Presentation - Reviews of the Medicare Benefits Schedule and the NHMRC

Presentation by Professor Bruce Robinson, Sydney, 18 April 2016

Page last updated: 18 April 2016

PDF version: Reviews of the Medicare Benefits Schedule and the NHMRC (PDF 978 KB)

Slide 0: Reviews of the Medicare Benefits Schedule and the NHMRC

Professor Bruce Robinson
Chair, MBS Review Taskforce
Chair, NHMRC
Sydney 18 April 2016

Slide 1: Today's presentation

  • The case for review and change in health and medical research
  • Overview and update on the work of the MBS Review Taskforce
  • NHMRC and translational research
  • Key points from the Primary health Care Advisory Group report

Slide 2: What motivates me?

  • Health care has advanced and the MBS has not kept pace
  • The MBS contains anomalies and is not consistent with current clinical practice guidelines
  • There is a significant amount of low or no-value care, some of which is driven by the MBS
  • The MBS is not a driver of quality care and data collection is inadequate
  • Belief in health and medical research to better inform health systems and individual patient care Top of page

Slide 3: What's the gap?

  • The MBS is seen as a funding instrument, not as a tool for better care
  • There is frustration that the MBS has not been over-hauled in 30 years
  • Clinicians are aware of the anomalies and variations in use of the MBS
  • Clinicians are frustrated by the ‘waste’
  • NHMRC success rates are only 13%, career structures are very poor

Slide 4: How will we address these issues?

  • A clinician-lead review of the MBS and a review of Primary Health Care
  • A review of the NHMRC – specifically to look for solutions to a very complex strategic and funding dilemma which has long-term implications for health and medical research in Australia
  • Solutions require assistance from all of the people who work in this area and the people who pay for, and benefit!

Slide 5: Why do I believe this is going to work? Who else believes this?

  • Clinicians and consumers are supportive
  • The Colleges are supportive
  • The AMA is supportive
  • The Minister is supportive
  • The process is using evidence, data, clinician opinion and consumer input
  • We are proceeding methodically, with good support from the Department of Health
  • The NHMRC review is being lead by Steve Wesselingh and supported by a range of levels of researchers Top of page

Slide 6: What's in it for you?

  • Health consumers – better health care
  • Community/society – better value for taxes
  • Clinicians – satisfaction that the care is more efficient, appropriate, effective and the 'best and latest'
  • Corporates – costs aligned to rebates, not dependent on 'cross-subsidies'
  • Less time wasted on unsuccessful research applications, better career structures for researchers, assistance with commercialization and innovation, clearer delineation of roles of NHMRC, MRFF and other funding agencies

Slide 7: The Medicare Benefits Schedule Review

Our objectives, methodology, and state of play.

Slide 8: The MBS Review

  • Established by Health Minister Sussan Ley in June 2015
  • At $20 billion per annum, MBS is the largest single health program – around 30 per cent of Commonwealth health expenditure
    • Overall health expenditure exceeds $150 billion per annum
  • More than 5,700 services funded – many haven’t been re-examined or evaluated since listing Top of page

Slide 9: The MBS is a significant component of the Australian healthcare system

Medicare benefits constitute approximately 30% of Australian Government health expenditure

Federal Government health expenditure

Not including capital expenditure
AUD (billions), 2013-14

Source: Australian Institute of Health and Welfare, Health Expenditure Australia 2013-14, 2015; Department of Health

See following text for an alternative text description of Federal Government health expenditure

Text version of Federal Government health expenditure

This bar chart shows the following Federal Government expenditure in AUD (billions):
  • MBS - 19.1
  • SPP to states - 16.8
  • PBS - 9.1
  • PHI rebates - 5.5
  • Other - 13.2 Top of page

Breakdown of MBS expenditure

Percent, 2013-14

Source: Australian Institute of Health and Welfare, Health Expenditure Australia 2013-14, 2015; Department of Health

See following text for an alternative text description of Breakdown of MBS expenditure

Text version of Breakdown of MBS expenditure

This pie chart shows the following breakdown of MBS expenditure:
  • GP services - 33%
  • Diagnostic imaging - 16%
  • Pathology - 13%
  • Operations and procedures - 11%
  • Specialist attendances - 11%
  • Other MBS services - 10%
  • Other health professionals - 6% Top of page

Slide 10: Total Medicare Expenditure in 2013-14

Diagram showing a breakdown of Medicare expenditure in 2013-14 - see following text for an alternative text description Larger version of slide 10 (PDF 333 KB) Top of page

