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04 Oct 2019

Moving from the MBS review to implementation and insurer fee setting – what could possibly go wrong?

As members would know, the AMA supported the concept of the Medicare Benefits Schedule (MBS) Review, provided it was clinician-led, because we believe in a system that reflects contemporary best practice.

Of course, like the rest of the profession, we wanted a contemporary system that provides for the innovations and improvements that have been made in medicine, and the opportunities that technological advancements can offer.

As we have repeatedly stated, any review must be one that is based on robust research and a strong evidence base. It also needs to be one that provides adequate patient rebates, so that we don’t end up with a two-tier system – those who can afford treatment and those who can’t.

The MBS Review – A recap

Back in 2015, the medical profession made a commitment to work with the MBS Review and the many Clinical Committees and Working Groups working under the Review Taskforce.

The medical professionals on the Clinical Committees and Working Groups provided considerable time, and expertise, to the promised task of modernising the MBS.

Throughout the Review, the AMA called for a review process that is transparent throughout its full lifespan. This included consultation and feedback on proposed implementation plans, consideration of the overall impacts on health funding, and an understanding of viable service delivery.

The AMA also called for the inclusion of clinicians who have the right experience – those who work with, and use, the MBS daily in private practice. The AMA continued to remind the Government that the MBS was an insurance scheme, not a mechanism to control the clinical judgement and the decision making of highly educated practitioners.

We called for the Review not to be a savings exercise, and for the establishment of a ‘reinvestment fund’ to ensure that every cent taken out of the MBS Review is reinvested in new and improved items. You can read about this in our budget submission and Federal Election campaign document.

Keeping an Eye on the Review

The AMA has also played a critical role in bringing together the profession to respond to the MBS Review. We held a meeting of all the Colleges, Associations, and Societies to discuss the MBS Review, including bringing Professor Bruce Robinson to present to us in Canberra.

We have published regular updates in Australian Medicine, and AMA communication channels, as well as a dedicated website, where you will find every one of the AMA’s responses to the dozens of clinical committees.

Most recently, you will recall the President wrote to all Colleges, Associations, and Societies, and many members, calling for responses to the Specialist and Consultant Physician report.

This was in addition to a survey of our members on their views of the proposed changes.

Despite this extensive advocacy on behalf of, and with, the profession, there is no doubt that some of the decisions taken by the Government will be unpopular and appear to be designed with a focus of savings or compliance in mind. In discussing these publicly, either as an organisation or as individuals, it is important to understand ultimately, despite the efforts of the many clinicians on the many committees, the final decision on each change rests with the Government.

Better Communication

The MBS Review Taskforce recently sent a newsletter updating the profession about its activities. The September 2019 newsletter was the first since June 2017 – over a two-year gap. It’s one of the ‘asks’ that the AMA has been calling for, for quite some time – more regular communications making transparent the work of the Taskforce.

Separate to that, the AMA has called for better fact sheets and education on the forthcoming MBS changes – pleasingly, the Department has now involved NPS MedicineWise to assist with this work. These materials are being refined, line by line, with feedback from the AMA.

There will now be a clearer explanation of what items are being deleted, what are being amended and what are new, and we hope soon an explanation of how the new fees relate to the old structure. They should also start to include examples of claiming, a quick reference guide, and far-easier-to-navigate formats and designs.

Implementation issues on the horizon

As with all important policy development, implementation is critical.

While actively participating in the MBS Review, the AMA has been lobbying the Minister and the Department about implementation concerns. We have repeatedly argued there needs to be adequate lead time for consultation with private health insurers, the relevant profession/s, peak bodies, and various compensation schemes.

This advocacy was rooted in real world experience. The AMA, as members know, has its own Fees List. When, last November, it came time to adapt to the new spinal MBS items (stemming from the Review) three things became apparent – firstly, that the changes were complex; secondly, practitioners, hospitals, and the insurance industry didn’t have the information they needed to implement the fee and descriptor changes; and third, there was simply not enough time to adapt to them.

As a result, no insurer was ready at 1 November with their rebates. Practices and patients could not access rebates. Informed financial consent could not be carried out. The AMA, for its part, couldn’t release its Fees List.

Equally troubling, it was not immediately apparent, based on the information released by the Department, how the old items and their fees relate to the new items and their schedule fees.

It is clear in talking to those involved with the MBS Review that there was deep, considered thought on how the old items should be streamlined and combined into new items. There was a clear methodology for how fees should be transitioned from old items (including taking into account the multiple services rule) to the new item structure. But none of this was publicly available to those who generate or set benefit schedules for the private health system, nor to the AMA.

As a result, it is unsurprising that none of this was reflected in some insurers’ rebates. Unsurprisingly with this confusion, cuts were made to some private health insurance rebates under the new structure, even where there was not a corresponding MBS cut.

