RURAL DOCTORS ASSOCIATION OF AUSTRALIA Response to the Review of the Medicare Benefits Schedule Consultation Paper Via email: MBSReviews@health.gov.au Contact for RDAA: Jenny Johnson Chief Executive Officer Email: ceo@rdaa.com.au 09 November 2015 PO Box 3636, Manuka ACT 2603 Phone: 02 6239 7730 Web: www.rdaa.com.au
RURAL DOCTORS ASSOCIATION OF AUSTRALIA The Rural Doctors Association of Australia (RDAA) is a national body representing the interests of all rural medical practitioners and the communities where they live and work. Our vision for rural and remote communities is accessible, high quality health services provided by a medical workforce that is numerically adequate, located within the community it serves, and comprises doctors and other health professionals who have the necessary training and skills to meet the needs of those communities. INTRODUCTION The Rural Doctors Association of Australia (RDAA) welcomes the review of the Medicare Benefits Schedule (MBS) as a means to improve health outcomes for individuals and for the Australian population more broadly. It affords the opportunity not only to secure the ongoing effectiveness and efficiency of a major part of the Australia s healthcare system but also to tackle the equity and access issues which exist in rural and remote Australia. RDAA strongly supports Medicare as an effective national universal health care scheme. It has a key role in delivering improved health and wellbeing outcomes for individual patients contributing to a healthier Australian population and social and economic benefits into the future. The MBS should: facilitate equitable and sustainable access to high quality care for all Australians; reflect best practice in evidence-based care and service delivery; support the maintenance of an efficient and high quality health care system; and facilitate innovation in service delivery and the capacity to utilise advances in technology. It is also important to ensure that the MBS Review is aligned with other healthcare reviews and processes, for example: the work of the Primary Health Care Advisory Group (PHCAG); the Practice Incentive Program Advisory Group (PIPAG); and the current initiatives with respect to ehealth and the My Health Record. Rural medical practice models and the needs of rural and remote communities differ markedly from those of their urban counterparts. The approximately one third of Australians living outside major urban centres have significantly poorer health outcomes than other Australians. The differences in socio-economic, equity and access attributes contributing to this situation are well recognised and documented. It is important that the MBS reflects the needs of rural patients and the scope and circumstances of rural practice, and supports the delivery of high quality, longitudinal and generalist care if patient outcomes are to be improved. A rural filter must be applied to MBS review processes and decisions to ensure that any changes are sensitive to the differential impact they may have in rural and remote Australia. 1
RECOMMENDATIONS RDAA believes the MBS Review should: 1. Ensure changes to existing MBS items are based on clear evidence. 2. Include appropriate rural representatives on all decision-making bodies. 3. Ensure Medicare items/descriptors and levels of reimbursement are appropriate to the rural context. 4. Remunerate rural GPs at the same rates as specialists for providing specialty services. 5. Disincentivise throughput-based models of care and reflect and reward evidence-based care. 6. Support the use of new health technologies that promote access to quality healthcare. 7. Facilitate flexible, GP coordinated, team-based care arrangements to reduce administrative imposts, maximise workforce efficiency and allow all health practitioners to work to their full scope of practice. 8. Clearly define and improve the coordination of funding arrangements and services provided by the Commonwealth and States/Territories. 9. Re-invest any savings achieved as part of the Review into the healthcare system. 10. Immediately discontinue the MBS indexation freeze. KEY PRINCIPLES Changes to existing MBS items must be based on clear evidence. RDAA recognises that there are a number of contextual difficulties associated with assessing the usefulness of specific items. Each patient and each case is different. What is useful in one instance may not be in another. While it is important to ensure that Medicare items are effective and provide value for money, it is also important that the evidence used to make decisions that any particular item is over-utilised for little or no benefit is unequivocal. Removing or lowering rebates will have a greater impact in rural and remote areas where socio-economic status is generally lower and private health insurance is less likely. Higher out-of-pocket expenses will cause greater hardship and may lead to patients choosing to delay visiting their doctor or seek treatment through hospital emergency departments resulting in higher systemic costs in the longer term. 2
Transparency of all Review processes to ensure that decisions are evidence-based is essential. A system for ongoing, rolling evaluation of Medicare items is necessary to ensure continuous rather than episodic systemic improvement. All decision-making bodies should include appropriate rural representatives. Rural doctors should be involved in all aspects of the review. In particular, there must be appropriate rural medicine representatives, such as a practising rural doctors or medical educators nominated by RDAA or ACRRM, on groups approving final changes to Medicare items, descriptors and processes to ensure that the rural context has been properly understood and rural and remote issues have been considered in order to minimise any unintended and adverse impacts on rural doctors, rural practices and rural communities. Rural doctors work across a range of craft groups. They usually provide generalist services spanning primary and secondary care in general practice, hospital and community settings. They also provide a range of public health, emergency and other services and have close links to their patients and communities and a clear idea of their needs. The breadth and depth of knowledge and experience engendered by this generalist practice means that rural doctors are well placed to be able to provide input on the operation of the MBS not only in rural areas but also on its impact on the healthcare system as a whole. Medicare items/descriptors and levels of reimbursement must be appropriate to the rural context. RDAA believes that the MBS should not merely be an administrative tool. It should both drive and underpin the provision and support of high quality, comprehensive, continuous and longitudinal care. This is especially important in rural areas where isolation, costs, content, context and complexity of practice pose significant challenges. In these areas maintaining financially viable general practices is a complex balancing act involving a range of mechanisms including the MBS, the General Practice Rural Incentive Program (GPRIP) and other Practice Incentive Programs (PIPs). It is important to recognise these mechanisms are not just interrelated but also interdependent. Any adverse changes will affect the capacity of rural doctors to provide services not just in their general practices but also in hospitals, residential facilities and community settings. After hours and emergency services may also be at risk. Acknowledging the importance of the generalist practice model in rural and remote areas and providing realistic reimbursement for this model through Medicare is important to: deliver appropriate medical services to patients in a cost effective manner; attract and retain doctors in these areas; maintain the viability of rural practices; and improve health outcomes in rural areas more broadly. There may be a need for rural exemptions to rules governing use of the MBS. For example, allowing doctors in rural and remote areas to claim for multiple items during a single consultation for patients under a chronic disease management plan can 3
