MBS review changes to phototherapy items

BY DR ANDREW MILLER

From November 1, the MBS review has brought a change to the ultraviolet phototherapy items, consolidating them into one item 14050 with imposed conditions.

It has become clear that there has been both an implementation and a communication failure regarding these changes and all GPs claiming these items since November 1 have had rebates refused. As a result of an intervention from the Australasian College of Dermatologists (ACD), the Department has agreed to reconsider these claims, where the necessary documentation regarding Dermatologist supervision is present, and allow them to be resubmitted. The ACD also requested a moratorium of three months on compliance implementation to allow affected GPs to make the necessary arrangements. This has been refused by the Department, however the AMA will continue to argue this case.

Poor communication has led to affected GPs being unaware of the impending changes. This is a time of frenetic activity in the MBS Review, with numerous cascading recommendations flooding stakeholders, in this instance GP organisations, and clearly overwhelming their capability to appropriately inform their constituencies.

In the instance of the changes to phototherapy items, there is an obvious need for receipting practices to be changed but this needs to be supported by a reasonable lead-in period. The Dermatology, Allergy and Immunology (DAICC)MBS Review working group recommended a grace period which the Department has chosen not to apply, which the ACD supported because of concerns particularly for patients in rural or remote areas, or in areas of Dermatology workforce shortage where appropriate support from a Dermatologist may be difficult to arrange, in the time made available before the changes were put in place.

In the meantime, information on the change is below:

14050

UVA or UVB phototherapy administered in a whole body cabinet or hand and foot cabinet including associated consultations other than the initial consultation, if treatment is initiated and supervised by a specialist in the specialty of dermatology

Applicable not more than 150 times in a 12 month period

TN 1.14

A component for any necessary subsequent consultation has been included in the Schedule fee for this item. However, the initial consultation preceding commencement of a course of therapy would attract benefits.

Phototherapy should only be used when:

· Topical therapy has failed or is inappropriate.

· The severity of the condition as assessed by specialist opinion (including symptoms, extent of involvement and quality of life impairment) warrants its use.

Narrow band UVB should be the preferred option for phototherapy unless there is documented evidence of superior efficacy of UVA phototherapy for the condition being treated.

Phototherapy treatment for psoriasis and palmoplantar pustulosis should consider the National Institute of Health and Care Excellence’s Guidelines at https://pathways.nice.org.uk/pathways/psoriasis

Involvement by a specialist in the specialty of dermatology at a minimum should include a letter stating the diagnosis, need for phototherapy, estimated time of treatment and review date.

First ever multi-drug Ebola trial for the Congo

The Ministry of Health of the Democratic Republic of the Congo (DRC) has announced that a randomised control trial has begun to evaluate the effectiveness and safety of drugs used in the treatment of Ebola patients.

The trial is the first-ever multi drug trial for an Ebola treatment. It will form part of a multi-outbreak, multi-country study that was agreed to by partners under a World Health Organisation (WHO) initiative.

Until now, more than 160 patients have been treated with investigational therapeutics under an ethical framework developed by WHO, in consultation with experts in the field and the DRC, called the Monitored Emergency Use of Unregistered and Investigational Interventions (MEURI).

The MEURI protocol was not designed to evaluate the drugs. Now that protocols for trials are in place, patients will be offered treatments under that framework in the facilities where the trial has started. In others, compassionate use will continue up to the time when they join the randomisation. Patients will not be treated noticeably differently from before, though the treatment they receive will be decided by random allocation. The data gathered will become standardised and will be useful for drawing conclusions about the safety and efficacy of the drugs.

“Our country is struck with Ebola outbreaks too often, which also means we have unique expertise in combatting it,” said Dr Olly Ilunga, Minister of Health of the DRC.

“These trials will contribute to building that knowledge, while we continue to respond on every front to bring the current outbreak to an end.”

