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Gatekeeper role of GPs under scrutiny in MBS review

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The crucial gatekeeper role played by GPs is coming under scrutiny as the Federal Government explores a possible overhaul of the operation of Medicare as part of its review of the MBS.

While around 35 Clinical Committees will be set up to conduct an item-by-item review of the MBS, a memorandum by Review Taskforce Chair Professor Bruce Robinson shows “high-level” issues affecting the overall functioning of the Medicare system are also under active consideration.

The Review Chair was at pains to insist that there was no set savings target for the MBS Review, but added there was “a need to look at the full breadth of the $19.1 billion MBS spend, not just general practitioner services”.

His comments came as it was revealed the final results of the MBS Review would not be submitted to the Government until December 2016, almost certainly putting them beyond the next Federal election, which is due by late next year.

Much of the attention so far has been on the Review’s appraisal of more than 5700 items on the MBS, and the fact that it also encompasses an examination of the over-arching rules governing the operation of Medicare is less well known.

But the far-reaching possibilities this entails started to become clearer at a series of stakeholder forums organised by the Taskforce, including fundamental changes in professional roles and responsibilities, models of remuneration, and the use of the MBS to “actively guide” clinical decision-making.

In his report on consultations, Professor Robinson said some had complained that the gatekeeper role played by GPs was limiting the effectiveness of team-based care, such as by requiring all referrals to be made through the GP.

The Taskforce Chair said that though some participants reaffirmed the importance of GPs as gatekeepers, there were suggestions that specialists be able to make direct referrals in selected cases, such as a physiotherapist requesting a knee x-ray.

Suggestions of any dilution in the central role played by GPs in coordinating care fly in the face of the latest advice from health experts here and abroad, who have argued that, far from diminishing the position of the family doctor, governments should enhance it.

In its latest review of the Australian health system, the Organisation for Economic Cooperation and Development argued strongly against any further fragmentation of the health system, and urged that primary health care be strengthened.

And University of Sydney researchers last month reported that GPs were holding health costs down by coordinating the care provided by hospitals, specialists, allied health professionals and community and aged care services.

“If general practice wasn’t at the core of our health care system, it is likely the overall cost of health care would be far higher,” the researchers said.

The MBS Review process has also included discussion about a shift away from the fee-for-service remuneration model to pay for performance – an issue being explored in detail by the Primary Health Care Advisory Group being led by former AMA President Dr Steve Hambleton.

“While many participants felt the MBS could improve quality of care by paying for performance, concerns were voiced that clinicians may be averse to taking on high-risk patients who are unlikely to achieve target outcomes,” Professor Robinson reported. “Furthermore, some rebates may need to reflect the additional risk that providers would be taking on – potentially a complex analysis.”

In addition to exploring so-called ‘macro’ issues, Professor Robinson provided more detail on how the review of individual Medicare items would proceed.

He said each of the Clinical Committees would conduct an initial “triage” of usage patterns, evidence and descriptors to identify items in need of more detailed investigation.

It would then conduct a rapid evidence review and make recommendations to the Taskforce based on its appraisal.

Given the scale of the task, Professor Robinson said the Committees, which would be peer-nominated and clinically-led, would be likely to appoint subsidiary working groups.

Already, six pilot Clinical Committees have been established, including in obstetrics.

The Taskforce Chair said items suggested for review fell into one of six categories: they were obsolete, misused, under-utilised, placed undue restrictions on providers or did not reflect modern practice.

He said participants stressed the importance of Taskforce plans to share the evidence used to support recommendations about items, to improve clinical practice and inform the future direction of research.

The Review Taskforce is due to provide an interim report to the Government by the end of the year.

Professor Robinson’s Memorandum of the MBS Review Taskforce November 2015 Stakeholder Forums can be viewed at: sites/default/files/Summary%20Memorandum%20MBS%20Review%20Stakeholder%20Forums%20November%202015%20%282%29.pdf

Adrian Rollins