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Medicare review taken off course

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The AMA has demanded the Federal Government recast its approach to the Medicare Benefits Schedule Review as medical researchers have distanced themselves from claims doctors are routinely ordering ineffective and potentially harmful tests and procedures that are costing the nation cost the nation hundreds of millions of dollars each year.

The AMA has reasserted its support for the Medicare Benefits Schedule Review (and the accompanying Primary Health Care Review) as long as it not only about removing outdated services and procedures, but replacing them with items that reflect modern practice.

AMA President Professor Brian Owler told The Australian Financial Review the medical profession backed efforts to update the MBS but “we’re not going to have a Review that takes money away and puts it on the bottom line of the Budget, and the [Health] Minister [Sussan Ley] says that’s where it’s going. It takes services away from patients.”

The blame game

There has been mounting disquiet over the Government’s handling of the Review, including the depth of consultation with clinician representatives and claims that the vast majority of items were not backed by evidence, and around 30 per cent of all care was of little worth.

Fears about the direction the Government was taking were crystallised on 27 September when Ms Ley launched public consultations by arguing that only a tiny fraction of the 5769 items on the MBS had been assessed for effectiveness and safety, and “inefficient and unsafe Medicare services…cost the nation dearly”.

Issuing the call for consumers to participate in the Review, Ms Ley said that, “30 per cent of expenditure is not necessary, wasteful, sometimes even harmful for patients”.

Professor Owler said the claim was not only “factually incorrect”, but was being used by the Government and the Review Taskforce Chair Professor Bruce Robinson to try and frame the discussion around the idea that there were massive savings to be made because doctors were milking the system.

The AMA President said the figure had been uncritically imported form the United States and there had been no evidence to support it in the Australian setting.

Instead, he said, the Government’s real intention was to use the Review to make Budget savings.

“They need to be upfront about what this process is and that it’s a budget preparation measure,” he told the AFR. “We’re having this conversation and it’s ‘No, no, this is not a cost saving exercise’. But, ‘Yes, the cost savings are going to the bottom line of the budget’. They say ‘Yes, we will reinvest’, but it’s going to be a very protracted, drawn out process to get any money back into MBS.”

Follow the evidence

A day after the Government launched the consultation process, ABC television’s Four Corners program aired claims that doctors were ordering tests and performing procedures that were of little or no benefit for patients and cost the nation hundreds of millions of dollars each year, including scans for lower back pain, spinal fusion surgery, knee arthroscopies and inserting stents in patients with stable angina.

Ms Ley seized on the program, which she said had exposed “real – not perceived – waste in health spending”, and demonstrated the need for the MBS Review.

The Minister said medical specialists and health researchers appearing on the program had “put their professional reputations on the line to provide important insight into billions of dollars being spent on unnecessary, outdated, inefficient and even potentially harmful procedures”.

But two researchers whose work was drawn on in the Four Corners program to help substantiate claims that doctors used inappropriate and unnecessary tests and procedures said their data had been misinterpreted and taken out of context.

Writing in Medical Observer, Associate Professor Helena Britt and Associate Professor Graeme Miller said that although their research showed GPs ordered imaging in about 25 per cent of new cases of low back pain, “conversely, we could equally state that 75 per cent of new cases were not sent for imaging”.

The researchers said that while they did conclude that the rate of imaging for back problems at the initial encounter was inconsistent with guidelines, this was only the case if there were no ‘red flag’ issues present, such as significant trauma, fever, weight loss, inflammatory conditions or advanced age.

“Unfortunately,” they said, “we cannot identify whether or not patients referred for imaging for back symptoms had any of these red flags, but the guidelines suggest that zero imaging for all cases would not represent best quality care.”

Ms Ley rejected claims the Government had launched an attack on the medical profession, and asserted that 97 per cent of MBS items had never been assessed for their clinical effectiveness or safety.

But Professor Owler said the Minister’s claim was “quite misleading”.

While just 3 per cent of items had been assessed through the Medical Services Advisory Committee process, the AMA President said, “but that doesn’t mean that there’s not evidence behind all of the other things that we do”.

He questioned the need for evidence-based reviews for performing life-saving operations: “I don’t need an evidence-based review to say that I should remove the tumour from a child that presents through the emergency department because I know they’re going to end up dead within the week if I don’t do it.”

“There are some things that, yes, we need to evidence-based review, but there are many on the schedule that don’t, and saying that 97 per cent doesn’t have evidence is quite misleading.”

MBS reviews nothing new

He said the medical profession had to be “vigilant” about the narrative being used to shape debate about the Review.

Professor Owler said the AMA not only supported the MBS reviews, but had been engaged with successive governments in undertaking them since 1990. He said in the last five years alone, the AMA had participated in reviews covering 26 areas of the MBS.

“Can we save money? Yes, and the AMA’s more than happy to engage in that process, but let’s actually go through and do the reviews and come up with the evidence before we actually pre-empt what the outcome is and what procedures might have conditions or be removed from the Schedule,” he said.

“The risks to patient care from an emasculated MBS are too great to allow this Review to go off the rails.”

Adrian Rollins