tag:theconversation.com,2011:/us/topics/mbs-review-16485/articlesMBS review – The Conversation2017-06-09T02:54:27Ztag:theconversation.com,2011:article/791082017-06-09T02:54:27Z2017-06-09T02:54:27ZOur study found after-hours GPs actually do reduce visits to emergency rooms<figure><img src="https://images.theconversation.com/files/172862/original/file-20170608-29582-z9b77j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Supporters of after-hours GP services say they reduce pressure on emergency rooms.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>A taskforce reviewing more than 5,700 items covered by the Medicare Benefits Schedule (MBS) released a <a href="http://www.mbsreview.com.au/reports/after-hours-report_1.html">preliminary report</a> this week on urgent after-hours GP services funded through the MBS.</p>
<p>The government-appointed taskforce reviewed these services amid <a href="http://www.smh.com.au/national/health/boom-in-afterhours-gps-raises-concerns-about-medicare-cost-blowout-20160511-gosr95.html">growing concern</a> doctors were inappropriately using the “urgent” item (<a href="http://www.healthygc.com.au/MedicareLocal/media/Site-Pages-Content/PHCIP/MBS-Quick-Guide-2014-No-Fees.pdf">number 597</a>) to bill Medicare, as it attracts a higher rebate than a standard consultation. Most commonly, the focus was on the inappropriate use of this item by <a href="http://www.namds.com/namds-mds-definition.html">medical deputising services</a> (MDS) – companies that employ registered medical practitioners to provide after-hours care. </p>
<p>The taskforce recommended <a href="http://www.mbsreview.com.au/factsheets/after-hours-factsheet.pdf">greater guidance</a> on when and why urgent after-hours items should be used; and restrictions on the use of these items to GPs working predominantly in normal business hours who might be called out to see their patients in an after-hours emergency.</p>
<p>Supporters of after-hours home medical services say the growth in Medicare claims associated with urgent, after-hours GP services reduces government spending as fewer people use emergency departments. The taskforce panel stated it was:</p>
<blockquote>
<p>… not convinced by arguments that the growth in use of urgent after-hours home visits has had a significant impact on hospital emergency department services.</p>
</blockquote>
<p>However, the results of our independent research suggest otherwise. In our survey of patients who had used deputising services, nearly half of them reported they would have attended an emergency room had an after-hours GP been unavailable.</p>
<h2>What our study found</h2>
<p>The number of <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/primary-ahphc-review">government-approved deputising providers</a> has grown from 16 in 2006 to 83 in 2014. Research has <a href="https://theconversation.com/after-hours-gp-home-visits-strain-the-budget-and-dont-help-emergency-departments-77462">also shown a rapid increase</a> in claims reported for all after-hours Medicare items. Calculations by some researchers found the <a href="https://theconversation.com/after-hours-gp-home-visits-strain-the-budget-and-dont-help-emergency-departments-77462">number of claims for item 597 increased</a> by 170% between 2010-11 and 2015-16.</p>
<p>Previously reported research in the <a href="http://www.racgp.org.au/afp/">Australian Family Physician</a> showed that, rather than reducing the need to visit the emergency department, the rise of deputising services has been accompanied by a slight increase in visits. This is in stark contrast to what we found.</p>
<p>Our research, published in the journal <a href="https://academic.oup.com/fampra/article-abstract/doi/10.1093/fampra/cmx038/3794258/Patient-reported-impact-of-after-hours-house-call?redirectedFrom=fulltext">Family Practice</a>, explored whether after-hours home visits had an effect on patients’ use of emergency department (ED) services in Australia.</p>
<p>The study was based on a survey of patients seen after hours by home doctors from MDS companies over the last week of January 2016. We reached out to all the registered MDS companies in Australia at the time of the survey, and identified eligible patients among those who agreed to participate. Anonymous questionnaires were sent out to these patients. We received a total of 1,211 valid responses.</p>
<p>We had no preconceived idea of what we might find. It is worth noting that our study design allowed for possible findings of either an increase, a decrease, or perhaps no impact at all on ED presentations.</p>
<p>Around 40% of our survey respondents (that is 486 patients) stated they would have gone to the ED on the day or night they used the after-hours home service had the service not been available to them. But we also found that, following the after-hours doctor visit, 103 patients, or 8.5% of the total seen, still ended up going to the ED (for the same ailment) within one week of being attended to. </p>
<p>This means 383 patients did not go on to use ED services, a decrease of 78.8% relative to the original 486. We found this decrease was Australia-wide and cut across all patient demographics.</p>
<p>Our findings show that after-hours home doctor services do have a significant impact on reducing the use of ED services in Australia, from the patient’s perspective at least.</p>
<h2>Why use a patient survey?</h2>
<p>Surveying the consumers of a particular service is an <a href="https://bmchealthservres.biomedcentral.com/articles/10.1186/1472-6963-13-22">effective method</a> of exploring its impact. Patients, or consumers, relay what their intentions were in using the service, what their options were, and how they rate the services received. In the case of the after-hours services, we believed the patients would give the best indicator of what they might otherwise have done had the service not been available to them. </p>
<p>We do acknowledge our approach may be limited in that it relies on self-reporting by the patients. This may introduce some elements of bias and potential accuracy issues, as they would have to recall their intentions and actions prior to and after the consultations with the after-hours doctors. This is why we conducted the survey within one week of the service the patients received. Our questionnaire also made clear the response was specific to the service received in the stated time.</p>
<p>Ours is the first study in this area using a patient-centred approach. Most publications, looking at the <a href="http://journals.sagepub.com/doi/abs/10.1177/2150131911408431">impact of after-hours care</a> on ED presentations, either rely on ED <a href="http://emj.bmj.com/content/27/1/22">records over time</a>, or on Medicare billing data, to make assumptions about correlation. Findings based on these other methods may claim any identified increase or decrease in ED presentations could be attributable solely to the existence of after-hours services. </p>
