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MBS Review process leaves much to be desired

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BY CHRIS JOHNSON AND LUKE TOY

The AMA is growing increasingly frustrated at the lack of transparency in the MBS Review process.

AMA President Dr Tony Bartone has written to the MBS Taskforce Chair, Professor Bruce Robinson, warning him that the peak medical body is fast losing confidence in the Review (see separate article in this edition).

The Taskforce has recently dumped numerous Clinical Committee reports out for consultation at the same time, demanding responses within short timeframes in a “targeted consultation” – meaning that the reports are not widely available.

Dr Bartone said the Taskforce had worked on recommendations over the past few years, but now wants the medical profession to respond in just a few weeks or months.

He has asked Professor Robinson to ensure these “unreasonable timeframes” are extended and that his Taskforce be more flexible in its consultation.

Dr Bartone also asked that the reports be made publicly available on the internet.

“This will ensure transparency of the review process,” he said.

The MBS Review Taskforce is assessing upwards of 5000 items on the Medicare schedule with regards to best practice and value for money.

Glaring examples of the irregularity of the Taskforce’s work include the oncology review failing to consult with the Royal Australasian College of Surgeons; and the colonoscopy review inadvertently excluding the Australian Private Hospitals Association.

These are just a few examples.

“But it’s not just the Review – if we don’t change how the implementation is carried out then we will have major financial issues as well,” Dr Bartone said.

The AMA has raised with the Health Department, and the Health Minister on behalf of the AMA and the membership, the fact that making significant changes, without adequate lead time before commencement, means that neither the health funds, members, the AMA, or patients are able to be part of an informed financial consent process.

This is because while the Department may be ready to implement items on a set date, unless they give the AMA, the health insurers and the profession time to know what the changes are, how they relate to the previous items, and then the ability to adapt their own schedules using the same methodology, a level of confusion will be created.

“You’ll either end up with insurers not ready with their benefit schedules, or insurers pricing the same service under the new items at a different price due to not having the information they need, or both,” Dr Bartone said.

“How do I know this? Well that’s what is happening right now with the 1 November changes.”

AMA members are upset because they don’t know what to charge under particular insurance arrangements or insurers gap schemes, and therefore can’t do an informed financial consent.

One insurer has already lowered one fee for the same service, while other insurers are not yet ready with their benefit schedules. Indeed, most of the major funds have not yet been able to revise their schedules, despite it being two weeks after the items have taken effect.

Without insurance schedules many patients will suffer from increased out of pocket costs, since insurers haven’t been able to help doctors set fees at the no or known gap levels.

Worse, without insurance schedules, insurers may have to revert to default payments which are only 25 per cent of the MBS rate. This could deliver even larger out of pockets and significant short time bill shock, even when patients have high levels of coverage and have undertaken their due diligence.

In the long-term we could see potentially even more variation across benefit schedules and inconsistencies with the intent of both the MBS Review and the Private Health Insurance reforms.

In reviewing the new items, it is clear the MBS Review team has given considered thought to amalgamating, deleting, streamlining and creating new items.

It has also employed a detailed process for generating new fees across the new items, with consideration to fee relativity compared to the old item structure.

“Yet these changes and their intent will not be realised if the methodology for achieving the new structure is not released, and if sufficient time isn’t allowed for the sector to adapt,” Dr Bartone said.

“And it wouldn’t be the insurers fault, nor the profession, nor the patients – we’ll have managed to create yet another problem simply from the implementation process.”

To that end, the AMA has called Government to:

  • Increase the lead time it provides before new items take effect
  • Provide the methodology and logic behind the changes, to give the funds and the chance to consider this
  • Convene a roundtable or consultation with the AMA and the funds about what else is required to protect patients from the potential of out of pocket expenses during the interim period. 

“Of course, this becomes all the more important when you consider the Gold Silver Bronze system has clinical definitions that are underpinned by stipulated MBS items,” Dr Bartone said.

 

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