n clear funding pathway fr nn-implanted technlgies. In the absence f clear funding arrangements access t new services invlving nn-implanted technlgy is limited. This ptentially creates a perverse incentive t use existing services, especially where there is certainty f funding f technlgies used t deliver the service. This is incnsistent with achieving the best pssible patient utcmes, particularly if a new service, using a nnimplanted technlgy is fund t be mre clinically and csteffective than existing services. This discnnect between psitive MSAC advice and the absence f definitive funding arrangements fr nnimplantable technlgy is incnsistent with ptimising the full ptential f new MBS services t deliver benefits t patients and the healthcare system. In additin, this discnnect represents an inefficient use f MSAC resurces i.e. it creates a situatin where cnsiderable time and resurces are spent infrming the develpment f a new MBS item, but cannt be ptimally implemented due t the absence f definitive funding f the technlgy used t deliver the service. It als limits clinicians ability t chse the mst suitable technlgies t best align MBS services with individual patient needs. Assessment and funding arrangements need t be develped t ptimise access t nn-implanted technlgies used in new MBS services. This culd invlve expansin f current Prstheses List arrangements t cnsider nn-implantable technlgies used in services implemented fllwing psitive advice frm MSAC. T ptimise services using nnimplanted technlgies, the MBS Taskfrce shuld ensure the review f items is thrugh and that the rt cause f lw-value service is apprpriately identified i.e. review f whle-system care mdels and funding pathways. The review t ensure there is equitable access t medical technlgies that are crucial fr the diagnsis, treatment and management f disease. There shuld als be an implementatin f prcesses t incentivise the use f services (and medical technlgies) that prvides highvalue patient care. Examples f technlgies where there is a discnnect between develpment f a new MBS service and absence f definitive funding arrangements include: Services using cardiac ablatin catheters and crnary pressure measuring systems t assess the extent f cardiac ischemia (measurement f fractinal flw reserve FFR). Althugh FFR imprves the practice f crnary percutaneus interventin (PCI) and has demnstrated clinical and cst benefits FFR is underutilised in Australia due t the current limited funding arrangements fr FFR measurement. 1 Funding f FFR (like mst ther nnimplantable technlgies examples) is typically sught n a case-by-case basis, thrugh the submissin f ex-gratia funding requests t private health insurers. There is n certainty that these funding requests will be apprved negatively impacting n clinician s right t chse the mst suitable treatment fr their patients. If funding requests are declined patient access t therapy is likely t be delayed and/r clinicians may need t chse a less clinically apprpriate treatment. Services using radiatin therapy (RT) fr cancer treatment Due t the current MBS items fr cancer therapy, there is under-utilisatin f RT fr the treatment f cancer. The 1 Harper et al. Hw changes t the Medicare Benefits Schedule culd imprve the practice f cardilgy and save the taxpayer mney. Medical Jurnal f Australia. 2015. 203(6):256-8.e1 MTAA Submissin t the Medicare Benefits Schedule Review Taskfrce Cnsultatin Paper Page 13 f 17
current utilisatin rate f RT des nt supprt the gld standard f cancer care i.e. utilisatin rate des nt meet the clinical need which is impacting negatively n patients health and utcmes. The lw use f RT is caused by the disincentive fr clinicians t use RT. Case management f chrnic diseases cnditins Example: Diabetes Care Management Diabetes care is cmplex, invlving a range f health prfessinals including Certified Diabetes Educatrs (CDE). Currently, the MBS prvides a benefit fr a specialist visit (acute phase f a disease treatment), but there is n funding fr Diabetes Educatrs (wh prvide the nging care and supprt fr the patient as they manage their cnditin) Peple with diabetes can claim rebates fr five (5) cnsultatins with allied health care prfessinals per year as part f Medicare s Chrnic Disease Management (CDM) framewrk. Diabetes educatin prvided by a CDE is in included in the ttal number f these five (5) visits. The specific MBS item number fr diabetes educatin is 10951.Five annual visits is insufficient fr diabetes patients with cmplex needs - Onging care fr diabetes is essential t imprve/maintain patient health and is widely described in clinical practice guidelines 2. Current MBS arrangements fr diabetes management are insufficient t meet the clinical needs f all patients. Limitatins f the current MBS arrangements fr diabetes care mean that sme patients with diabetes may nt receive the apprpriate level f care/supprt t manage their cnditin. If the diabetes care mdel des nt meet the apprpriate clinical need, then diabetes-assciated cmplicatins and c-mrbidities are likely t increase, therefre, increasing the healthcare cst burden f diabetes i.e., annual csts fr patients with the mst severe cmplicatins and least severe cmplicatins are 5 times and 2 times greater, respectively, than patients with n cmplicatins. 