<p>This is despite the fact other factors might influence these figures in that same period. For instance, periodic outbreak of illnesses, such as the recent “thunderstorm asthma” outbreak in Melbourne, might increase ED attendances, while the establishment of other medical services (such as telephone medical services or office-based after-hours services) might decrease such presentations. </p>
<p>Some of these studies also don’t differentiate the severity (acuity) of the ailments of the patients in their analysis. After-hours home doctors generally see patients who are not severely sick (called low-acuity patients). These can include those experiencing vomiting, minor wounds, moderate pain or shortness of breath (<a href="http://www.bhi.nsw.gov.au/__data/assets/pdf_file/0016/170620/Examples_of_triage_conditions.pdf">classified in EDs</a> as categories 3 to 5). So, any survey of the impact of after-hours GP services on ED presentations would need to focus on these categories – for equal comparison.</p>
<p>Most cases in categories 1 and 2 (such as major trauma or heart attacks) would likely call an ambulance, not the after-hours GP. For these reasons, while the approaches of other studies have some merits, we feel that results from such studies may not be wholly reflective of the actual impact of after-hours services. </p>
<p>We recommend the government and other stakeholders commission a larger (and perhaps longer) version of our study. This will provide a first-hand idea of the actual impact of these services, rather than relying on “assumed” impacts.</p><img src="https://counter.theconversation.com/content/79108/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Chris Ifediora is a general practitioner who works a combination of regular-hours and after-hours home visits. He, however, does not own shares in, or receive funding from, any company or organisation that would benefit from this article, and has disclosed no other relevant affiliations beyond the academic appointment with the Griffith University Medical School. </span></em></p>Nearly half of the surveyed patients who had used after-hours doctor services reported they would have attended an emergency room had an after-hours GP been unavailable.Chris Ifediora, Senior Lecturer (Clinical Skills), Griffith UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/713442017-01-18T03:05:33Z2017-01-18T03:05:33ZWhat’s in store for new health minister Greg Hunt?<p>Greg Hunt was today announced as federal health (and sport) minister following Sussan Ley’s expenses scandal and subsequent resignation. Hunt will be the third minister to hold this portfolio since the Coalition was elected in 2013. Successful health ministers need well-honed political skills, a lot of patience and even more backbone for the very public battles needed for real change.</p>
<p>So far, the Coalition has not covered itself with glory in the health portfolio. Ley took over in 2014 from the hapless Peter Dutton – whose main achievement was to unite almost all sectors of health against his plans for co-payments for GP visits. </p>
<p>The freeze on GP payments was inherited from the Gillard government, but now seems to be a permanent part of primary care policy. The pressure on GP earnings creates strong incentives to introduce or increase co-payments. The result will be continued pressure in the sensitive area of bulk-billing rates.</p>
<h2>Implementation of Ley’s many health reviews</h2>
<p>Ley launched a series of major reviews of spending programs – especially the Medicare Benefits Scheme. The proposals from these reviews are now on the table, and Hunt will have difficulty implementing them.</p>
<p>Private health insurance provides one of the government’s most intractable quandaries. Some 20 years ago, then Prime Minister John Howard devised an assistance program to prop up a failing industry. Government subsidies, through the private health insurance rebate, now stand at more than A$6 billion, <a href="https://theconversation.com/is-a-5-6-increase-in-private-health-insurance-premiums-justified-55435">increasing at well over inflation</a> and outstripping wages growth. </p>
<p>Last year Ley pushed funds to reduce their original claims. Hunt will shortly have to consider the next round of increases.</p>
<p>The core problem is costs, especially of hospital services. However, the government abandoned a significant attempt to reduce the costs of prostheses, so that private insurers would pay closer to the much lower prices negotiated by public hospitals. After intense lobbying from the private hospitals and manufacturers that benefit from the current system, these issues were <a href="https://theconversation.com/is-the-investment-in-private-health-insurance-worthwhile-68980">shunted to yet another committee of inquiry</a>.</p>
<p>More broadly, the private health insurance industry has been struggling to find a long term and sustainable place. For the first time since the 1990s, there has been a <a href="http://www.news.com.au/finance/money/budgeting/private-health-exodus-premium-rises-lead-to-membership-decline/news-story/8041d9ffe7d9c6d9f877afeecfd2cd4f">significant decline</a> in the proportion of Australians buying insurance policies. Attempts to broaden its base – such as Medibank’s links with GP services – resulted in a backlash from consumers and medical practitioners.</p>
<p>The costs of unnecessary or low-value medical services has been at the heart of the government’s review of the Medicare Benefits Schedule (MBS) – the list of Medicare payments for services. </p>
<p>A <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)32586-7/fulltext">recent series of articles in the prestigious Lancet journal</a>, with substantial Australian content, has underlined the importance of improving the use of evidence-based approaches and value for money. The Lancet authors have stressed the need for system reform:</p>
<blockquote>
<p>… policies must move beyond the purely incremental; that is, policies that merely tinker at the policy edges after underuse or overuse arises.</p>
</blockquote>
<p>Expert taskforces led by clinicians to review the almost 6,000 MBS items have made detailed recommendations of changes to the use of items and levels of payment. Hunt will need to chart the government’s response to these recommendations. The MBS review has maintained an admirable air of consensus so far. This is unlikely to last as particular areas are singled out for action.</p>
<h2>Primary care trial for 2017</h2>
<p>The other areas of unfinished business offer more prospects. The government’s <a href="https://theconversation.com/time-for-better-chronic-disease-management-in-primary-care-57035">Health Care Homes pilot</a>, commencing in July 2017, is a response to calls for a health system that is more focused on <a href="http://apo.org.au/node/60503">community-level primary care</a>. </p>
<p>The experiment <a href="https://ama.com.au/gp-network-news/ama-calls-adequate-funding-health-care-home">has been heavily criticised</a> for a lack of funding and attempts to micromanage systems that are meant to be increasing GP initiatives. </p>
