The AMA last month convened a high-level Roundtable of the medical colleges, associations, and societies to discuss the profession’s involvement in, and response to, the Government Reviews of items on the Medicare Benefits Schedule (MBS).

The meeting was attended by over 70 people, representing 53 organisations.

Professor Bruce Robinson, Chair of the MBS Review Taskforce, made a presentation to the meeting and responded to questions from the floor.

Following the meeting, AMA President Professor Brian Owler wrote to Health Minister Sussan Ley to inform her that the profession would be united in its response to the Reviews, and outlined some of the major concerns arising from the meeting.

Here is the text of that letter …

I am writing to you to set out broad concerns with the Medicare Benefits Schedule (MBS) Reviews: the broadened scope that will impact long standing arrangements; the composition of the review working groups; and that new items are out of scope.

The AMA is concerned that the Reviews will be undertaken in the absence of an overarching vision and specific direction for the Australian healthcare system to guide the final outcomes. 

In addition, as there are no specific and quantifiable aims, other than delivering better patient outcomes, there is a risk that the scope of the reviews will extend into dangerous territory, whereby the fundamental structure of our healthcare system will be interfered with.

The latter was highlighted in Professor Bruce Robinson’s presentation to a forum of the medical colleges, specialist associations, and societies convened by the AMA on 19 August 2015 to discuss the medical profession’s involvement in the MBS Reviews.  Professor Robinson made a presentation to the group and very generously answered all of the participants’ questions.

We learnt that the Reviews will now also consist of groups to review “macro issues and rules”, and that this will consider issues such as referral arrangements and the potential removal of surgical assistance fees. We heard that patients find it inconvenient to visit their GP for a referral to a specialist. Given that the referral arrangements are the most fundamental feature of our healthcare system, providing the gateway to clinically necessary tertiary care, it is incredible that such a change might be contemplated in an environment where Government wants to reduce expenditure. 

In addition, the surgical assistance fees support the very basis of vocational training in Australia. Removal of them will have a significant impact on the training opportunities and therefore the future medical workforce. It is equally incredible that a change to these arrangements is being contemplated.

On both these issues it is not clear what the objective is, and therefore why they would even be on the table for review.

The 70 participants representing 53 medical organisations at the AMA forum were extremely vexed by this latest turn of events.

Working groups

The profession is very concerned that the working groups will not comprise a representative from the relevant specialist college, association or society. While working group members will be able to “confer with colleagues”, it is more appropriate for professional organisations to be formally included in the working groups. We believe this is critical to professional buy‑in to the outcomes of the Reviews, as well as continuity of the professions’ participation in the ongoing maintenance and management of the MBS into the future. 

Further, there are potential problems with the members of the in-scope speciality discipline comprising less than 50% of the working group numbers, with decisions to be made using a >60% majority. The equation has the potential to arrive at incorrect outcomes because the members of the speciality discipline with the knowledge and expertise will be in the minority. We appreciate the need to transparently manage conflicts of interest, but this should not be at the expense of arriving at sensible outcomes in the decision making process. 

New items

The medical profession supports an MBS that facilitates patient access to evidence based modern medical procedures and practice. This cannot occur if the review process is limited to removing obsolete and infrequently used items, and working groups are not able to consider and recommend the inclusion of new items on the MBS. While there is scope to update items, this may not always be the best way to bring the MBS up to date, and the objectives of the Reviews will be only partly achieved. 

In many cases, completely new items for procedures that have evolved in the 20+ years since they were first included on the MBS will be the only sensible outcome. If this is not resolved, the Reviews could thwart patient access to services that have been provided for several years even though they are not explicitly catered for in existing items. If the rapid review questions are appropriately framed, these services should be substantiated by the relevant literature.

There must be capacity to include new items on the MBS as a result of the reviews, which does not involve a full health technology assessment and consideration by the Medical Services Advisory Committee.

Professor Brian OwlerAMA President

Based on discussions at the MBS Roundtable, the AMA compiled the following list of issues for medical colleges, associations and societies to consider and discuss in preparing for the Reviews.

1.         Identify how the MBS should be changed to reflect current practice

• Identify current practice for specific services.
• Describe those services and the clinical circumstances for which they are intended.
• Identify how the MBS currently covers those procedures.
• Determine what is needed for the MBS to properly reflect current practice.
• Identify services that are new due to ‘evolution’ and therefore require an update to the item descriptor compared to ‘novel’ services where there is new technology used.
• Identify the time period in which the ‘novel’ service/s was introduced in your practice.
• Identify items that can be deleted and the reasons for deleting them.
• Frame the questions that will form the literature review.
• Determine what data you need to demonstrate/inform the changes.

2.         Identify the key participants

• Identify who of your colleagues is best placed to represent you.
• Identify the craft groups that also provide the services.
• Identify the craft groups that do not provide the services, but whose clinical practice might be affected.
• Anticipate how they might respond.

3.         Identify other issues

• Are there quality considerations?
• Are there compliance issues?
• What are the likely impact on business structures of the changes and what transition is needed?

4.         Guiding principles for participating in the reviews

• Ensure services support best practice, provides value for public expenditure and supports quality, safe and effective care that is appropriate to the patient’s needs and circumstances.
• Avoid limiting services to specific specialties, expertise, scope of practice, credentialing, and/or endorsement arrangements.  If there are safety and quality issues, consider how these can be best dealt with i.e. medical registration and/or hospital credentialing arrangements.
• Accept the MBS rebates are inadequate. The reviews are not the vehicle to address inadequate rebates, and certainty not at the expense of another specialty group.
• Share information about the reviews to ensure consistent outcomes and clinician participation throughout the review process.

The MBS Review Taskforce is seeking nominations from clinicians to participate in clinical committees and working groups. The Taskforce is seeking people who have sound clinical knowledge and experience, are committed to interpreting evidence and research, and are interested in furthering the objectives of the Review. Nominations can be made to MBSReviews@health.gov.au providing the name, position, clinical expertise, and email contact.