3 Example: Treatment and Management f Chrnic Wunds The current directive that a service must be delivered by a physician needs t be reviewed. Fr example, in the area f chrnic wunds, treatment and management is nt nly delivered by physicians, ther health prfessinals acting within their scpe f clinical practice (e.g. nurse practiners) shuld als be able prvide the service. Examples include the applicatin f cmpressin therapy (which can be cmpleted by a nurse) and the use f hydrsurgery (which culd als be cmpleted by a pdiatrist). Chrnic cnditins/diseases such as diabetes and chrnic wunds require nging care acrss a number f healthcare prfessinals and specialties. MBS service funding mdels shuld cver all aspects f chrnic disease management (e.g. bundled payments instead f feefr-service payments). The type and annual frequency f different types f care (e.g. cnsultatins, tests, nging mnitring) shuld be reflected in services available n the MBS and aligned with best practice and clinical guidelines. MBS service funding mdels fr chrnic cnditins shuld be flexible enugh t readily adpt new clinical practice with demnstrated benefits fr patient benefits, clinical utcmes and healthcare csts. Fr example, flexibility in funding arrangements fr the management f chrnic cnditins has been recmmended in a recent evaluatin f Diabetes Care 4 The Review shuld cnsider the benefits medical technlgies can prvide i.e. imprve patient utcmes and cst savings t the healthcare system. 2 Diabetes Clinical Practice Guidelines. Available: https://www.diabetesaustralia.cm.au/best-practice-guidelines. (Accessed 16th Octber, 2015) 3 Diabetes Australia 2012: diabetes: the silent pandemic and its impact n Australia (prepared by Baker IDI). Available: http://ap.rg.au/research/diabetes-silent-pandemic-and-its-impact-australia (Accessed 16th Octber, 2015). Page 30 describes the average annual healthcare csts per persn with diabetes. 4 Evaluatin Reprt f the Diabetes Care Prject. Available: http://www.health.gv.au/internet/main/publishing.nsf/cntent/eval-rep-dcp (Accessed 16th Octber, 2015) The Diabetes Care Prject was a three year pilt prgramme which analysed new mdels f health care delivery fr adults with type 1 and type 2 diabetes. Key recmmendatins relevant t reviewing MBS arrangements fr chrnic disease management include: change the current chrnic disease care funding mdel t incrprate flexible funding fr registratin with a health care hme; payment fr quality and funding fr care facilitatin, targeting resurces where they can realise the greatest benefit; cntinue t develp bth ehealth and cntinuus quality imprvement prcesses; and better integratin f primary and secndary care t reduce preventable hspitalisatins (and hspitalisatin csts). MTAA Submissin t the Medicare Benefits Schedule Review Taskfrce Cnsultatin Paper Page 14 f 17
ANNEX 2 Imprvements t the rules, prcesses and systems that supprt the MBS: Rules which apply t individual MBS items that shuld be reviewed r amended - as these rules adversely affect patient access t high-quality care Case Examples Are there rules which apply t individual MBS items which shuld be reviewed r amended? If yes, which rules and why? Please utline hw these rules and why? Please utline hw these rules adversely affect patient access t high-quality care. Recmmendatins Technlgy advances that enable mre efficient delivery f healthcare Example: Mving healthcare frm hspitals t utpatient settings - Technlgies that enable healthcare t mve frm hspitals t utpatient settings. Current MBS arrangements are limited and funding fr certain items are restricted nly t prcedures perfrmed in-hspital settings i.e. require patients t be admitted in the hspital fr Medicare benefits t be payable. Additinally, current funding arrangements d nt efficiently allw delivery f newer prcedures invlving advanced medical technlgies. An example is the implantable lp recrders (ILRs). ILRs meet criteria fr private reimbursement fr the device. Hwever, the benefits arising frm advancements in ILR design which enable implantatin in utpatient settings cannt be maximized i.e. current MBS arrangements prvide funding fr implanting prcedure (MBS