<p>With more political commitment, it could shift Australian health care towards rewarding prevention and more effective management of chronic illness. The alternative is expensive, disconnected high-tech patches to a system <a href="http://www.publish.csiro.au/AH/pdf/AH14087">increasingly inaccessible to ordinary consumers</a>.</p><img src="https://counter.theconversation.com/content/71344/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jim Gillespie has receives funding from Western Sydney Primary Health Network and NSW Ministry of Health.. </span></em></p>Sussan Ley launched a series of major reviews of health spending programs. The proposals from these reviews are now on the table, and Greg Hunt will have a series of difficult tasks in implementation.Jim Gillespie, Deputy Director, Menzies Centre for Health Policy & Associate Professor in Health Policy, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/653362016-10-04T23:44:21Z2016-10-04T23:44:21ZFactCheck: Is suicide one of the leading causes of maternal death in Australia?<figure><img src="https://images.theconversation.com/files/140227/original/image-20161004-20213-o9fhmq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Suicide is uncommon during pregnancy -- it occurs more frequently when a pregnancy is over.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/mikel450/7544423608/in/photolist-cuF9i7-rQVijN-6eunts-kAQebc-hfoPc3-8uW4Ee-3wd6ZE-3GSarN-6KUZPG-8dbGLR-npGxaH-79TMC2-9w296Q-aM9d4R-q6L74n-aKH57z-9k2sRG-qQFizY-9G1H4N-ahjewq-3aqnNy-4ZETCg-akNWYh-M9sRY-34wTCm-deFesQ-6ShhSr-oMnyps-M9Ae6-M9sQE-3aqnpj-owUwSb-M9tVb-47gCiJ-3ESukT-6XmKNK-3akRov-6qnV3k-3akQLr-aM9fF8-emcipD-M9u1C-j4wBu-hpsHQ1-M9sSU-6uZESC-2V17Zw-3aqnrd-doDzxQ-h5rET3">Mikel Garcia Idiakez/flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span></figcaption></figure><blockquote>
<p>The Committee notes that … suicide has become one of the leading causes of maternal death in Australia. – The Obstetrics Clinical Committee, <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/24913E0474E75768CA2580180016A033/$File/MBS-Obstetrics.pdf">report</a> to the <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/MBSReviewTaskforce">Medicare Benefits Schedule Review</a>, August 2016.</p>
</blockquote>
<p>The federal government’s <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/MBSReviewTaskforce">Medicare Benefits Schedule review</a> is well underway. Teams of clinicians are looking at more than 5,700 items on the Medicare Benefits Schedule (MBS) to see if health services are up to date and in line with the latest clinical evidence.</p>
<p>In its <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/24913E0474E75768CA2580180016A033/$File/MBS-Obstetrics.pdf">report</a> for the review, the Obstetrics Clinical Committee called for changes aimed at ensuring more women were screened for perinatal (meaning the period just before and after birth) anxiety and depression by suitably qualified health professionals.</p>
<p>The committee said suicide has become one of the leading causes of maternal death in Australia.</p>
<p>Is that right?</p>
<h2>Checking the source</h2>
<p>Obstetrics is the branch of medicine and surgery that specialises in the care of women before, during and after childbirth. The <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/MBSR-committees-obstetrics">Obstetrics Clinical Committee</a> is a group of 11 experts commissioned by the federal government to review the obstetrics items on the MBS and report on their findings.</p>
<p>When asked for data to support the assertion, the committee’s chair Professor Michael Permezel referred The Conversation to the Australian Institute of Health and Welfare report <a href="http://www.aihw.gov.au/publication-detail/?id=60129551119">Maternal deaths in Australia 2008-2012</a>.</p>
<h2>Is suicide a leading cause of maternal death?</h2>
<p>Yes. The <a href="http://www.aihw.gov.au/">Australian Institute of Health and Welfare (AIHW)</a> produces the best data on this question. </p>
<p>Its latest <a href="http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129551117">report</a> on the issue, which was the one the committee cited, was released in 2015 and covers the years 2008 to 2012. It shows that suicide is one of the leading causes of maternal death in Australia. If late maternal deaths are included, it is the leading cause.</p>
<p>When we’re talking about this issue, it’s important to distinguish between “maternal death” and “late maternal death”:</p>
<ul>
<li>Maternal death is when a woman dies in pregnancy or within 42 days after the end of any pregnancy</li>
<li>Late maternal death is when a woman dies within 12 months of the end of any pregnancy.</li>
</ul>
<p>In Queensland, suicide is <a href="https://www.health.qld.gov.au/improvement/networks/docs/qmpqc-report-2015-full.pdf">the leading cause of death</a> for women during pregnancy and within 12 months of the end of a pregnancy. Suicide was <a href="http://www.hqsc.govt.nz/assets/PMMRC/Publications/tenth-annual-report-FINAL-NS-Jun-2016.pdf">the leading cause of maternal death</a> in New Zealand between 2006 and 2013, and remains a leading cause today.</p>
<p>Suicide is uncommon during pregnancy – it occurs more frequently when a pregnancy is over. Recent investigations have revealed a high proportion of late maternal deaths are linked to preexisting mental health disorders and what clinicians call “psychosocial distress”. Psychosocial distress is a broad term that covers depression, stress and dissatisfaction with life.</p>
<p>There are standard definitions used worldwide to describe the type, or category, of maternal death: </p>
<ul>
<li>Direct deaths – those directly attributable to the pregnancy, for example, post-partum bleeding</li>
<li>Indirect deaths – when preexisting conditions, such as heart disease, are exacerbated by pregnancy</li>
<li>Incidental deaths – are not usually related to pregnancy, for example, accidents.</li>
</ul>
<p>Suicide, homicide and deaths related to mental health, such as accidental overdose, are described as being due to “psychosocial causes”. </p>
<p>The <a href="http://www.who.int/en/">World Health Organization</a> <a href="http://www.who.int/bulletin/volumes/87/10/09-071001/en/">recently recommended</a> that deaths from psychosocial causes be categorised as “direct deaths” – directly attributable to the pregnancy. This recommendation has not yet been widely adopted. </p>
<p>In Australia, death by suicide is usually categorised as an “indirect” death if there is evidence the mother had a preexisting mental health condition.</p>
<p>Some international reports continue to class deaths by suicide and other psychosocial causes as “incidental” – not related to pregnancy. This means they don’t count towards the maternal mortality ratio, which is the international measure of the number of women dying during pregnancy or within 42 days of a pregnancy ending. </p>
<h2>How many deaths are we talking about?</h2>