In October, WHO convened a meeting of international organisations, United Nations partners, countries at risk of Ebola, drug manufacturers and others to agree on a framework to continue trials in the next Ebola outbreak, whenever and wherever that is. Over time, this will lead to an accumulation of evidence that will help to draw robust conclusions across outbreaks about the currently available drugs, and any new ones that may come along.

At the heart of the long-term plan and the current trial is always the goal to ensure that patients with Ebola and their communities are treated with respect and fairness. All patients should be provided with the highest level of care and have access to the most promising medications.

The current trial is coordinated by WHO, and led and sponsored by the DRC’s National Institute for Biomedical Research (INRB), in partnership with the DRC Ministry of Health, the National Institute of Allergy and Infectious Diseases (NIAID) which is part of the United States’ National Institutes of Health, The Alliance for International Medical Action (ALIMA) and other organisations.

Building tolerance may beat peanut allergy

Peanut allergy sufferers have been given new hope following the results of a landmark study.

Children diagnosed with a severe allergy took part in a trial where they were given increasing amounts of peanut protein over a year.

The trial found that participants not normally able to tolerate exposure to even a tenth of a single peanut could eventually cope with two whole peanuts.

It is believed that by gradually building up tolerance levels, allergy sufferers could protect themselves from accidental exposure.

Researchers from Evelina London Children’s Hospital and King’s College London took part in a study which suggests immunotherapy treatment, already used to treat pollen and bee sting allergies, could protect people from life-threatening reactions.

The PALISADE study recruited nearly 500 children aged four to 17 from the US and Europe to take part in the largest-ever peanut allergy treatment trial.

Participants were split into groups who received either a capsule of peanut protein or a dummy powder.

Doses were gradually increased every two weeks for a period of six months, before continuing on a “maintenance dose” of peanut for a further six months.

The results, published in the New England Journal of Medicine, found about two-thirds (67 per cent) of children and teenagers could tolerate at least 600mg of peanut protein, compared with just four per cent of participants on the dummy placebo.

Professor George du Toit, paediatric allergy consultant at Evelina London and the study’s chief investigator, said: “Peanut allergy is extremely difficult to manage for children and their families, as they have to follow a strict peanut-free diet.

“Families live in fear of accidental exposure as allergic reactions can be very severe, and can even lead to death.

“Until recently there has been nothing to offer peanut allergy sufferers other than education around peanut avoidance and recognition and self-treatment of allergic reactions.”

Peanut allergy, a potentially life-threatening condition, has doubled over the last two decades and affects about 1 in 50 children in the UK.

Funding boost for microbiome research

Cutting-edge research into the gut microbiota is set to receive a significant funding boost from the federal government, allowing researchers to potentially unlock more mysteries of this new frontier of medicine.

Prime Minister Scott Morrison has committed $4 million to the UNSW’s Microbiome Research Centre (MRC) based at St George Hospital. The MRC, which is set to open in February 2019, is a collaboration between UNSW, the St George and Sutherland Medical Research Foundation, and the South Eastern Sydney Local Health District.

“What is happening in Australia is innovative, visionary and specialised. I never cease to be excited about the science community and how passionate the science community is.”

“The studies being done on the impact of the microbiome in mothers, infants and the future health of Australian children – that’s exciting”, Mr Morrison said at the time of the announcement.

What we know about the microbiome and the role it plays in our health

Professor Emad El-Omar, professor of medicine at the St George and Sutherland Clinical School and director of the MRC, told doctorportal that the funding boost would allow critical research to be undertaken in this “new frontier of medicine”.

“We’ve known about it for many years, but in the last decade is where we’ve seen a dramatic advancement in technology that has allowed us to study the microbiome better and better design studies to look at these trillions of bugs that live on us, within us, and contribute to normal health.”

“People are also becoming more aware of the impact the gut microbiome has on metabolism, the immune system, and how all of this could be implicated in many diseases.”

Professor El-Omar said that “probably the most basic thing we’ve discovered is having that normal microbiome, which is acquired in the first years of life, sets the barometer correctly for the rest of your life because it educates your immune system and allows you to have normal interactions with environmental exposures.”