Text version of total Medicare expenditure in 2013-14

This diagram shows the breakdown of the total MBS expenditure of $19.1 billion in 2013-14:
  • Professional attendances $8.7 billion
    • GP attendances $6.4 billion
      • Level B consultation $3.2 billion
      • Level C consultation $1.0 billion
      • Other GP services $2.1 billion
    • Specialist attendances $2.0 billion
    • Optometry $0.4 billion
  • Therapeutic procedures $3.2 billion
    • Surgical operations $1.7 billion
    • Radiotherapy $0.3 billion
    • Value guide for anaesthesia $0.4 billion
    • Other therapeutic procedures $0.8 billion
  • Diagnostic imaging $2.9 billion
    • Ultrasound $1.0 billion
    • Computed tomography $0.8 billion
    • Diagnostic radiology $0.5 billion
    • Nuclear medicine imaging $0.3 billion
    • Magnetic resonance imaging $0.3 billion
  • Pathology services $2.5 billion
    • Tissue pathology $0.3 billion
    • Haematology $0.3 billion
    • Microbiology $0.4 billion
    • Chemical $1.0 billion
    • Other $0.5 billion
  • Diagnostic procedures $0.5 billion
    • Cardiovascular $0.2 billion
    • Other diagnostic procedures $0.3 billion
  • Other services $1.3 billion
    • GP bulk billing incentives $0.5 billion
    • Allied mental health $0.2 billion
    • Allied health services $0.3 billion
    • Psychological therapy services $0.2 billion
    • Oral and maxillofacial & cleft lip and cleft palate services $0.01 billion Top of page

Slide 11: Expenditure through Medicare since 1984

See following text for an alternative text description of expenditure through Medicare since 1984 Larger version of slide 11 (PDF 215 KB)

Text version of expenditure through Medicare since 1984

This cumulative graph shows expenditure through Medicare from about $0.7 billion in 1983-84 to approximately $19.3 billion in 2013-14. The graph is sub-divided into GP services, diagnostic imaging, pathology, operations and procedures, other and specialist attendances. Approximate expenditure for these categories in 2013-14 was as follows (please note that this data is approximate as it has been read from the graph):
ServiceApproximate expenditure in 2013-14
GP services$6.4 b
Diagnostic imaging$2.9 b
Pathology$2.6 b
Operations and procedures$2.1 b
Other$3.2 b
Specialist attendances$2.1 b
Top of page

Slide 12: Terms and references for the MBS review

In scope

  • All current MBS items and the services they describe
  • Increasing the value derived from services
  • Concerns about safety, clinically unnecessary service provision and concurrence with guidelines
  • Evidence for services, appropriateness, best practice options, levels and frequency of support
  • Legislation and rules that underpin the MBS

Out of scope

  • Division of responsibilities between Government – Federation White Paper
  • Innovative funding models for chronic and complex disease – Primary Health Care Advisory Group

Slide 13: What will this review mean for patients and consumers?

  1. More evidence-based care
  2. Increased access to valuable, yet underutilised, treatments
  3. Prevention of unnecessary treatments and tests
  4. More appropriate referrals and appointments
  5. Better use of best-practice health care services Top of page

Slide 14: It will be challenging to evaluate over 5,700 items in the review timeframe

The 40 most common MBS items (0.7%) account for approximately 70% of all services.

Top 40 Medicare Benefits Schedule services, 2013-14

See following text for an alternate description of top 40 Medicare Benefits Schedule services, 2013-14

Text version of top 40 Medicare Benefits Schedule services, 2013-14

This image consists of a graph and a list of items:
This line graph shows the number of services for each of the top 39 items. Item number 23 has the highest number of services, at almost 90 million. The next-highest number of services is for item number 73928, with less than 20 million. The number of services for the other top items gradually decreases. In order, these items have the following item numbers: 66512, 36, 65070, 116, 73938, 105, 5020, 104, 66716, 66596, 69333, 66608, 53, 65120,10900, 3, 11700, 66602 (note - this item was recently amended, which will change service volumes), 73939, 35, 10962, 110, 17610, 66719, 80110,10918, 73926, 58503, 57521, 721, 66536, 80010, 73053, 73930, 723, 10960 and 16500.
Top 15 items
  • #23: Standard consult (under 20 minutes)
  • #73928: Pathology episode Initiation - collection of a specimen in an approved collection centre
  • #66512: Pathology item: 5 or more chemical tests
  • #36; Long consult (over 20 minutes)
  • #65070: Pathology item: full blood count
  • #116: Subsequent consultant physician consultation
  • #73938: Pathology episode Initiation - collection of a specimen by or on behalf of the treating practitioner
  • #105: Subsequent specialist attendance
  • #5020: After hour attendances
  • #104: Initial Specialist attendance
  • #66716: Pathology item: Thyroid-stimulating hormone (TSH) quantitation
  • #66596: Pathology item: Iron studies
  • #69333: Pathology item: Urine examination
  • #66608: Pathology item: Vitamin D test (replaced by items 66833 to 66837)
  • #53: OMP short consultation Top of page