<p>The latest AIHW <a href="http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129551117">report</a> on the issue notes:</p>
<blockquote>
<p>Maternal death in Australia is a rare event in the context of worldwide maternal deaths. In 2008–2012, there were 105 maternal deaths in Australia that occurred within 42 days of the end of pregnancy, representing a maternal mortality ratio (MMR) of 7.1 deaths per 100,000 women who gave birth.</p>
</blockquote>
<p>The AIHW data show there were 16 deaths in the psychosocial causes category, of which 12 were due to suicide. Death by psychosocial causes ranked equal first with heart disease. Death by suicide ranked equal second with sepsis, obstetric haemorrhage and non-obstetric haemorrhage.</p>
<p>Australian state and territory data also show suicide to be a prominent feature in maternal death. The <a href="https://www.health.qld.gov.au/improvement/networks/docs/qmpqc-report-2015-full.pdf">latest report</a> by the <a href="https://www.health.qld.gov.au/improvement/networks/qmpqc.asp">Queensland Maternal and Perinatal Quality Council</a> reported on 40 maternal deaths – including late maternal deaths – over 2013 and 2014.</p>
<p>Out of these 40 deaths, 12 (28%) were due to psychosocial causes – making it the largest category. Overall, suicide was the leading cause of maternal death in Queensland in 2013-14.</p>
<p>The <a href="http://www.hqsc.govt.nz/assets/PMMRC/Publications/tenth-annual-report-FINAL-NS-Jun-2016.pdf">most recent report</a> from New Zealand shows a similar picture. Between 2006 and 2013, 24% of maternal deaths were due to suicide. That’s 22 women out of 90 who died by suicide during pregnancy or within 42 days of their pregnancy ending.</p>
<h2>What don’t we know?</h2>
<p>What is unknown is the nature of the relationship between pregnancy and suicide. Not all pregnancies are diagnosed or recorded, especially if a woman is early on in her pregnancy when she dies by suicide. </p>
<p>Despite efforts to capture all deaths in pregnancy and in the postpartum period, experts still don’t know yet the full story. To gain a full understanding of the impact of pregnancy on suicide risk, we would need to compare the suicide rates for women who were or had recently been pregnant, and those who had not.</p>
<h2>Verdict</h2>
<p>The <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/MBSR-committees-obstetrics">Obstetrics Clinical Committee</a> was correct to say suicide is one of the leading causes of maternal death in Australia. If late maternal deaths are included in the analysis, it is the leading cause. <strong>– David Ellwood.</strong></p>
<hr>
<h2>Review</h2>
<p>I have reviewed this article and the author presents a fair and accurate view of the data.</p>
<p>Suicide has also been found to be a leading cause of maternal death in the <a href="http://onlinelibrary.wiley.com/store/10.1111/j.1471-0528.2010.02847.x/asset/j.1471-0528.2010.02847.x.pdf;jsessionid=3E32E4EC9E3834118E826600CD8E6AA5.f04t02?v=1&t=itnslmv2&s=3d1cb4776103d69bd1b539684185f1b6ed606c49">United Kingdom</a> and the <a href="https://www.ncbi.nlm.nih.gov/pubmed/22015873">United States</a>.</p>
<p>A paper my colleagues and I <a href="https://www.hindawi.com/journals/bmri/2013/623743/">published in 2013</a> showed that of the women who died by suicide and trauma in Australia between 2000 and 2006, 67% had a mental health condition, and/or a condition related to substance abuse.</p>
<p><a href="https://www.hindawi.com/journals/bmri/2013/623743/">We reported</a> a notable peak in deaths from suicide and trauma from nine to 12 months after the end of pregnancy when compared to deaths in the first three months after the end of a pregnancy. The World Health Organization wants to see more emphasis placed on this issue and clearer identification of deaths by suicide up to one year after the pregnancy ends.</p>
<p>We may be underestimating the numbers of late maternal deaths by suicide. If Australia follows the WHO recommendation to classify more deaths by suicide as directly attributable to pregnancy, we would likely see the numbers rise. <strong>– Hannah Dahlen</strong></p>
<hr>
<p><em>If this article has raised issues for you or if you’re concerned about someone you know, call <a href="https://www.lifeline.org.au/">Lifeline</a> on 13 11 14.</em></p>
<hr>
<p><div class="callout"> Have you ever seen a “fact” worth checking? The Conversation’s FactCheck asks academic experts to test claims and see how true they are. We then ask a second academic to review an anonymous copy of the article. You can request a check at checkit@theconversation.edu.au. Please include the statement you would like us to check, the date it was made, and a link if possible.</div></p><img src="https://counter.theconversation.com/content/65336/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>David Ellwood is Chair of the Queensland Maternal and Perinatal Quality Council, and a member of the National Maternal and Mortality Advisory Group. He is Deputy Head of School (Research) at Griffith University School of Medicine and Director of Maternal-Fetal Medicine at Gold Coast University Hospital. </span></em></p><p class="fine-print"><em><span>Hannah Dahlen has received funding from the NHMRC and the ARC. She is the national spokesperson for the Australian College of Midwives.</span></em></p>The clinical committee reviewing obstetrics services for the federal government’s Medicare review said suicide is one of the leading causes of maternal death in Australia. Is that true?David Ellwood, Professor of Obstetrics & Gynaecology, Griffith UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/607852016-06-15T20:11:49Z2016-06-15T20:11:49ZIs Medicare facing a cost blowout from ‘urgent’ after-hours care rebates?<figure><img src="https://images.theconversation.com/files/126650/original/image-20160615-22377-3m82f5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The cost for after-hour services has increased by 98% in the last ten years.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>Recent news reports have signalled another potential Medicare cost blowout; this time due to the billing practices of GPs providing care after hours – at night, on weekends and on public holidays.</p>
<p>The reports <a href="http://www.smh.com.au/national/health/boom-in-afterhours-gps-raises-concerns-about-medicare-cost-blowout-20160511-gosr95.html">cite Department of Health data</a> that shows A$195 million was billed to the Medicare Benefits Schedule for urgent after-hours visits (<a href="http://www.healthygc.com.au/MedicareLocal/media/Site-Pages-Content/PHCIP/MBS-Quick-Guide-2014-No-Fees.pdf">under item number 597</a>) in 2015, compared to A$90.8 million in 2010.</p>
<p>Inappropriate use of this item number by private <a href="http://www.namds.com/namds-mds-definition.html">medical deputising services</a> (MDS) – companies that employ registered medical practitioners to provide after-hours care – is thought to be behind the alleged blowout. </p>