item 38285) and Prstheses List (PL) arrangements (funding fr the device) therefre restrict prcedure nly t in-hspital settings. This limitatin arises because current Private Health Insurance Rules 5 require the patients t be admitted fr Medicare benefits t be payable Mving healthcare frm hspitals t utpatient settings ffers an pprtunity t maintain clinical utcmes and patient safety while reducing healthcare csts and delivering efficiency benefits t hspitals. The MBS Review Taskfrce shuld cnsider the number f MBS items relate t prcedure t be perfrmed in a hspital fr the Medicare benefit t be payable and whether these MBS items are relevant/aligned with imprving the efficiency f the healthcare system. Other examples include funding f medical technlgies fr the treatment and management f chrnic diseases e.g. mdern wund care devices. Current MBS arrangements fr the remte prvisin f cnsultatins Example: Telehealth MBS items Telehealth MBS items require that the patient and remte specialist be at least 15 km apart. A specialist, cnsultant physician r psychiatrist can be lcated anywhere thrughut Australia but the lcatin f the patient at the time f the cnsultatin must be in a remte, reginal r an uter metrplitan area. This restrictin n patient lcatin des nt take int accunt patient circumstance and implicitly assumes that all patients are willing and/r able t travel fr cnsultatins. All patients living in inner metrplitan areas are nt eligible fr telehealth services. Patients in inner metrplitan areas with cmplex health needs, limited mbility and/r difficulties in making travel arrangements may be unable t attend face-t-face cnsultatins necessary fr ptimizing their care. If nging care is cmprmised, then there is an increased likelihd f pr health utcmes and assciated cst cnsequences. The MBS Review Taskfrce shuld cnsider whether the restrictins relating t lcatin f the patient are apprpriate fr Telehealth MBS items Telehealth MBS items culd be mdified t take accunt f individual patient circumstances enabling flexibility in care arrangements. 5 Private Health Insurance (PHI) - HOSPITAL SUBSTITUTE TREATMENT: Hspital substitute treatment is a subset f general treatment and is defined under Sectin 69 10 f the PHI Act. It is treatment prvided by a prvider that is nt a declared hspital, but which substitutes fr an episde f hspital treatment, i.e. it is the same treatment that is usually prvided by a hspital. It is nt mandatry fr private health insurers t cver Hspital substitute treatment. It is up t private health insurers t decide the services they pay benefits fr and t determine that the services prvide value fr mney in terms f cst utlays and health utcmes fr their members. The definitin f Hspital Substitute Treatment in the Private Health Insurance Act 2007 is unnecessarily restrictive in that a number f MBS items are excluded frm this definitin within the Private Health Insurance (Health Insurance Business) Rules. MTAA Submissin t the Medicare Benefits Schedule Review Taskfrce Cnsultatin Paper Page 15 f 17
REFERENCES 1. Medicare Benefits Schedule Review Taskfrce Cnsultatin Paper September 2015. Available at: www.health.gv.au/internet/main/publishing.nsf/cntent/922cb2933b0f1645ca257ec1001 D5C12/$File/MBS%20Review_Cnsultatin%20paper_FINAL.pdf 2. MTAA Submissin t the Medical Benefits Divisin (MBD): Medicare Benefits Schedule (MBS) Reviews Octber 2014. Available at: http://mtaa.rg.au/dcs/submissins/mtaasubmissin-t-mbd-mbs-reviews-final.pdf?sfvrsn=2. 3. Willett K. If it's abut quality and cst; let clinicians run healthcare. Presented at The Activity Based Funding Cnference, Adelaide 2015. 4. Kecmanvic M and Hall J. The use f financial incentives in Australian general practice. Medical Jurnal f Australia. 2015. 202(9)488-491. 5. MTAA Submissin t the Discussin Paper n Better utcmes fr peple with chrnic and cmplex health cnditins thrugh Primary Health Care, September 2015. Available at: http://www.mtaa.rg.au/dcs/submissins/mtaa-submissin-t-discussin-paper-n-'betterutcmes-fr-peple-with-chrnic-and-cmplex-health-cnditins-thrugh-primary-healthcare.pdf?sfvrsn=2. 6. Gruman J et al. Frm patient educatin t patient engagement: Implicatins fr the field f patient educatin. Patient Educatin and Cunselling. 2010. 78(3):350-6. MTAA Submissin t the Medicare Benefits Schedule Review Taskfrce Cnsultatin Paper Page 16 f 17
Cpyright 2015 Medical Technlgy Assciatin f Australia Limited (MTAA) T the extent permitted by law, all rights are reserved and n part f this publicatin cvered by cpyright may be reprduced r cpied in any frm r by any means except with the written permissin f MTAA Limited. MTAA Submissin t the Medicare Benefits Schedule Review Taskfrce Cnsultatin Paper Page 17 f 17