Issue 45 / 19 November 2012

MANY of 150-plus potentially low-value health services on the Medicare Benefits Schedule identified in a systematic review could be delisted after appropriate consultation, says an expert in health care reform.

The research, published in the latest MJA, used a multiplatform approach to identify non-pharmaceutical health care services listed on the Medicare Benefits Schedule (MBS) which were potentially unsafe, ineffective or inappropriately applied. (1)

The researchers screened 5209 articles to identify 156 potentially ineffective or unsafe services that required further “expert clinical detailing”. About half of the services identified were operative procedures and the rest a mix of diagnostic, screening and monitoring investigations.

In an MJA editorial in the same issue, Professor Ian Scott, director of internal medicine and clinical epidemiology at Brisbane’s Princess Alexandra Hospital, said some of the services identified would be instantly recognised by seasoned clinicians as obsolete, such as adenoid removal in children with recurrent otitis media with effusion, and hysterectomy as first-line treatment for heavy menorrhagia. (2)

However, he wrote that opinions would be divided on the value of others services, such as exercise electrocardiography in patients with suspected angina, and endovascular repair of infrarenal abdominal aortic aneurysms in medically fit patients.

The research was conducted as part of the federal government-funded Comprehensive Management Framework for the MBS, which was established to improve management and governance of the MBS. The researchers used a three-pronged approach to identify low-value, non-pharmaceutical services — a PubMed search of peer-reviewed literature; analysis of databases such as the Cochrane Library and the UK’s National Institute for Health and Clinical Excellence “do-not-do” recommendations; and opportunistic sampling.

The researchers wrote that the review had confirmed that the use of ineffective and/or unsafe services across the entire patient population was probably quite rare.

Professor George Rubin, professor of public health at the Universities of Sydney and NSW, told MJA InSight there were constantly new and more sophisticated interventions making health care more complex.

“We have fairly good mechanisms for adding new interventions and new drugs, but we tend not to drop off the ones that are found to be ineffective”, said Professor Rubin, who is also director of clinical governance, South Eastern Sydney Local Health District.

Methods were needed to ensure the health system achieved the maximum health gains for each dollar, Professor Rubin said. “The methodology that’s advanced [in the research and editorial] is a great starting point.”

In his editorial, Professor Scott suggested a staged approach to removing items from the MBS, with the first step being to engage with professional colleges. Items associated with robust evidence of no benefit or of harm compared with “usual care” could be removed first (50% of items identified), followed by items associated with equivocal evidence of benefit that required further research (42% of items).

Professor Scott said MBS funding could be reinstated “if and when unequivocal evidence of benefit and no serious harm becomes available”.

The group of items associated with both benefits and potential harms could continue to be funded while risk–benefit trade-offs were investigated, he said.

Professor Rubin said a staggered approach to removing items was a “nice compromise”. He said such a system should not be punitive to particular interventions where it was not clear if there was a benefit to patients.

A Department of Health and Ageing spokeswoman told MJA InSight that as part of the Comprehensive Management Framework for the MBS, the department was undertaking 22 reviews of existing medical services, including knee arthroscopy, rhinoplasty surgery, botox injection items, and lipectomy items.

“Four demonstration reviews have also been completed — ophthalmology, colonoscopy, obesity surgery and pulmonary artery catheterisation”, she said. The full program for reviews is listed on the Medical Services Advisory Committee website.

The spokeswoman said extensive consultation with clinical stakeholders and health care consumers was a critical part of any change to the MBS, including reviews of existing items.

“The approach to stakeholder engagement proposed in the MJA editorial is already being incorporated into refinement of the MBS reviews process, with the establishment of consultative review committees, comprised of clinical and consumer stakeholders, to advise on reviews”, the spokeswoman said.

– Nicole MacKee

1. MJA 2012; 197: 556-560
2. MJA 2012; 197: 538-539

Posted 19 November 2012

9 thoughts on “Call to delist low-value MBS items

  1. daman langguth says:

    Having had ongoing dealings with the federal government, both DOHA and over the last 6 years, It is obvious the only thing of interest is cost, and not utility, low or high. DOHA act capriciously and without consultation. They see removing things as their task, ie spend less. They do not display any interest in pt ouctome. In addition cochrane is blunted by poor trial design historically. To say CRP should be removed is just silly, although for community acquired pneumonia it may not have evidence.

    The new MSAC process pretty much ensures only large interested companies/organisations will have the resource to list new items. Look at the government’s approach to funding genetics, they are only starting to look at this, and it’s pathetic.