promote better health outcomes for patients. People who live in rural and remote communities may have to travel for a number of hours to see a doctor or wait for a number of weeks to be seen close to home. They are also more likely to delay seeking treatment for a number of reasons including the distance from the medical practice, time and transport costs or the perceived relative value of other activities such as harvesting or shearing. These issues of equity and access must be taken into account. A rural loading for isolation, advanced skills and complexity of practice should be provided through the MBS. GPs providing specialty services should be remunerated at the same level as specialists. Many rural doctors who work in private practice often also provide essential services as Visiting Medical Officers or work on a salaried basis for their local hospital. Many have undertaken additional education and training to work across a range of craft groups including, but not limited to, obstetrics, anaesthetics and general surgery. GPs providing these specialty services should be recognised through remuneration equivalent to specialist rates. The MBS should disincentivise throughput-based models of care and reflect and reward evidence-based care. Optimal health outcomes will not be achieved under a system that does not adequately recognise or reward high quality, evidence-based care. Current MBS arrangements reward greater throughput and promote a reliance on acute, specialist and sub-specialist care which is detrimental to the viability and sustainability of rural practices. High-volume, episodic, low quality practice will not improve health outcomes or systemic efficiency in the longer term. It is particularly important that the MBS schedule supports the generalist model of practice which works so effectively in rural areas. While there will always be a need for specialist and sub-specialist care, the rural generalist model provides an efficient and effective model for delivering a wider range of services and improving access for rural patients. Specialist general practitioners working in full-scope general practices should be rewarded for the quality, longitudinal, comprehensive continuity care that is provided for a broad spectrum of presentations; preventive care; and management of chronic and complex health conditions. The MBS should support the use of new health technologies that promote access to quality healthcare. In rural and remote areas the technology used to provide and access telehealth is becoming a part of the doctor s bag. Health practitioners now have relatively easy access to a range of previously unavailable diagnostic and treatment tools and are able to arrange some specialist consultations and treatment for their patients via computer or smart phone. New MBS items should be created to reflect the changes in the use of technology and support the uptake of these technologies in rural practices by providing realistic 4
reimbursement which recognises the additional costs of service provision in rural and remote areas. MBS items for telehealth should be designed so that they support existing rural practices that are providing high quality generalist services in their communities rather than encouraging urban-based business models which could potentially undermine the viability of rural practices. The administrative imposts of the MBS must be taken into consideration. Administrative imposts can have a particularly severe impact on rural practices, which are likely to be smaller and without access to skilled administrative resources and staff. In some rural practices, these imposts form part of the workload of an already busy medical practitioner. MBS items should facilitate flexible, GP coordinated, team-based care arrangements to maximise workforce efficiency and allow all health practitioners to work to their full scope of practice. Funding arrangements and services provided by Commonwealth and States/Territories must be clearly defined and better coordinated. RDAA recognises the difficulties posed by a tiered funding system and consequent cost shifting that occurs. For example, under some circumstances in rural areas in some States, doctors are required to privately bill through Medicare for the services they provide in public hospital emergency/urgent care centres. This causes misunderstanding among patients, who expect care to be covered under State hospital emergency department arrangements, and puts the onus on doctors to recover fees. This policy can potentially reduce access to emergency services in rural areas. The provision of Medicare-funded primary care services from State-funded public hospitals is another area where some clarification of protocols is required. Better coordination of funding and services provided by Commonwealth and States/Territories would reduce the potential for cost shifting; clarify responsibility for various aspects of the health care; reduce the potential for double dipping and duplication of services; and facilitate efficient and effective delivery of health care services and continuity of care. Any savings achieved as part of the Review should be re-invested in the healthcare system. The Review should not be seen as a cost-cutting exercise; however if savings are identified, they should be re-invested back into the health care system to maintain quality and sustainability. Given that approximately one-third of Australians live in regional, rural or remote areas, and that their health outcomes continue to be poorer than those of their urban counterparts, there is a strong case for rural health to be a priority area for these investments. 5
The current MBS indexation freeze is continuing to have a detrimental effect on rural medical practices and must be immediately discontinued. The MBS has failed to keep up with inflation or accurately reflect practice costs and its structure has driven volume-based practice funding models. A rural general practice is most often run as a private small business. Like any small business, private investment requires certainty to mitigate risk. There will be limited future investment in the business of general practice without certainty and realistic funding which will compromise the ongoing provision of care to many rural communities. The negative impact that the continuing MBS indexation freeze is having on general practices has been well publicised. If the freeze continues more rural doctors will be forced to re-evaluate their capacity to maintain their rural practice and given the role they play in providing hospital and emergency services this will have an immediate and ongoing impact on rural health more broadly. 6