Funding will support three research initiatives on the microbiome

The $4 million funding boost will go towards supporting three key areas at the MRC. The first is to enhance the bioinformatics capacity of the centre, which will be crucial to the success of the MRC. “We want this capacity to be fully integrated with our team, so we can understand the clinical questions and the biological questions we’re looking at”, Professor El-Omar said.

The MRC will look at the role the microbiome has in pregnancy and how this influences outcomes for mother and baby. “What we’re talking about here is being able to look at the microbiome and predict adverse events.”

“The idea is that you’d be able to define a signature that will tell you if someone is at increased risk of diabetes or pre-eclampsia, and this would allow us to pre-emptively change the future”, Professor El-Omar said

The MRC will also be conducting more research into the healthy microbiome and what this looks like.

“If we want to change the microbiome, we need to know what we want to change it to and what we’re aiming for. This study will hopefully tell us what the target is for any type of manipulation”, Professor El-Omar said.

Health records in the USA

It seems that the challenge of achieving broad acceptance of an electronic health record – for privacy, clinical, security, or technical reasons – is not confined to Australia.

CNBC reports that one of the biggest and most overlooked problems in the US health system is that patients still find it too hard to share their medical information between doctors, especially those working in different hospitals.

It’s a huge problem for many reasons. It makes it harder for consumers to access the highest-quality care, and new patients who walk into a hospital are like strangers – caregivers won’t know if they have an allergy or a chronic disease.

But some of the largest technology companies in the world announced in August that they are undertaking a new effort to fix that. And they have a good reason to do it, as the lack of open standards around health data is a huge barrier for them to get into the $3 trillion health system.

Tech giants – Alphabet, Amazon, IBM, Microsoft, and Salesforce – released a joint statement, saying that:

We are jointly committed to removing barriers for the adoption of technologies for healthcare interoperability, particularly those that are enabled through the cloud and AI. We share the common quest to unlock the potential in healthcare data, to deliver better outcomes at lower costs.

These companies are rivals in some important ways, so it’s a strong signal that they came together on this issue.

To address the problem, these tech companies are proposing to build tools for the health community around a set of common standards for exchanging health information electronically.

Allergy funding not to be sneezed at

The Federal Government has announced it will invest more than half a million dollars in projects to improve the lives of Australians who live with allergies.

It will fund projects identified as part a National Allergy Strategy, which was developed by the Australasian Society of Clinical Immunology and Allergy and Allergy and Anaphylaxis Australia.

Projects include development of standardised food allergy content to be included in all accredited food hygiene courses, and the development of online resources for teens and young adults with allergies to share their experiences.

Another project will determine how to improve access to care for people with allergic conditions, particularly those in rural and remote areas.

Allergies can have significant adverse effects on the quality of life and overall health of people, and affect about 20 per cent of the Australian population living with allergies.

About 4.5 million Australians are affected by hay fever and allergic rhinitis, while one in 20 Australian children and one in 50 adults has a food allergy.

Getting the right My Health Record

AMA PRESIDENT DR TONY BARTONE

For well over a decade, successive Australian governments have worked to make an electronic health record a reality.

The AMA and the medical profession have been strong supporters of such a record. It promises greater efficiencies in recording, storing, and sharing vital health information. But it must be the right record – one that combines a safe, single record of a patient’s health information with the necessary privacy and security systems in place.

There is a lot of misinformation around now, and people concerned fears of hacking and third-party access to files, but we continue to be assured that the current My Health Record model offers all the relevant protection.

The finite benefits far outweigh the possible concerns. It is a great asset for the health system.

If health care was simple and predictable, and if a patient only ever needed clinical treatment from a single, regular clinician, we would not need a My Health Record at all. The patient’s doctor would have all the patient’s clinical information in their own clinical software on the desktop.