Slide 15: Review methodology

  • Clinician-led review and significant consultation with stakeholders
    • Clinicians
    • Consumers
    • Industry
    • Other health disciplines, including public health
  • Clinical Committees
    • Discipline-specific clinical committees
    • Subordinate working groups for reviews of particular services
    • Membership is broad-based:
      • Clinicians, requestors, generalists, academics with public health and health economics expertise, consumers
    • Members are an expert in their own right and not a ‘representative’ of an organisation Top of page

Slide 16: MBS review activities have been distributed among several groups

See following text for a text description of MBS Review Taskforce structure

Text version of MBS Review Taskforce structure chart

The MBS Review Taskforce establishes Clinical Committees which may, in turn, establish service specific working groups. The MBS Review Taskforce has also established the Principles & Rules Committee. The Principles & Rules Committee and Clinical Committees undertake consultation with stakeholder groups and the public. Top of page

Slide 17: The Clinical Committees are following a consistent five-step approach

  1. Triage - examine item descriptors and usage patterns to identify items requiring detailed investigation
  2. Evaluation - conduct rapid evidence reviews and targeted analyses as needed for each item
  3. Clinical Committee recommendation - propose changes to items and articulate rationale
  4. Consultation - Colleges, peak bodies and other affected stakeholders are notified of the recommended changes and invited to contribute feedback
  5. Taskforce recommendation - Taskforce finalises recommendations to government

Slide 18: The Principles and Rules Committee examines issues which affect many or all Clinical Committees

Description of the Principles and Rules Committee

  • The Taskforce will recommend updates to the legislation which underpins the MBS
  • The Committee contains a broad range of participants, including Taskforce members clinicians, and others
  • Stakeholders are invited to actively contribute to the refinement of Rules

Examples of issues raised by stakeholders

  • Referral regulation: how can the current model be optimised for patients and providers
  • MBS item descriptors: how can MBS items be more clearly defined and user-friendly?
  • MBS principles: e.g., complete medical service, aftercare etc. Top of page

Slide 19: New services

  • The focus is on existing items, but the Taskforce may recommend new items or services
  • MSAC remains the primary gateway for health technology assessment and new MBS services
    • Where good clinical practice requires addition of a service, Minister might ask MSAC for expedited advice
    • For a completely novel treatment or technology, Minister might choose a full MSAC review of the evidence
  • Existing item/s can be combined to form new item/s to better describe the service
    • Normally will not need MSAC review
  • Rapid reviews undertaken by a clinical committee may reduce the time required by MSAC in adding new items
    • Onus is on clinical committee to commission rapid review and make recommendation

Slide 20: Obsolete items - first tranche

  • 23 MBS items were identified by Clinical Committees as obsolete.
    • Diagnostic Imaging: 58706, 58924, 59503, 59715, 59736, 59760, 61465
    • Ear, Nose and Throat Surgery: 11321, 18246, 41680, 41695, 41758, 41761, 41846, 41849, 41852
    • Gastroenterology:13500, 13503, 30493, 32078, 32081
    • Obstetrics: 16504
    • Thoracic Medicine: 11500
  • Public consultation from 18 December 2015 to 8 February 2016
  • Amendments to some recommendations after taking into account feedback
  • Government consideration of Taskforce recommendation Top of page

Slide 21: To ensure the review is clinically led, each category is being evaluated by a peer-nominated clinical committee

Clinical committees - first tranche

CommitteeChairExamples of members
ObstetricsProf. Michael Permezel Midwife, GP obstetrician, specialist OB, rural obstetrician, pathologist
Diagnostic ImagingProf. Ken ThomsonRadiologist, nuclear medicine specialist, GP, health economist
GastroenterologyProf. Anne DugganGastroenterologist, general surgeon, GE nurse, GP
ThoracicProf. Christine JenkinsThoracic medicine, respiratory and sleep specialists, GP
Ear, Nose and ThroatProf. Patrick GuineyENT surgeon, paediatrician, GP working in Indigenous health
PathologyAssociate Prof. Peter StewartPathologist, haematologist, endocrinologist, immunologist
Top of page

