6 May 2019

College slams MBS pain proposals

General Practice MBS Pain

The committee reviewing pain management for the MBS Review Taskforce has got it “completely wrong” on the role of general practice, the RACGP says, and its proposals would fragment care while claiming to do the opposite.

The Pain Management Clinical Committee’s draft recommendations focus on pain as a single condition, the college’s submission says, when most chronic pain patients have a complex mix of health concerns.

And the college strongly rejects the idea that GPs should have to complete a six-month pain diploma before they can claim a proposed new chronic pain item, suggesting instead that pain doctors learn the fundamentals of generalism.

Dr Mark Morgan, chair of the RACGP’s Expert Committee on Quality Care, told The Medical Republic the college had no issue with the recommendations about specific clinical and surgical elements of pain care that made up the bulk of the report.

But when it came to a model of patient management that effectively sidelined the general practitioner while keeping them “informed”, he said the recommendations reflected the lack of GP representation on the committee.

“They said the management of chronic pain needed a biopsychosocial and cultural overview, and that the tenets of management were self-management and long-term multidisciplinary care, which we have no argument against,” said Dr Morgan, who is associate dean of external engagement in Bond University’s Faculty of Health Sciences & Medicine, and who sits on the MBS Review’s General Practice and Primary Care Clinical Committee and its Allied Health Reference Group.

“But then it suggested chronic pain specialists be able to write something that looks like a GP management plan but for a single condition, and directly access allied health providers [without GP involvement].

“The rationale for that was that accessing a GP was difficult and costly and unnecessary and ineffective, and fragmented the care.

“I think that’s completely wrong. You have a group of people [specialists] who are geographically restricted to major urban centres, creating a multidisciplinary team around them, who look after a patient for a short time – typically 10 visits, sometimes more – to deal with a specific issue, albeit with a biopsychosocial approach. Even so, pain is only a subset of what patients have, often they have multiple chronic diseases.

“Then at some point they hand the care back to the GP. I would call that fragmentation.

“What you’re generating there is a silo of people to look after one aspect of a patient’s care, and in a way that’s limited in availability and geographic spread.

“They don’t have a clear understanding of what primary care looks like and the fact that when there’s a good strong primary care system, a patient’s health outcomes and wellbeing and experience and care and cost of care and connection within the community all improve.

“We are the group of people who don’t have a financial conflict – we’re not building an empire for our subspecialty – we are able to look at the whole of the patient, and understand where their family fits, what the community can offer in terms of social referring. We can build relationships with our own referral networks with allied health, often within our primary care teams, to provide that longitudinal care and deal with any exacerbations of the condition, well after the specialist team involvement has ceased.”

The proposal for a Chronic Pain Management Plan item to be accessible only to diploma-accredited GPs was also a major concern, he said.

The RACGP submission counter-proposes “that pain management specialists undertake a significant placement in general practice in order to learn the skills of longitudinal care across the ages, with attention to multimorbidity and use of available community resources”.

Dr Morgan said GPs were continually upskilling to fit the needs of their patients. 

“Micro-credentialling would create a block to continuity of care. It’d be much more sensible to upskill these specialists in general practice, to understand community care, longitudinal care, impact of families and cultures.

“It’s a little tongue-in-cheek, but I think it’s a serious point. They talk about biopsychosocial practice, and that’s where GPs have expertise.

“We want GPs to look at the goals and what’s been achieved and work out next steps, with a shift over time to self-management and prevention and community activities and successful employment, rather than an unending number of visits to allied health providers.”

Dr Morgan said the college was not in favour of disease-specific item numbers and that schedule should value high-quality care, longer consults when necessary and GP-led team-based care.

He said many of the MBS review committees were looking to add fee-for-service items at the severe end of the spectrum, where patients were currently served by hospitals and outpatient clinics.

If they became Medicare items, he said, those services would be cut and there would be no net  gain, just cost-shifting.