12 September 2016

Why bashing GPs won’t repair the budget

MBS TheHill

 

Once again, GPs are left wondering why they are being unfairly targeted as the key pain point in healthcare spending

The Medicare Benefits Schedule Review Taskforce has stunned GP groups by issuing an interim report loaded with claims of waste and inefficiency in general practice.

The tone of the report, and the manner in which it was leaked to the mainsteam media, were seen as worrying signs that the government was using the MBS review for political purposes after it was weakened by a bruising fight over Medicare policy during the 3 July election campaign.

The RACGP said the document was “yet another example of the federal government seemingly unfairly targeting GPs”.

“It seems that the report uses very limited anecdotal evidence and it makes assumptions and conclusions without an independent evidence-based assessment,” RACGP President Dr Frank Jones told The Medical Republic.

It was a “he-said, she-said” exercise drawing on a small pool of evidence, he said.

“Apart from the fact that we have concerns about the report itself, the fact that it was also leaked with highly selective topics to the general media really only makes the whole debate more problematic. “

The leak led to a report in The Australian newspaper on 6 September under the headline “Routine GP tasks blow out Medicare benefits”, which said having doctors write sickness certificates and repeat prescriptions and conduct “low-value” consultations had been identified as “priority areas” for MBS reforms.

Health Minister Sussan Ley discussed the issue on ABC radio the same day, emphasising the government’s budget constraints and the need to find savings to offset expenses in the health system.

“If the government is paying, effectively, too much for small appointments that aren’t necessarily adding to a person’s overall health, particularly if they have chronic conditions, that money does need to be reinvested,” she said.

“Part of my job as health minister is to make sure that where we see inefficiency we reinvest it for the benefit of patients.”

Ms Ley added: “Labor’s insistence on blocking any changes to Medicare is out-of-date and puts them at odds with health professionals and patients.”

Dr Jones said the college accepted that every part of the health system could make cost efficiencies and was ready to make constructive changes on its turf.

“But really, the inefficiency in general practice pales into absolute insignificance compared with the rest of the health system.”

He said the focus on GPs was unwarranted, given the leading role of general practice in keeping down costs across the health system.

“Why general practice?  It’s obvious that it’s an exaggeration of the true facts, and it’s disappointing that it has come out this way.”

The report has reignited alarm that the MBS review, established in mid-2015 after the government abandoned attempts to introduce a GP co-payment, could drift towards cost-cutting at the expense of sound practice in primary care.

In its response, the Rural Doctors Association of Australia said the most important aim of the MBS review should be quality outcomes for patients, not budget savings.

It warned the government against imposing rules to designate other health practitioners to perform “low-value” consults such as writing sick notes and prescription repeats, saying a “low-value” consultation for one patient could be life-saving for another.

“While health policy-makers might argue that a so-called ‘low value’ or ‘routine’ consult — like getting a repeat prescription — is not something that the MBS should cover a doctor to provide, in reality this is often the only chance a doctor has to follow-up on the overall health of a patient,” RDAA President Dr Ewen McPhee said.

“And it can often show the need for more intensive medical investigations and essential medical care.

“Sometimes a routine consult provides an open door for a patient in discussing more pressing and complex medical issues. So to deny them the opportunity to see the doctor for this can lead to a serious gap in their care.”

Dr McPhee said the opportunity was particularly important in rural and remote Australia, where a visit to the GP could mean a round-trip of hundreds of kilometres.

In his introduction to the interim report, taskforce chair Dr Bruce Robinson said the panel was only at the “end of the beginning” in its work to conduct the first comprehensive review of Medicare and some 5700 item numbers.

Indeed, the taskforce’s special committee on general practice was not even convened when the interim report was compiled, making the prominence of criticisms of GP practices even more surprising.

In feedback and stakeholder forums with consumers and health practitioners, the taskforce said it had heard complaints about GPs’ role in writing referrals to specialists as an area of unnecessary cost.

“Responses on these topics commonly focused on two scenarios: where the gatekeeping function of referrals was seen as unnecessary, or where systems for repeat referrals wasted time and resources,” the report said.