Slide 22: Clinical committees - second tranche

  • The second tranche of Clinical Committees is underway
  • This tranche includes:
    • Cardiac Services - Cardiology and cardiothoracic surgery
    • Dermatology, Allergy & Immunology - Skin conditions and allergy testing (skin cancer surgery review completed)
    • Endocrinology - Includes endocrine surgery
    • Intensive Care and Emergency Medicine - Includes neonatology
    • Oncology - Chemotherapy and radiation oncology (not cancer surgery)
    • Renal Medicine - Includes dialysis

Slide 23: Public consultations

  • The Taskforce is committed to engaging with all stakeholders and welcomes input into all aspects of the review
    • Consultation will occur regularly throughout 2016
  • Public consultation will follow recommendations from Clinical Committees
    • Recommendations including obsolete items, rapid reviews, changes to existing items, new services
    • Detailed information to provide context and rationale
    • Targeted consultation by directly contacting organisations with relevant interests
    • Broad consultation by publishing on website, media release, and newsletter
  • Taskforce considers recommendations from Clinical Committee and feedback from public consultation, prior to making recommendations to Minister Top of page

Slide 24: The clinical committee program for 2016

  • The third tranche of clinical committees will commence in the next few months
  • Items specific to pain management will be considered in this review by a Pain Management clinical committee – commencement will be later in the year
  • As with all committees, this committee will have a broad based membership including clinicians, requestors, generalists, academics with public health and health economics expertise, and health consumers
  • The items specific to pain management include:
    • GP and specialist consultation
    • Specific pain management procedures (including nerve blocks)
    • Multidisciplinary care plans
    • Allied health services
    • Mental health services

Slide 25: The NHMRC review

Slide 26: Scope and terms of reference

The Review will examine and provide advice to the CEO of NHMRC about the structure of the grant programme, including:
  1. The impact of the grant programme on the health and medical research sector;
  2. The flexibility of the grant programme to meet future needs for health and medical research in Australia; and
  3. Alternative models and their potential to overcome the current challenges.
The Review will consider relevant overseas experience with medical research grant programmes. NHMRC will also consider feedback provided in response to its Fellowship Consultation.

Chaired by Prof Steve Wesselingh, SAHMRI Top of page

Slide 27: Should we have a National Institute for Health Research?

  • In the UK the NIHR undertakes research in health systems and health care delivery
  • Funds provided by the health system (NHS Trusts)
  • Competitive funding of projects which can be pilots but must be able to be ‘scaled up’
  • Would free up significant research $ for clinical and basic research
  • Could be linked to MBS with some clinical trials being part funded using temporary item numbers.

Slide 28: Primary health care

Slide 29: PHCAG final report

  • The Advisory Group delivered its final report, Better Outcomes for People with Chronic and Complex Health Conditions, to Government on 3 December 2015.
  • The final report was released on 31 March 2016 and can be found at Healthier Medicare on the Department of Health’s website
  • The PHCAG made 15 key recommendations designed to establish a Health Care Home model of care for patients with chronic and complex conditions.
  • Government have accepted the findings of the PHCAG report and is beginning staged implementation of the Health Care Home model.

Slide 30: Health Care Home model

  • Eligible patients will voluntarily enrol with a participating medical practice known as their Health Care Home
  • This practice will provide a patient with a ‘home base’ for ongoing coordination, management and support.
  • Care coordination and team-based care
  • Regional clinical ‘patient pathways’
  • Patient participation Top of page

Slide 31: Care coordination

  • Care coordination is critical to ensure that patients with high care needs can navigate the health care system
  • Patients enrolled in the Health Care home may also be eligible to receive support services through other programs that can improve their ability to manage their care
  • Approximately 59% of practices employ an additional staff member to coordinate their patients’ care
  • These resources need to be effectively targeted to those patients who have the greatest need

Slide 32: A new payment mechanism

  • A new blended payment mechanism will provide flexibility in the delivery of care and incentivise delivery of high quality care.
    • Health Care Homes will be paid a quarterly bundled payment to provide care related to a patient’s chronic and complex condition.
    • Fee for service payments will be maintained for care not relating to the enrolled patient’s chronic conditions.
    • Existing MBS items for allied health services will remain in place for patients enrolled in a Health Care Home.
  • Pursue collaborative approaches to planning and allocation of health system resources, including joint and pooled funding with State and Territory governments and private health insurers. Top of page

Slide 33: Evaluation of the Health Care Home model

  • As a first step Health Care Homes will be rolled out in up to seven Primary Health Network regions across the country.
  • Up to 200 Health Care Homes will offer services to up to 65,000 people with chronic and complex conditions.
  • Health Care Home services will be delivered in these regions from 1 July 2017.
  • Any national roll out of Health Care Homes will be informed by the results of a rigorous evaluation of the first stage of implementation and consideration by Government.

Slide 34: Contact details

Email MBS reviews
MBS Review web page