PDF version: Introductory presentation - MBS Review stakeholder forums July 2015 (PDF 662 KB large file)

Slide 1: Medicare Benefits Schedule (MBS) Review Stakeholder Forums

Australian Government - Department of Health
Canberra (8 July 2015) / Adelaide (24 July 2015) / Perth (25 July 2015)

Slide 2: Agenda item - Introduction

• Background to the MBS revview
• Why review the MBS?

Slide 3: Australian high-level health outcomes

Larger version of slide 3 (PDF 198 KB)Top of page

Text version of slide 3

This image consists of two bar charts:

Life expectancy at birth (years)

Years per capita, 2013

Country	Life expectancy (years)
Japan	84
Australia	83
Italy	83
Spain	83
Switzerland	83
Canada	82
France	82
Iceland	82
Luxembourg	82
New Zealand	82
Norway	82
South Korea	82
Israel	82
Sweden	82
Austria	81
Finland	81
Germany	81
Portugal	81
United Kingdom	81
Greece	81
Ireland	81
Netherlands	81
Belgium	80
Denmark	80
Chile	80
Slovenia	80
USA	79

Highlighted on this graph is that Australia has the second-highest life expectancy of the listed countries.

Source: World Health Organization Top of page

Self-reported health score

Percentage of population aged 15+ who report their health to be good/ very good, 2011.

Note. This graph provides 2011 data for most countries. Exceptions: for some countries only prior data is available (2006-2010). Newer data is used (2012-2013) where available.

Country	% of population aged 15+ who report their health to be good/ very good
New Zealand	90
Canada	89
USA	88
Australia	85
Israel	84
Ireland	83
Switzerland	82
Sweden	81
Norway	79
Iceland	77
Netherlands	76
Greece	75
United Kingdom	75
Belgium	74
Spain	74
Luxembourg	74
Denmark	71
Austria	70
Turkey	69
Italy	68
France	68
Finland	67
Slovak Republic	66
Mexico	66
Germany	65
Slovenia	63

Highlighted on this graph is that Australia has the fourth-highest self-reported health score of the listed countries.

Source: OECDTop of page

Slide 4: Number of services per person, by age group

Per capita per year
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Text version of slide 4

This line graph shows number of services between the years 2003-04 to 2013-14 for age groups 0-9, 10-19, 20-29, 30-39, 40-49, 50-59, 60-69, 70-79 and 80 and over. Over this period the number of services per person has been trending upwards for all age groups, with the greatest increases occurring for older people. Approximate data for 2003-04 and 2013-14 is as follows (please note that this data is approximate as it has been read from the graph):

Age group	2003-04	2013-14
0-9	6.2	7.4
10-19	5.0	6.7
20-29	8.1	10.1
30-39	9.7	12.8
40-49	10.6	13.7
50-59	14.3	17.7
60-69	20.5	25.7
70-79	26.9	37.3
80 and over	24.9	40.6

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Slide 5: Expenditure through Medicare since 1984

Larger version of slide 5 (PDF 203 KB) Top of page

Text version of slide 5

This cumulative graph shows expenditure through Medicare from about $0.7 billion in 1983-84 to approximately $19.3 billion in 2013-14. The graph is sub-divided into GP services, diagnostic imaging, pathology, operations and procedures, other and specialist attendances. Approximate expenditure for these categories in 2013-14 was as follows (please note that this data is approximate as it has been read from the graph):

Service	Approximate expenditure in 2013-14
GP services	$6.4 b
Diagnostic imaging	$2.9 b
Pathology	$2.6 b
Operations and procedures	$2.1 b
Other	$3.2 b
Specialist attendances	$2.1 b

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Slide 6: Medicare benefits paid in 2013-14 ($19.1 billion)

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.Top of page

Slide 7: The history of the MBS

Timeline:

• 1950 - First schedule underpinned by the National Health Act 1953
• 1970 - MBS to include a list of "Most common fees" for each state
• 1984 - Medicare introduced (replacing Medibank), bulk-billing restored, and Medicare Levy introduced
• 1986 - Listing of separate fees for each state replaced by uniform fees across Australia
• 1991 - MBS reconstructed into categories, groups and subgroups (replacing previous parts and divisions) to better reflect sequence of services
• 1999-2000 - Enhanced Primary Care (EPC) MBS items introduced
• 2004-05 - Chronic Disease Management (CDM) items were introduced to replace the existing EPC care planning items
• 2015 - Over 5,500 active items listed in MBS, 70% of which have not been amended since they were created Top of page

Slide 8 - There are a variety of reasons to review the MBS

• Items not consistent with best practice
• Poor value/ superseded
• Inappropriate frequency/ intensity
• Rebate inappropriate over time
• Need to create space for new items

Slide 9 - Terms of reference for the MBS reviews

In scope

• All current MBS items and the services they describe
• Increasing the value derived from servicesConcerns 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