But patients’ lives are more dynamic and unpredictable than this. Emergencies happen. Each patient will be seen by many different doctors for different reasons at different times, and will be treated in multiple settings.

As well as their GP, patients might be treated in hospital, see specialists and allied health professionals, be referred by different doctors to different pathology labs and diagnostic imaging providers. These realities mean that each doctor who treats the patient doesn’t currently have a clear overview of the range of treatments the patient has received.

The My Health Record will help connect care across the health system and start to address the treatment fragmentation.

The multiple doctors and allied health professions who all treat the same patient at various points in time will be able to access a summary of relevant patient clinical data at the time of treatment – irrespective of the clinician’s specialty or physical location in Australia. The result will be safer, faster, and more efficient health care.

We would see a reduction in things like medical harm due to anaphylaxis because clinicians other than the patient’s usual doctor can access the patient’s records quickly and efficiently no matter the location.

The electronic record can save lives. A Brisbane GP recently told a Senate inquiry how the earlier version of the My Health Record saved the life of one of his patients.

He said that the hospital was able to access the information that was in that electronic record and made the decision not give the diabetic patient, who was in a coma, the usual antibiotic that would have been administered for sepsis. This person had a severe anaphylactic allergy to that antibiotic and, if it had been given, would have been killed. That is a powerful example of the value of an electronic health record.

The electronic record will also go a long way to addressing the intractable problem of delayed or non-existent handovers of admitted patients to their GPs on discharge.

It will reduce medical harm due to polypharmacy, which is a big issue. There are an estimated 230,000 hospital admissions costing over $1.2 billion annually due to medicine misadventure in Australia.

My Health Record should also deliver increased efficiencies and reduced waste. Treasury estimates suggest savings of around $123 million by 2020-21 by eliminating avoidable duplicated pathology tests, diagnostic images, and averted medical misadventures.

We have come a long way over the last decade. There has been considerable consultation and trialling to get things right – and safe. We must push ahead with this My Health Record.

This article was first published in Fairfax newspapers on 24 July 2018

Your patients’ health in their hands

Information for AMA Members from the Australian Digital Health Agency about My Health Record.

By Professor Meredith Makeham

Australians are being offered an important choice over the next three months about how they want to interact with their health information.

By the end of 2018, all Australians will have a My Health Record created for them, unless they choose not to have one.

The decision, importantly, is theirs to make after considering the benefits of having immediate online access to their health and care data, and being able to share it with their clinicians.

They will have access to information such as their medicines and allergies, hospital and GP summaries, investigation reports and advance care plans which could not only save their life in an emergency but also help their clinicians find vital information more quickly so that they can make safer health care decisions.

Trusted health care providers – GPs, specialists, pharmacists and others – are likely to find their patients want to talk to them about their decision. The My Health Record system is here to support better, safer care – not to replace current clinical record keeping systems or professional communication. Neither will it replace the patient-doctor relationship and clinical judgement. It is simply a secure online repository of health data and information that wouldn’t be accessible otherwise.

The data flows into the record from securely connected clinical information systems in hospitals, general practices, pharmacies, specialists’ rooms, and pathology and radiology providers. It also provides access to Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) data, the Australian Immunisation register and the Australian Organ Donor registry.

People understandably want reassurance that the Australian Digital Health Agency (the Agency) holds the privacy and security of their health information as its first priority. The system’s security has not been breached in its six years of operation. There is no complacency however – My Health Record system security operates to the highest standards, working with the Australian Cyber Security Centre and others. It is under constant surveillance and threat testing.

The legislated privacy controls are world-leading and easily accessed on the consumer portal. They include features such as a record access control – similar to a PIN – that a person can apply to their entire record so it can’t be viewed unless shared with their clinician. In an emergency, the legislation allows a clinician to ‘break glass’ and see vital medicines and allergy information. However, all instances of this are audited and people can choose to receive a text or email informing them if this happens.