<p>There are also concerns quality of care after hours may be lower when the GPs working for deputising services may have less experience than those employed by regular GP practices.</p>
<p>A recent <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/primary-ahphc-review">government review</a> of GP after-hours services found no solid evidence of whether care provided by deputising services was more costly or of lower quality than that of regular GP practices.</p>
<p>However, when looking at the <a href="http://medicarestatistics.humanservices.gov.au/statistics/mbs_item.jsp">numbers</a>, it is clear the cost of after-hours services has grown much faster – by 98% in ten years – than the overall cost of all Medicare GP services, which grew by only 60% over the same period. As the below graph shows, since 2012 there has been an upturn in the growth of the cost of after-hours care. These figures have been adjusted for population growth. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/126470/original/image-20160614-29229-1lz53kt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/126470/original/image-20160614-29229-1lz53kt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/126470/original/image-20160614-29229-1lz53kt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=320&fit=crop&dpr=1 600w, https://images.theconversation.com/files/126470/original/image-20160614-29229-1lz53kt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=320&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/126470/original/image-20160614-29229-1lz53kt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=320&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/126470/original/image-20160614-29229-1lz53kt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=402&fit=crop&dpr=1 754w, https://images.theconversation.com/files/126470/original/image-20160614-29229-1lz53kt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=402&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/126470/original/image-20160614-29229-1lz53kt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=402&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Growth in Medicare after hours costs since 2005.</span>
<span class="attribution"><span class="source">Medicare Australia</span></span>
</figcaption>
</figure>
<p>How much of this growth is due to MDS services is more difficult to show as Medicare data doesn’t distinguish between MDS services and those provided by regular GPs.</p>
<p>But regular practices are increasingly using deputising instead of providing care after hours themselves. Data from the BEACH study show the <a href="http://ses.library.usyd.edu.au/bitstream/2123/13974/4/9781743324554_ONLINE.pdf">proportion of GPs working</a> in practices that only used deputising services after hours increased from 38.3% in 2005 to 48.2% in 2014.</p>
<h2>Deputising services</h2>
<p>Deputising services are private companies, regulated by Commonwealth legislation, that can only provide services in the government-defined after hours periods.</p>
<p>These private companies have a strong incentive to convert a phone call to a visit, as only the latter attracts a fee. They are not allowed to schedule follow-up visits or further appointments beyond the current after-hours period. Only the patient or “<a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/primary-ahphc-review">other responsible adult</a>” can initiate a visit.</p>
<p>Deputising services are therefore driven by demand, from patients requesting services and practice-based GPs. The number of <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/primary-ahphc-review">government-approved deputising providers</a> has grown from 16 in 2006 to 83 in 2014.</p>
<p>It is possible to break down the Medicare data as there are separate items for non-urgent after-hours visits to residential aged-care facilities (A$70 per visit), non-urgent GP clinic visits (A$53 per visit), non-urgent home visits (A$74 per visit), and urgent visits in clinics, residential aged care or at home (A$132 per visit). </p>
<p>The below graph shows the changes in the mix of funding for these visits over the past ten years. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/126471/original/image-20160614-29225-1601kj5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/126471/original/image-20160614-29225-1601kj5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/126471/original/image-20160614-29225-1601kj5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=360&fit=crop&dpr=1 600w, https://images.theconversation.com/files/126471/original/image-20160614-29225-1601kj5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=360&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/126471/original/image-20160614-29225-1601kj5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=360&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/126471/original/image-20160614-29225-1601kj5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=453&fit=crop&dpr=1 754w, https://images.theconversation.com/files/126471/original/image-20160614-29225-1601kj5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=453&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/126471/original/image-20160614-29225-1601kj5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=453&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Mix of Medicare after hours funding.</span>
<span class="attribution"><span class="source">Medicare Australia Statistics</span></span>
</figcaption>
</figure>
<p>Though all types of visits can be provided by GPs in deputising services or regular practices, it is clear the proportion of after-hours spending for urgent visits and visits to residential aged-care facilities were falling until about 2011, and then rose.</p>
<p>After controlling for the increasing population, spending on non-urgent, after-hours visits to aged-care facilities increased by 90% since 2011. In the same period, spending on urgent visits (including aged-care, home and clinic) increased by 32%; there was a 30% increase for non-urgent home visits, and non-urgent clinic visits increased by 14%. </p>
<p>There is no definition of “urgent” provided in the Medicare Benefits Schedule – it is entirely up to the GP or deputising service to determine. This seems to be a flaw in the payment system as it is doubtful whether an urgent visit requires double the resources as a non-urgent visit. More evidence is required to appropriately set the fees and definitions of urgent visits. </p>
<h2>Filling the gap</h2>
<p>The Royal Australian College of General Practitioners (RACGP) <a href="http://www.smh.com.au/national/health/gps-call-for-crackdown-on-booming-outofhours-doctor-services-20160603-gpberd.html">recently called for after-hours services</a> to be formally linked to regular clinics, in part due to concerns that junior doctors employed by MDS were providing lower quality care to patients.</p>