It meant the careful deliberations of the MBS Review were not being realised, due to the difference in insurer fee setting responses. The MBS Review determined that some procedures are worth less, while others more. But this wasn’t reflected in the real-world outcomes via insurer schedules.

The AMA Response

Since late 2018, the AMA has undertaken a sustained behind the scenes advocacy campaign.

The AMA wrote to, and met with, the Minister and his office on many occasions, as well as the Secretary of Health and the Department’s Senior Executive Service. We called for the MBS and the PHI areas of the Department to come together to hold a forum for insurers, and for the Chair of the relevant Clinical Committee to spend the day going through the MBS changes. This was necessary so that insurers, practitioners, and hospitals could glean the information they need to translate the changes to their systems.

The most recent forum, held in September 2019, was the first time that such information has been conveyed by the Department as part of a new implementation and communication strategy.

While it was still too late to ensure we avoid all difficulties with the 1 November changes on the horizon, it is a step in the right direction.

Our advocacy will continue to call for this communication approach to be improved, before any more items are released. Without it, we risk confusion, inconsistent responses across the industry, increases and greater variation in out-of-pocket costs for our patients, and the carefully thought out design of the MBS Review being undermined.

It is for this reason have asked for a formal agreement between the AMA and the Department, outlining the information and timing we need to successfully implement wholescale MBS changes.

For our members, this additional information and time is critical in carrying out Informed Financial Consent, as per our guide.

Interestingly, it is one of the occasions where we have the support from the Private Health Insurers, and State and Territory workers compensation providers who are in the same predicament as the profession.

At the time of writing, the Government has not responded in agreeing to the new process. We are hopeful a response will be provided soon.

AMA Fees List Changes

While the AMA has been relentless in our pursuit of the right information at the right time to ensure that the AMA Fees List is ready at the same time as the new MBS item takes effect, we continue to be reliant upon the timelines set by the Department of Health.

We will work to have the AMA Fees List ready as soon as is possible after the MBS items take effect – but it is unlikely it will all be loaded by 1 November 2019. There is a significant volume of changed MBS items expected in anaesthesia, gastroenterology, diagnostic imaging, a new suite of eating disorder items for GPs, specialists and allied health providers, GP telehealth, and several other minor changes.

To better prepare the AMA for the tight timelines, and the considerable volume and expected complexity of the changes, the AMA has undertaken an extensive review of our AMA Fees List processes.

Over many meetings and with Federal Council approval, we have put in place a new Fees List Committee to provide governance of a rigorous, but streamlined, approval process and a new methodology for adaptation of the AMA Fees List.

The AMA has a deep knowledge of the Department’s ongoing and increasingly comprehensive compliance activities targeted at those who may utilise MBS items outside of an item’s descriptor, notes, or intent. The last thing we want is practitioners to breach MBS compliance rules by relying on an AMA item descriptor that differs from an MBS item one.

Because of this, the AMA Fees List, in an attempt to better inform members of these limitations within the MBS, will more closely align item descriptors, along with warning notes where we have identified restrictions in the corresponding MBS items with which we may disagree.

The AMA List will also try as far as possible to reflect the changes in the MBS item structure and fee relativities – while still setting a fair and independent fee suggestion via a robust methodology.

We are very aware that members find great value in the AMA Fees List providing a guide on what a fair fee to charge is for any particular MBS item – failure to adapt the AMA Fees List to a new MBS structure will make life harder for our members, something we wish to avoid.

At the same time, we will continue to ensure that the AMA Fees List represents a fair fee, without leading to excessive fee suggestions, noting the current prolonged media debate about medical fees.

Some MBS changes may not be reflected in the AMA list, and will be clearly marked, to indicate that the AMA does not support the change, and there may be some AMA items retained where there is now no corresponding MBS item.

Our move to an online platform two years ago means that we are now prepared to adapt the AMA Fees List as MBS Review changes roll out – the previous process of printing a physical book once a year would have rendered adapting to the constantly changing MBS a near impossibility.

Finally, in considering any changes to the AMA Fees List we will continue to engage with the relevant Society or Association before our Fees List Committee considers any change.

For the 1 November changes, we have been working closely with representatives from the Australian Society of Anaesthetists (ASA) and the Gastroenterological Society of Australia (GESA) to ensure that we have the anaesthetic and colonoscopy changes ready as close to 1 November as is possible.

Other speciality groups will be consulted on the other expected 1 November changes, including eating disorders, diagnostic imaging, sleep study, further spinal changes, ENT, reconstructive, urology, and cystic fibrosis.

However, these changes will not be able to be reflected in the AMA List in November and will follow anaesthesia and colonoscopy as closely as possible before the end of the year. Of course, our annual fee indexation will occur, ready for 1 November.

There is no doubt the next few years will be interesting ones as we seek to bed down this significant change.



Published: 04 Oct 2019