On the first count, it said criticisms from health professionals substantially reflected the views of psychologists, physiotherapists and other allied health practitioners who felt patients should have MBS access to their services without needing GP referrals.

In addition, nearly 200 consumers reported what they regarded as unnecessary GP services, such as visits to get medical certificates and for mental healthcare plan reviews.

Consumers argued that the need for a GP referral could act as a barrier to receiving mental health services, while both consumers and health professionals said the three-month

limit on specialist-to-specialist referrals was inconvenient.

The taskforce said “about 300” health professionals gave specific examples of low-value and high-value usage in an online survey in response to a consultation paper issued in September 2015, as well as examples of potential obsolete items or misuse.

“Chronic disease management items were also frequently cited as low-value services,” the report said.

“One health professional reported that … ‘the Chronic Disease Management (CDM) Plan is often being used in an inappropriate manner.  Referrals under a Team Care Arrangement are often being made purely as a revenue generator by the referring GP/practice nurse. The patient is rarely informed of the MBS fee the referrer will receive by arranging the plan and patients report they are pressured into it. The practice nurse (which is government rebated) usually performs the bulk of the work’.”

“However, another participant at the Sydney stakeholder forum warned against abandoning the CDM program:

‘Yes, [there are] problems with these items but please don’t throw the baby out with bathwater. These items are critical to support team based multi-disciplinary care. Re-engineer the items – don’t disregard them’.”

Unnecessary diagnostic imaging and pathology tests were identified by health professionals and consumers as areas requiring review.

For consumers, such tests were the second most commonly cited as unnecessary services. Nearly 20% of those responding to this question reported having had unnecessary diagnostic imaging and 15% reported unnecessary pathology testing.

Among health professionals, diagnostic imaging was the third most commonly mentioned area of unnecessary expense.

In one welcome development, the interim report revealed an in-principle recommendation that GP fees should be raised to match specialists’ fees for identical procedures.

The taskforce’s MBS Principles and Rules Committee endorsed the call for fee parity in at least 34 services where two items existed with different fees for GPs and specialists.

“The committee recommends abolishing this differential arrangement on the principle that MBS benefits are paid for the provision of a surgical service by a medical practitioner… regardless of the medical practitioner’s background qualifications,” the interim report said.

The call arose from the taskforce’s pilot clinical committees on obstetrics and ear, nose and throat surgery, launched earlier this year to conduct in-depth reviews along with committees on diagnostic imaging, thoracic medicine and gastroenterology.

The committee on general practice was deferred until the second half of this year and will operate until mid-2017.  In total there will be 40 specialty groups.

“It is anticipated that generalists and, in particular, general practitioners will participate in most groups,” the report said.

Dr Jones said GPs should be on every one of the committees, “because we are the gate keepers and we are the referral pathways to all these specialties”.

Weighing into the debate after Ms Ley’s radio comments, AMA President Dr Michael Gannon said health systems around the world that did not require referrals to go through a GP tended to be more expensive and end up with lower-quality consultations.

“Just even listening to the minister again, we always have this story about the need to repair the budget and think about health savings,” Dr Gannon said.  “We support the MBS review, but general practice is simply not the problem. It represents only 6% of the cost of the health system.”

Separately concerns have been raised about a lack of public engagement with the MBS overhaul.

“Now that the review has established a rolling program of clinical committees to examine all Medicare items, there needs to be effective and systemic way for consumers – those with most at stake – to provide meaningful input,” the Consumers Health Forum said.

The lobby group said it was pleased to be engaged to advise on the best ways to engage consumers throughout the review process.

“Our concern, however, is that the review process has been going ahead without adequate and robust input from consumers.”

It said the engagement strategies should include public information in clear, plain English about the review process and how people can contribute, a dedicated public website and a public involvement adviser on every committee.

“The review has made a decision to be ambitious in its approach and seize this unique opportunity to recommend changes to modernise Medicare on all levels … This is all the more reason for consumer insights and advice to be integral.”