<p>Yet regular GPs <a href="http://www.sciencedirect.com/science/article/pii/S0277953613003882">do not want to provide</a> after-hours care. And our research shows that practice-based GPs cannot be persuaded to provide more after hours care by <a href="http://www.melbourneinstitute.com/downloads/working_paper_series/wp2016n12.pdf">financial incentives.</a> </p>
<p>In fact the RACGP’s own standards were <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/primary-ahphc-review">changed</a> in 2013 where the duty of GPs to provide care 24/7 was removed as the then new Medicare Locals took over some of the funding for after hours care. </p>
<p>So deputising services, that are accredited according to RACGP standards, are filling an unmet need. It is also possible they are seeing patients who would otherwise be presenting to emergency departments, saving the health system money.</p>
<p>However, since the GP from an MDS is not the patient’s regular GP, and it is not yet possible to have a portable electronic medical record that could be accessed by the deputising service, the patient could receive lower quality care simply because the MDS GP doesn’t know the patient’s medical history. This also means patients could secure prescriptions their regular GP may not provide.</p>
<p>MDS services are <a href="http://www.medicalrepublic.com.au/hours-billing-spotlight/?utm_source=The%20Medical%20Republic_Medcast_Newsletter&utm_campaign=d2130e3ee6-Newsletter_June_14_06_16&utm_medium=email">claimed</a> to often hire younger doctors with less experience or those from overseas with different training and cultural backgrounds. These GPs are considered to be undergoing training, though how they are being trained is unclear.</p>
<p>The government review of after-hours care was ambivalent about the role of deputising services, saying:</p>
<blockquote>
<p>MDSs are recognised as having a critical role in meeting after hours needs, providing valuable support for GPs already working long hours, access to home visits and in many cases good continuity of care. </p>
</blockquote>
<p>However, the review also recommended deputising services not be able to advertise directly to the public and that they should move away from a fee-for-service funding model. These recommendations have not been acted upon, but <a href="http://www.medicalrepublic.com.au/hours-billing-spotlight/?utm_source=The%20Medical%20Republic_Medcast_Newsletter&utm_campaign=d2130e3ee6-Newsletter_June_14_06_16&utm_medium=email">reports</a> that the Medicare Benefits Review Taskforce will examine these issues are welcome.</p><img src="https://counter.theconversation.com/content/60785/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anthony Scott currently receives funding from NHMRC, ARC, and The World Bank.</span></em></p>Recent reports have signalled another potential Medicare cost blowout due to the billing practices of GPs providing care after hours. Is it true and is there a problem with these services?Anthony Scott, Professor, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/516042015-12-02T05:28:58Z2015-12-02T05:28:58ZGovernment policy, not consumer behaviour, is driving rising Medicare costs<figure><img src="https://images.theconversation.com/files/103980/original/image-20151202-30804-1100paf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A significant proportion of the growth in Medicare costs has been driven by government policies such as items for new services and larger rebates. </span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-159748715/stock-photo-close-up-of-a-doctor-checking-blood-pressure-of-a-patient.html?src=4njE667OEJsNJfoD8p9dsA-1-4">Rido/Shutterstock</a></span></figcaption></figure><p>Announcing the ill-fated 2014 budget initiative to introduce a consumer co-payment for general practice visits, the <a href="http://www.health.gov.au/internet/budget/publishing.nsf/content/budget2014-hmedia02.htm">then health minister, Peter Dutton, lamented</a> that annual Commonwealth health costs had increased from A$8 billion to A$19 billion over a decade. He described the increase as “unsustainable” and used it to justify the budget’s bitter pill.</p>
<p>The implication of his announcement was that consumers were driving the increase in costs and that action to change consumer behaviour was necessary to rein them in.</p>
<p>The growth numbers were presented as part of the government’s then mantra of a “debt and deficit disaster”, and massaged to create maximum shock and awe. The minister’s numbers did not adjust either for population growth or inflation.</p>
<p>Nonetheless, a more legitimate set of growth numbers would still show Medicare Benefits Schedule (MBS) payments growing at an annual rate of 2.3% in real per-head terms, faster than growth in government expenditure overall (1.8%).</p>
<p>But this still leaves open the question of whether consumer behaviour is driving rising costs or whether there may be other causes.</p>
<p>A <a href="http://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Budget_Office/research_reports/Medicare_Benefits_Schedule">report</a> released last week by the Parliamentary Budget Office shows that government policy has driven a significant proportion of the growth in MBS costs. In fact, of the A$325 real increase in MBS spending per head since 1993-94, all but A$74 has been the result of explicit government decisions. </p>
<p>MBS spending per head is the product of the rebate for each MBS item and the per head use of those items. Both elements of this calculation have been tinkered with as part of policy change over the last two decades. </p>
<p>Governments have increased rebates for some items faster than inflation. This has been done, for example, to encourage an increased rate of bulk billing. New item numbers have also been added as part of major policy reviews. </p>
<p>(Each MBS service involves one or more item numbers and an associated description. For example, an ordinary consultation with a general practitioner is <a href="https://theconversation.com/gp-co-payment-2-0-a-triple-whammy-for-patients-35334">item number 24</a>.)</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/104022/original/image-20151202-14437-u7n4qh.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/104022/original/image-20151202-14437-u7n4qh.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/104022/original/image-20151202-14437-u7n4qh.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=655&fit=crop&dpr=1 600w, https://images.theconversation.com/files/104022/original/image-20151202-14437-u7n4qh.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=655&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/104022/original/image-20151202-14437-u7n4qh.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=655&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/104022/original/image-20151202-14437-u7n4qh.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=823&fit=crop&dpr=1 754w, https://images.theconversation.com/files/104022/original/image-20151202-14437-u7n4qh.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=823&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/104022/original/image-20151202-14437-u7n4qh.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=823&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
