Can the MBS Review deliver on its goals?

THE interim reports into the Medicare Benefits Schedule (MBS) Review have been published, and I imagine that a few eyebrows were raised among political commentators and health economists as well as critical thinkers in health.

Can this taskforce actually deliver on all four key goals of the review? The interim reports appear to advocate the “same old” approach: a “spit and polish” of the existing systems rather than a tactical change to address critical problems that have arisen in Australia’s health system. The results are variable, with some subcommittees functioning suboptimally. Management oversight and tact is needed to ensure maximum benefit out of this MBS review opportunity.

The interim report has been presented to the minister and its associated committee reports were also released. The taskforce has made “a conscious decision to be ambitious in its approach and seize this unique opportunity to recommend changes to modernise the MBS on all levels”.

The organisational task has been large and undoubtedly difficult. There has been significant analysis of MBS use, isolation of defunct procedures and questionable claiming practices. This is to be commended; but whether this is ambitious, or indeed effective, is subject to debate.

The health landscape has changed dramatically since the beginning of the MBS, and arguably this is because of the MBS. Health corporatisation and increased use of vertical health models have seriously impacted on MBS expenditure.

Commentary on rising MBS budgetary strain from corporate radiology and pathology is significant by its absence in the review. Cancer care industries, cardiac, fertility and ophthalmology business models have also flourished, as has the practice of safety net gaming.

Should the same Medicare rules apply in the modern business oriented health world?

Subspecialisation has thrived and been supported by the MBS without question of its value to the wider health system. Our system has also supported the specialist workforce to a point where specialists now outnumber general practitioners, despite this being identified as a reason for poorer population health and medical overservicing. The “zombies” of the Relative Value Study appear to be rising again, cementing incomes of proceduralists above cognitive practitioners, and specialists above GPs.

Should the same funding principles across the medical profession be continually supported?

Australia has high hospital admission rates by world standards. The populations we admit for procedures are now “older and sicker”; “futile care” and “non-beneficial care” have become common words in health lexicons. “Too much medicine” is a common criticism of many universal health systems, yet there is little discussion to address perverse funding incentives for inappropriate care.

Are we so blind to these inappropriate health developments that we cannot change funding incentives that support them? Should we consider “stop” or “limitation” rules?

There are many very positive recommendations coming from the principles and rules committee, and while their work is commendable, it is nonetheless conservative and lacking in big picture considerations. Turning a blind eye to critical environmental issues which influence MBS expenditure is not ambitious and not where our health system needs to travel. Without consideration, it’s doubtful that value and affordability of Medicare can be maintained.

The committee reports can also be similarly evaluated, that is, despite significant analysis of MBS use, defunct procedures and claiming practices, it is debatable whether this will result in effective change. The outputs produced would raise doubts as to whether some of these committees have the capacity, expertise or necessary independence to make these decisions.

Problematic for all committees is the standard of evidence required for procedures and investigations to justify continued inclusion and financial support from the MBS. The benchmark of being “consistent with contemporary best practice and the evidence base where possible” is simply not a valid standard. For example:

• How do we decide what preventive health interventions are funded by the MBS? Why should antenatal mental health screening be funded before other evidence-based preventive health screens?
• The epidemic of overdiagnosis and overuse stems from our funding for procedures and investigations that help with diagnosis, rather than providing a proven health benefit for patients – spinal imaging being a classic example. Proven health benefit from procedures and interventions should be the standard for MBS funding.

There needs to be strict governance regarding this. Unless standards are established, agreed and robustly applied, we will continue to experience difficulties funding interventions like capsule endoscopy or imaging modalities.

There is a known lack of health outcomes evidence for most radiologic procedures, yet medical imaging is a major reason for growing MBS expenditure. While the report rightly expresses concern at the amount of computed tomography scanning occurring, the radiology committee is only focusing on three small areas: dual energy x-ray absorptiometry scanning, imaging of the knee, and diagnosis of deep vein thrombosis and pulmonary embolism. This subcommittee is off course.

Ensuring that radiologists undertake their responsibilities to reduce inappropriate imaging; time-based payments for ultrasound, limiting cascade imaging, and broad reduction of all unnecessary and expensive imaging would seem to be more pressing issues for this committee to address.

National concern regarding the number of funded endoscopies and large variations (up to 30 times) in use did not convince the expert committee that scopes were necessarily excessive or inappropriately costed. They proposed new items at a “cost neutral” position to government and also requested additional funding to support further procedures. The committee is evading facts of financing, that payments for relatively short procedures are excessive.

Both these committee reports expose the MBS review to criticism of whitewashing or protection of financial gravy trains.

Ensuring consumer participation is long overdue and is a welcome development. The release of general practice data and allied health feedback with the interim report was medico-politically naive. The report appears to reinterpret “low value care”. No longer were expensive and unnecessary procedures the problem, but rather “low value” administrative GP services.

The medical and lay press leapt on the material and reported low-value general practice services as a cause for major Medicare overexpenditure. The Royal Australian College of General Practitioners reacted with a terse official response claiming unfair targeting and questioning the impartiality of the review.

Tensions were compounded by references in the report to MBS performing suboptimally in facilitating access to specialists. Individual GPs launched a social media campaign (#justaGP) venting the frustrations of practising as a GP in a system which seemed to continually value and reward other types of care. Having half the profession offside is not an optimal outcome for the review so early in the process.

Overall however, at “the end of the beginning” Professor Robinson, chair of the taskforce, can be justifiably pleased. There are signs the review has glitches, but these can be corrected. Whether the review will be seen as an ambitious or perfunctory effort, whether it will deliver, will depend on a refocus on strategic priorities at this point. Funding and reform go hand in hand, and a more calculated oversight is needed to ensure maximal benefit out of this MBS review opportunity.

Dr Evan Ackermann is a GP at the University Medical Centre, Southern Cross University, Gold Coast, Queensland, and the chair of the Royal Australian College of General Practitioners Expert Committee – Quality Care.

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