Reviews of the Medicare Benefits Schedule and the NHMRC Professor Bruce Robinson Chair, MBS Review Taskforce Chair, NHMRC

Sydney 18 April 2016

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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

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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

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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

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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!

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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

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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

The Medicare Benefits Schedule Review

Our objectives, methodology, and state of play

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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

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The MBS is a significant component of the Australian healthcare system

Federal Government health expenditure 1 AUD (billions), 2013-14

1 Not including capital expenditure 2 Operations and Procedures include anaesthetics services; other MBS services include radiotherapy, obstetrics, IVF and other diagnostics; other health

professionals include optometry, allied health and psychology services

Medicare benefits constitute ~ 30% of Australian Government health expenditure

Other 13.2

5.5

PBS

SPP to states

19.1

16.8

MBS

9.1

PHI rebates

Breakdown of MBS expenditure 2

Percent, 2013-14

GP Services

33%

Operations and procedures

11%

6%

11%

Pathology Diagnostic Imaging

16%

Other MBS services

Other health professionals

10%

13%

Specialist attendances

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

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Total Medicare Expenditure in 2013-14

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Expenditure through Medicare since 1984

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Terms and references for the MBS review

Out of Scope 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

▪ Division of responsibilities between Government – Federation White Paper

▪ Innovative funding models for chronic and complex disease – Primary Health Care Advisory Group

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What will this review mean for patients and consumers?

More evidence-based care

More appropriate referrals and appointments

Better use of best-practice health care services

Prevention of unnecessary treatments and tests

Increased access to valuable, yet underutilised, treatments

1

2

3

4

5

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

0

10

20

30

40

50

60

70

80

90

100

#585

03

#165

00

#721

#667

19

#739

30

#730

53

#665

36

#3

#651

20

#693

33

#667

16

#666

08

#739

39

#109

60

#800

10

MBS item number

#723

#575

21

#739

26

#109

18

#801

10

#176

10

#110

#35

#666

021

#109

62

#117

00

#109

00

Number of services Millions

#665

96

#739

28

#116

#6

5070

#665

12

#53

#739

38

#36

#23

#105

#5

020

#104

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

SOURCE: MBS online, accessed 2 July 2015

Top 40 Medicare Benefits Schedule services, 2013-14

1 Item recently amended which will change service volumes

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

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Review methodology

▪ Clinician-led review and significant consultation with stakeholders o Clinicians o Consumers o Industry o Other health disciplines, including public health

▪ Clinical Committees o Discipline-specific clinical committees o Subordinate working groups for reviews of particular services o Membership is broad-based:

• Clinicians, requestors, generalists, academics with public health and health economics expertise, consumers

o Members are an expert in their own right and not a ‘representative’ of an organisation

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MBS review activities have been distributed among several groups

MBS Review Taskforce

Principles & Rules Committee

Service specific working groups

Consultation with stakeholder groups and public

Clinical Committees

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The Clinical Committees are following a consistent five-step approach

Propose changes to items and articulate rationale

Taskforce finalises recommendations to Government

Conduct rapid evidence reviews and targeted analyses as needed for each item

Examine item descriptors and usage patterns to identify items requiring detailed investigation

Colleges, peak bodies and other affected stakeholders are notified of the recommended changes and invited to contribute feedback

Triage 1

Evaluation 2

Clinical Committee Recommendation

3

Taskforce Recommendation

5

Consultation 4

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

Examples of issues raised by stakeholders

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

▪ 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.

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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 o Where good clinical practice requires addition of a service, Minister might ask

MSAC for expedited advice o 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 o Normally will not need MSAC review

▪ Rapid reviews undertaken by a clinical committee may reduce the time required by MSAC in adding new items o Onus is on clinical committee to commission rapid review and make

recommendation

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Obsolete items – first tranche

▪ 23 MBS items were identified by Clinical Committees as obsolete. o Diagnostic Imaging: 58706, 58924, 59503, 59715, 59736, 59760, 61465 o Ear, Nose and Throat Surgery: 11321, 18246, 41680, 41695, 41758, 41761, 41846,

41849, 41852 o Gastroenterology:13500, 13503, 30493, 32078, 32081 o Obstetrics: 16504 o 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

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To ensure the Review is clinically led, each category is being evaluated by a peer-nominated clinical committee

Chair Examples of members

Obstetrics Prof. Michael Permezel

Midwife, GP obstetrician, specialist OB, rural obstetrician, pathologist

Prof. Ken Thomson Radiologist, nuclear medicine specialist, GP, health economist

Prof. Anne Duggan Gastroenterologist, general surgeon, GE nurse, GP

Prof. Christine Jenkins Thoracic medicine, respiratory and sleep specialists, GP

Prof. Patrick Guiney ENT surgeon, paediatrician, GP working in Indigenous health

Clinical Committee – First Tranche

Diagnostic Imaging

Thoracic

Ear, Nose and Throat

Pathology

Gastroenterology

Associate Prof. Peter Stewart

Pathologist, haematologist, endocrinologist, immunologist

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Clinical Committees – Second tranche

▪ The second tranche of Clinical Committees is underway ▪ This tranche includes: o Cardiac Services

• Cardiology and cardiothoracic surgery

o Dermatology, Allergy & Immunology • Skin conditions and allergy testing (skin cancer surgery review completed)

o Endocrinology • Includes endocrine surgery

o Intensive Care and Emergency Medicine • Includes neonatology

o Oncology • Chemotherapy and radiation oncology (not cancer surgery)

o Renal Medicine • Includes dialysis

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Public consultations

▪ The Taskforce is committed to engaging with all stakeholders and welcomes input into all aspects of the review o Consultation will occur regularly throughout 2016

▪ Public consultation will follow recommendations from Clinical Committees o Recommendations including obsolete items, rapid reviews, changes to existing

items, new services o Detailed information to provide context and rationale o Targeted consultation by directly contacting organisations with relevant interests o 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

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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

The NHMRC Review

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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

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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.

Primary Health Care

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• 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 on the Department of Health’s website at www.health.gov.au/healthiermedicare

• 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.

PHCAG Final Report

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• 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

Health Care Home model

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• 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

Care Coordination

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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.

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• 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.

Evaluation of the Health Care Home model

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MBSReviews@health.gov.au Email :

www http://www.health.gov.au/internet/main/publishing.nsf/Content/MBSReviewTaskforce Website :