</figcaption>
</figure>
<p>The single largest cost impact (A$51 per head) came from changes to diagnostic imaging items, including new items for magnetic resonance imaging (MRI). But implementation of policies to expand <a href="http://www.anao.gov.au/%7E/media/Uploads/Documents/1999%2000_audit_report_42.pdf">magnetic resonance imaging</a> and reform diagnostic imaging items <a href="http://www.anao.gov.au/%7E/media/Files/Audit%20Reports/2014%202015/Report%2012/AuditReport_2014-2015_12.PDF">more generally</a> has been poor. </p>
<p>It is questionable whether consumers are getting value for money from this investment. Also, <a href="https://theconversation.com/getting-doctors-to-reduce-diagnostic-testing-is-hard-but-we-should-keep-trying-42312">some diagnostic imaging tests</a> appear to be overused.</p>
<p>Policies designed to increase bulk billing accounted for an extra A$70 per head: increasing the GP rebate from 85% of the schedule fee to 100% accounted for A$42 per head; targeted increases in the rebate to increase bulk billing rates accounted for the rest. </p>
<h2>When did Medicare spending soar?</h2>
<p>In the decade to 2003-4, Medicare spending grew by A$53 per head. Just over half of that was attributable to the addition of new diagnostic imaging items to the schedule. In the next decade, spending grew at five times that rate – by A$272 per head. </p>
<p>Most of the growth was due to decisions taken when <a href="https://theconversation.com/medicares-best-friend-lessons-from-abbotts-days-as-health-minister-17893">Tony Abbott was health minister</a>, between 2003 and 2007. In fact, almost half (47%) of the growth in Medicare spending over the last two decades is the result of policy decisions taken when he was running the health portfolio. </p>
<p>The changes were introduced over the years for a mix of policy and political reasons. The decline in bulk billing was associated with public dissatisfaction with Medicare and was clearly having political impacts. This led to new bulk billing incentives and increases to the rebates for general practitioner fees.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/103989/original/image-20151202-14461-1bp5b4o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/103989/original/image-20151202-14461-1bp5b4o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=475&fit=crop&dpr=1 600w, https://images.theconversation.com/files/103989/original/image-20151202-14461-1bp5b4o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=475&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/103989/original/image-20151202-14461-1bp5b4o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=475&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/103989/original/image-20151202-14461-1bp5b4o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=596&fit=crop&dpr=1 754w, https://images.theconversation.com/files/103989/original/image-20151202-14461-1bp5b4o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=596&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/103989/original/image-20151202-14461-1bp5b4o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=596&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Policy changes meant GPs received larger rebates for seeing the same number of patients.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-4355401/stock-photo-female-doctor-and-assistant-filling-out-medical-cards.html?src=f8fyMSBnySC1F_VWTLRTpw-7-122">StockLite/Shutterstock</a></span>
</figcaption>
</figure>
<p>The increasing prevalence of chronic diseases, such as diabetes and heart disease, led to new assessment and care planning items. </p>
<p>A decline in the proportion of GPs providing after-hours care led to new items to redress that as well.</p>
<p>General practitioners got more rebate income (in real terms) for seeing the same number of patients, so it was actually changes initiated by government that led to the increase in spending.</p>
<h2>What does this mean for Medicare reform?</h2>
<p>Two main lessons can be drawn from the Parliamentary Budget Office report. </p>
<p>First, the government must be clear about what is driving growth in expenditure. The co-payment proposal sank like a lead balloon partly because it was seen as inefficient and unfair, but also because the public didn’t have any ownership of the “problem” the changes sought to address. </p>
<p><a href="https://theconversation.com/factcheck-does-the-average-australian-go-to-the-doctor-11-times-a-year-26242">The way the problem was initially presented was wrong</a>, causing confusion between Medicare services (which include diagnostic tests) and GP visits. The vast majority of the population, who have few visits, refused to accept that per-head use was going up. </p>
<p>Second, the report shows how much governments have relied on tinkering with the Medicare Benefits Schedule to drive system change in the last decade. “Here a new item, there a new item, everywhere a new item” became the Canberra policy song sheet. </p>
<p>Health Minister Sussan Ley wiped the slate clean when she was appointed in December, setting up a raft of reviews to look at everything from primary care to disinvestment. Importantly, reviews must consider whether the Medicare schedule is still “fit for purpose” in the context of the increase in chronic disease and the impact this is having on clinical practice. </p>
<p>It must be hoped new policies developed in response will be both more sophisticated and less profligate than we have seen over recent decades.</p><img src="https://counter.theconversation.com/content/51604/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stephen Duckett provided comments to the Parliamentary Budget Office on a draft of their Report</span></em></p>The Coalition tried to justify its failed GP co-payment as an attempt to rein in consumers, who were driving the increase in Medicare costs. Turns out government policy was mostly to blame.Stephen Duckett, Director, Health Program, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/408192015-04-29T19:40:47Z2015-04-29T19:40:47ZMedicare review must deal with ‘elephant in the room’ incentives<figure><img src="https://images.theconversation.com/files/79705/original/image-20150429-7086-1ba39ki.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">There's elephant in the room that government-appointed reviewers need to notice if they're going to overhaul the Medicare Benefits Schedule. </span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/mikewoodward/6808625479">mike woodward/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span></figcaption></figure><p>Federal Health Minister Sussan Ley has <a href="http://www.abc.net.au/am/content/2015/s4221124.htm">announced a review of Medicare</a> that will “reform and revamp both the MBS (Medicare Benefits Schedule) and the primary care system so that they deliver better for patients”. But the reviewers will fail in their task unless they deal with the incentives to over-treat created by our fee-for-service system. </p>
