Australia’s Medicare Benefits Schedule contains around 6,000 items ranging from brain surgery to treatment for a common cold. It details each medical service as well as the rebate payable by general practitioners and other specialists, including pathology and diagnostic imaging services.
It is the mechanism through which the Commonwealth makes the payments that constitute our universal health insurance scheme, Medicare.
But in such a rapidly changing and expanding field as health, many of these items can be quickly rendered out of date, both in the rebates they pay, and the procedures they fund.
While many medical procedures are now done much faster and with different technology, many prices remain unchanged from the rate set when the procedure was first added to the schedule. Given that clinical services, and the biomedical and comparative effectiveness research that underpins them, change over time, it makes medical and financial sense to regularly review them.
A 2012 study published in the Medical Journal of Australia found that of the 6,000 items on the MBS, barely 3% have been properly assessed against contemporary evidence for safety, effectiveness and cost effectiveness.
In the 2009/10 budget, Labor initiated an independent systematic review of MBS items via an MBS Quality Framework. However, prior to this we also funded the translation of work being conducted nationally and internationally on reducing so-called “low-value” healthcare into the Australian setting.
In Ontario, for example, substantial work had already been undertaken by the Ministry of Health and in the UK the National Institute for Health and Clinical Excellence (Nice) had begun similar work in 2005.
These reviews were successful and have resulted in changes to MBS item rebates, some which occurred with little notice, while others attracted significant attention, as was the case with changes recommended to the rebate paid for cataract surgery.
The work initiated by Labor continues to realise significant savings to this day. One such example has been recent changes to vitamin D testing.
In 2003 Medicare was funding 90,000 vitamin D tests a year. A decade later, this had soared to 4.3m – a staggering 4,800% increase. The cost to Medicare rose from $3m to $145m in a decade for a single blood test, despite a very low prevalence of moderate to severe vitamin D deficiency in Australia.
As a result of Labor’s review process, testing is now refined to better target patients who really do need a Vitamin D test. Combined with another move to split Folate and Vitamin B12 testing, close to $1bn in savings are being realised over the next five years on just two MBS items.
But this cannot and should not be a case of saving for saving’s sake. It is critical that the focus of such reviews is on quality and safety and that any savings are reinvested back into the healthcare system, and particularly in areas of healthcare reform.
Moves to review the MBS will only succeed where there is strong clinical engagement in the outcome and that the public also understands the value of such decisions made by experts via a transparent, evidence-based process. That is certainly the lesson we learned in government and one that is guiding international efforts in this area.
A key mechanism to update the MBS is the Choosing Wisely initiative, established in Philadelphia that has expanded to 12 countries and is soon to be launched in Australia by NPS MedicineWise.
Peak medical colleges and consumer groups will collaborate in this national initiative to identify tests, treatments and procedures that are commonly used but can often provide no or limited benefit to the patient and in some cases, lead to harm.
Lists of tests, treatments and procedures that should be considered or questioned will be developed by participating medical colleges and societies.
This is good, and smart health reform, based on evidence, quality and safety in healthcare. It is not about rationing healthcare but ensuring informed decisions on the part of both doctors and patients about the best approaches.
A government-sponsored systematic review of the MBS can complement the work of Choosing Wisely. But it needs to be transparent, have strong input from clinicians and be based on a reinvestment of savings in healthcare.
We are pleased to see the Abbott government now seeking to adopt Labor’s reform process. We are willing to ignore the irony that this process was vigorously rejected by them in opposition with ferocious campaigns against proposed reforms to the MBS items for cataract surgery and a PBS review on cancer drugs.
Our only concern is that this government will revert to type and simply use the work as another excuse to rip money out of healthcare, instead of pursuing the great opportunities offered for healthcare reform in the MBS.
Sadly, that is exactly what it has done with the savings from the changes to vitamin D tests, as indeed it has been the case with every one of its cuts to health.
Working with clinicians to improve the quality, safety and cost-effectiveness of healthcare is how a government that is genuinely committed to Medicare sustains Medicare and modernises Medicare as an affordable healthcare system for all Australians.
Until the current government recognises this, and stops using such exercises as an excuse to rip money out of healthcare, then any proposals it presents to review MBS items will deservedly be met by the profession with the greatest suspicion