Out of scope

• Division of responsibilities between Governments – Federation White Paper
• Innovative funding models for chronic and complex – Primary Health Care Advisory Group
• Introduction of new MBS services – Medical Services Advisory Committee
• No savings target – scope for reinvestment Top of page

Slide 10: Methods 1

Top of page

Slide 11: Methods 2

Three stages in the review process:

• Evidence
  • Rapid review of published evidence
  • Medicare data
• Consult
  • Discipline group
  • Broader consultation - community and professional group input
• Recommend
  • Changes to items
  • Changes to rules/ systems

Slide 12: Overview of MBS review process and where this forum fits

• June - Taskforce established
• July - Stakeholder forums
• September - Discussion paper
• December - First report to government
• 2016 - Bulk of reviews
• December 2016 - Second report to government Top of page

Slide 13: Agenda item - What are the major shifts we need to make to how the MBS works?

Slide 14: What are the major shifts we need to make?

Note: This is input received at the Canberra forum.

From	To
Sickness focus	Wellness focus
Silo-ed structure	System view, team-based focus
Activities	Outcomes
Opaque	Transparent (evidence based, data driven, linked/ integrated, pricing assumptions)
Inflexible, discrete	Flexible, bundled
Static	Dynamic and evolving
Dense and lengthy	Simple and short
Prices out of step with cost of delivery	Prices aligned to cost
Inconsistent (across providers, settings)	Consistent
Conservative towards new technology	Embrace new technology
Consumer views not considered	Consumer views considered

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Slide 15: Agenda item - What specific issues should the review consider?

Slide 16: What specific changes should the review consider?

Please discuss specific changes in your groups and populate this page. Consider:

• Macro/ system changes e.g. increase frequency of MBS review
• Cross-discipline changes e.g. identify substantial mismatches between prices and cost of delivery
• Specific changes to item numbers e.g. review of #22020 and investigate whether to bundle this item

Slide 17: Top issues for the MBS review

Note: This is the input received at the Canberra forum.
Macro issues:

1. Increase frequency of MBS review
2. Review referral mechanisms and gatekeeping
3. Improve transparency on MBS usage and variation

Cross work stream issues:

1. Identify substantial mismatches between prices and cost of delivery
2. Create shift from activity to outcomes focus
3. Review of literature to determine impact of new standards of care and technologies
4. Structuring the MBS arrangements to support best clinical practice Top of page

Slide 18: Agenda item - What barriers will we need to address in changing the MBS?

Slide 19: What are the barriers we need to address in changing the MBS?

Note: This is the input received at the Canberra forum.

What are the barriers?	How can we overcome them?
Skepticism on purpose/goal from public, clinicians	Communication – case for change – and consultation
Financial implication to livelihood	Ensure sustainable business models (understand impact, ensure sustainability)
Lack of research / evidence	Build behind evidence base / gather
"Here we go again"	Communication – evidence of political will
Inertia	Clear articulation of benefits and reasons for change
Workload and magnitude of change	Well-designed implementation
Poor data availability	Use linked systems (and improve)/ better use data we have
Complexity of services provided	Focus on quick wins with simple services, acknowledge "reasonable practice" threshold

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Slide 20: Agenda item - How should we prioritise where to focus?

Slide 21: It will be challenging to evaluate over 5,500 items in the review timeframe

The top 15 Medicare Benefits Schedule services in 2013-14 were:

• #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

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

Source: MBS online, accessed 2 July 2015
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Slide 22: How should we prioritise them?

Note: This is the input received at the Canberra forum.

• Various category filters
  • Disease types
  • Patient types
  • Craft groups
  • Areas where models of care rapidly changing
  • Areas with poor outcomes
• High cost / volume / growth
• Degree to which obsolete / unnecessary
• “High priority rules” (e.g., referral requirements)
• Consensus view / expert hypothesis (incl leverage college / society / association expertise)
• Complaint volumes
• Variation – geographic, provider
• Feasibility
• Disparity in prices for same procedure across settings of care

Question – should the approach vary across disciplines?

Slide 23: Agenda item: What are the most effective methods for consulting stakeholders?

Slide 24: What are the most effective methods for consulting stakeholders?

Consumer

• Consumer groups / focus groups
• Citizen juries
• Social media
• Engage through clinicians
• Case studies
• Issues / discussion areas
  • Expert consumer vs “normal” consumer
  • Co-design
  • Survey/email
  • Inform them beforehand
  • Potentially chair Discipline Groups

Clinicians

• Peak bodies / Colleges / Boards
• Case studies
• Scientific meetings
• Written submissions / consultations (2-3 month window)
• Issues / discussion areas
• “Scare campaigns”
• Nominate champions
• Next generation of leaders

Other

• Media – educate, engage
• Q&A response sheets
• Lots of various stakeholders listed! Top of page

Slide 25: Who would you like to nominate for the discipline groups?

Provide name of nominee, organisation, and specialty/ expertise.

Slide 26: MBS review email address

email MBS Reviews