  2. Justin Coleman says:

    Interesting that 5 of the 6 first comments point out the negatives. To me, it makes absolute sense to have ongoing expert review of MBS items. It is a furphy to say that taking an item off the MBS is ‘giving money away’. No country has a bottomless pit of taxpayer’s money, and we are clearly better off with a robust system for deciding when the value of an existent item becomes low enough that it should be removed.
    An evidence-based argument to keep an individual item number is commendable, and should be taken into account during any review. However, to argue that a review shouldn’t happen at all is ludicrous. In any finite budget, the less you cross off the list, the less you can add in. Daman, if you were in charge and found there was too little funding for new MBS items, wouldn’t reviewing the current list be an obvious place to start?

  3. Greg the Physician says:

    I think we need to be careful of rigidly following “evidence-based medicine” as defined by Cochrane reviews etc. The core of medical care is to individualize treatment for each patient, based on the likely benefit, the known risks in that particular patient, and the risks and benefits of other management options (including no treatment). No two patients are alike – they differ in all the aspects we have been trained to assess (co-morbidities, other medications, socio-economic factors, compliance, etc). There would be very few treatments on the MBS which have been shown to have absolutely no benefit in any possible clinical situation. Let’s not reduce clinical decision-making to unthinkingly following a set of guidelines for each condition, as the bureaucrats would like.

  4. John Curotta says:

    I am well ‘seasoned’ and I can’t leave Prof Ian Scott’s instantly dismissive view of adenoidectomy as obselete go unchallenged:
    In April this year the UK Medical Research Council Multicentre Otitis Media Study reported on 357 randomised children that “adenoidectomy doubles benefit from short stay ventilation tubes by extending hearing through the second year…Adenoidectomy also substantially reduces eligibility for revision surgery.”

  5. Tom Ruut says:

    Is there any mechanism for removing items that have become obsolete such as oral and intravenous cholecystography,xray pelvimetry?

  6. Dr M says:

    I agree. The older multidose tetracyclines and penicillin seemed more effective than some of the newer drugs (and better tolerated) but have just been swept away. Also, wrt hysterectomy for intractable menorrhagia – does this mean patients should be allowed to exsanguinate while various ineffective methods are tried because they are cheaper? If there is an obvious bleeder and embolisation has failed this is effectively a surgical emergency. It wouldn’t necessarily be a common indication, but that doesn’t mean it shouldn’t exist at all.

  7. Barrister says:

    it is obvious the people reviewing the MBS do not use it on a day to day basis – either they are academics or public hospital based – the increasing costs to the MBS is directly related to the number of people being allowed access to MBS – there were 12,000 psychologists in Australia until MBS accessed – in 3 to 4 months there were 40,000 mental health workers accessing MBS – any allied health worker seems to be able to order expensive tests either directly or by proxy – doctors often comment to me that dieticians / chiropractors / physiotherapists have told patient you need CT scan for that or zinc levels low or some other fanciful test that natural practitioners think up – so in reality the patient comes with the expectation of expensive tests – and no amount of medical advice will deter their expectations – they merely go down the road until they find a compliant provider.
    There is nothing wrong with the Item numbers – it is the government ever expanding the access to usage of the item numbers – and the creation of item number of fictitious benefit – reviewing prescriptions/ football team conferences for chronic diseases / rewarding of non-treatment of diseases by flicking to an allied health – returns greater reward than actually treating – all these newly minted wasteful Item numbers are not cost effective – but politically effective. Wish we had Lawcare – equivalent to Medicare – come to think of it why not start Taxcare, GFCcare.

  8. Dr. ARC says:

    In many instances, some of the older medications are removed from the PBS without consultation with the medical profession because they are only being used occasionally or have been superceded by more expensive, but not necessarily more effective medications.
    In particular, Nicotinic Acid which I have been using for more than 30 years, a proven adjunct with statins to lower cholesterol, was removed from the PBS 10 years ago and now costs in excess of $50 per month to purchase over the counter!

  9. daman langguth says:

    Only a fool gives money away, we should make sure the MBS pot doesnt shrink. For those clinicians who largely dont use the MBS, of course it’s easy to say take it away. I’m not saying there arent old things and perhaps overvalued things on the MBS, but there are many procedures that have inadequate or no remuneration e.g. food challenges in allergic children and Quantiferon testing for Tb as respective examples.

    I would completely refute the concept that it is easy to get things on the MBS. It is not. The new MSAC process is a nightmare to navigate. The people commenting on this review clearly dont live using the MBS day to day.

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