<p>We’re going to talk about the first step in the process, the review of the Medicare Benefits Schedule (MBS), which is the list of services covered by Medicare. The list also specifies the amount of money the government will pay for each service. The schedule has changed considerably since its introduction after World War II, just as the practice of medicine has changed. </p>
<p>Ley says a clinician-led team will review all 5,500 items to ensure they’re both effective and provide value for money. Of course, good clinical practice should be based on the best scientific evidence. So the review sounds like a good idea. But apart from the size of the task, the review faces several tricky issues.</p>
<h2>Some caveats</h2>
<p>First, it’s important to note that evidence of no benefit is not the same as no evidence of benefit. The first means the case is settled; the second that there’s uncertainty. Many items on the MBS are likely to fall in the latter category, as the requirement to demonstrate effectiveness is relatively recent. </p>
<p>Australia’s approach to investment in new health technologies, whether a service or a medicine, is based on this principle so public funding follows evidence. New items have to wait for funding until there’s demonstrable benefit.</p>
<p>That means ineffective technologies are not subsidised by taxpayer largesse but also that some good technologies take longer to get listed. This approach is not popular with commercial interests and patients, as the current Senate inquiry into the <a href="http://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/Cancer_Drugs">availability of new cancer drugs</a> illustrates.</p>
<p>But most MBS items precede stringent review requirements, though many may be well established in clinical practice. If the principle of no coverage without evidence is applied to existing services, it would mean well-established procedures and investigations lose access to Medicare funding.</p>
<p>The next issue is that few medical services are good or effective, or bad or harmful, in themselves. Usefulness depends on the patient and the patient’s condition. So the process of assessing the service always starts with identifying the medical condition, the target group and the alternative treatment. </p>
<p>Pap smears, for instance, have well-demonstrated value in terms of saving lives. But that doesn’t mean greater use of pap smears is necessarily better; it depends on targeting women at risk of cervical cancer with no recent pap smear. </p>
<p>Recent additions to the MBS have generally been much better in terms of specifying who should get access to what. This is an opportunity to review older items and take the same approach.</p>
<p>Then there are investigations – X-rays, ultrasounds, MRIs, pathology tests. Investigations provide information but they only lead to better patient outcomes if there’s an effective way to treat what’s found, and it’s applied. These present a more complex challenge as they are just one link (albeit a very costly one) in the investigation, diagnosis and treatment chain.</p>
<h2>Further complications</h2>
<p>What about MBS items that haven’t been shown to be ineffective, or have been shown to have some benefit in some conditions for some patients? In some cases, the benefit is trivial, so should it be funded? In others, the benefit may be large but so may be the cost. </p>
<p>If the MBS review is going to tackle efficiency, it will need to consider not just the value of the service but also how much should be paid for each. We cannot determine value for money if the money paid is unknown. But this could open a can of worms. </p>
<p>Back in 2009, the Rudd government tried to reduce the MBS fee paid to ophthalmologists for cataract surgery, on the basis that the technology had changed and the procedure took so much less time that a lower fee was warranted. But after a major media campaign against the proposal, the government backed down.</p>
<p>Then there’s the issue of the threshold for investigation or treatment. Take pain, for example: how much of it is serious enough to warrant an MRI? The point we’re trying to make here is that it’s rare that an indication or symptom is clear and without room for discretion.</p>
<p>And that leads to the elephant in the room that the reviewers have to deal with if they’re going to be successful. Our health system is based on a fee-for-service model, so every time a doctor provides a service, the government pays a fee via Medicare. This means the more services provided, the higher the provider’s income. Not surprisingly, this unintentionally encourages increasing volume but not necessarily appropriateness (the right treatment for the patient) or quality. </p>
<p>Of course, this doesn’t mean patients are not treated well or that doctors don’t provide good quality care. But the incentives in the system are not well aligned with delivering the most efficient care.</p>
<p>Ensuring that what’s good for the patient and good for the future of Medicare is also good for medical business is really the only long-term fix for a better health system. We’ve long talked about making healthy choices the easy choices for consumers, now it’s time to focus on making efficient choices easy choices for health service providers. </p>
<p>This review is an indication of a more considered and consultative approach to formulating health policy. But let’s not forget that it’s the incentives that matter.</p><img src="https://counter.theconversation.com/content/40819/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jane Hall receives funding from Australian Primary Health Care Research Institute and the NHMRC. </span></em></p><p class="fine-print"><em><span>Kees Van Gool receives funding from the Australian Primary Health Care Institute.</span></em></p><p class="fine-print"><em><span>Michael Woods is a consultant to the OECD Southeast Asia Regional Programme.</span></em></p><p class="fine-print"><em><span>Rosalie Viney receives funding from the ARC and NHMRC.</span></em></p><p class="fine-print"><em><span>Stephen Goodall receives funding from Department of Health, Australian Research Council, and NHMRC.</span></em></p>The review of Medicare recently announced by the health minister is not only a pachydermal task, it will also fail unless it acknowledges the elephant in the room – our fee-for service health system.Jane Hall, Professor of Health Economics and Director, Centre for Health Economics Research and Evaluation, University of Technology SydneyKees Van Gool, Health economist, University of Technology SydneyMichael Woods, Professor of Health Economics, University of Technology SydneyRosalie Viney, Professor of Health Economics, University of Technology SydneyStephen Goodall, Associate Professor of Health Economics, University of Technology SydneyLicensed as Creative Commons – attribution, no derivatives.