The steps required for a healthcare practitioner to view a My Health Record require a number of security authentications to take place. For a provider to access the My Health Record via their clinical information system, they must be a registered health care provider – for example, registered with the Australian Health Practitioner Regulation Agency. They must also have a valid provider identifier and work in an organisation with a valid organisational identifier.

Software must be conformant, with a secure and encrypted connection to the My Health Record system. In addition, the patient must have a record on the provider’s clinical information system as a patient of the practice.

The Agency has not and will not release documents without a court/coronial or similar order. No documents have been released in the past six years and no other Government agencies have direct access to the My Health Record system.

We know 230,000 hospital admissions occur every year as a result of medication misadventure, costing the Australian taxpayer $1.2 billion annually. Many of these could be avoided if people and their clinicians had better access to vital medicines and allergy information.

The ‘Medicines View’ is a recent addition to My Health Record. It provides a consolidated summary of the most recent medicines information from notes entered by GPs, hospitals, pharmacies and consumers.

Over the past 12 months, the system has enriched its clinical content. Public and private pathology and imaging providers are now connecting and a vast increase in connected pharmacy systems as well as hospitals has occurred. This will accelerate the realisation of benefits as clinicians find they can access a more comprehensive source of information within the My Health Record system.

This month, a national communication plan was launched to ensure Australians are well informed when making their decision. Almost 20,000 My Health Record education kits were distributed to GPs, community pharmacies, aboriginal health services, post offices and public and private hospitals.

Our role as health care providers is to be our patients’ advocate, to support them in making the decisions and choices that will lead to better health outcomes and ensure that they have access to safe and effective care. My Health Record isn’t here to solve all of our problems, but it is an important step forward in our ability to deliver a safer and better-connected healthcare system.

Clinical Professor Meredith Makeham is Chief Medical Adviser of the Australian Digital Health Agency.

[Correspondence] Alpha-chain disease: a lymphomagenesis model

Science is generally more interested in exploring the unknowns and mysteries of the present and future than in commemorating events of the past. However, recalling certain works (ie, apparent breakthroughs in their given field at the time of publication) to measure their contributions and the progress made over the ensuing years, can be useful. In this case, alpha-chain disease is of paramount interest. Thanks to the exemplary collaboration between a clinician, Jean-Claude Rambaud, and a physician scientist in immunology, Maxime Seligmann, the discovery in 1968 of alpha-chain disease1,2 in a young Syrian woman with an abdominal lymphoma led to game-changing outcomes over the following 50 years, including a model of lymphomagenesis that is still in progress.

GPs to retain access to MBS item 30202

Following representations from the AMA, it has now been confirmed by the Department of Health that GPs will not be precluded from accessing MBS item 30202.

In response to questions from the AMA, the DoH has stated that the MBS Taskforce response to the recommendations of the Dermatology, Allergy and Immunology Clinical Committee had been misreported in the Taskforce’s finding on the website. The reported change to MBS item 30202 would have seen GPs, the predominant users, excluded from claiming the cryotherapy item for removing malignant neoplasms.

The Clinical Committee recommended that the descriptor for MBS item 30202 be amended to replace “specialist” with “Australian Medical Council (AMC) recognised dermatologist”. It was also recommended that the Department of Health should monitor high-volume users to ensure that providers were requesting the appropriate pathology tests to confirm malignancy. At no point was it recommended that GPs be excluded from claiming the item.

However, the material that was released was inconsistent with this and suggested that the MBS Taskforce had recommended to Government that the descriptor be amended to restrict the use of this item to AMC recognised dermatologists and plastic surgeons to support appropriate use of the item and improve patient safety.

The DoH has now acknowledged the concerns raised by the AMA about the potential impact of the change and has confirmed an error was made during the publication of the taskforce’s findings. This will be corrected and amendments to the item descriptors will ensure GPs retain access to this item.

Many GPs, particularly those in rural areas, will be relieved that appropriate patient treatment will not have to be delayed for an unnecessary specialist referral.

MICHELLE GRYBAITIS