NACCHO Aboriginal Health News Alerts : Sweeping #Medicare changes to curb rorts


 “The taskforce reviewing the $21 billion Medicare Benefits Schedule is finalising the most sweeping changes in more than a decade to crack down on rebate rorts and protect patients, including restricting GPs ordering powerful scans for back pain and reducing the ­number of colonoscopies and sleep tests.

The MBS Review Taskforce has called for feedback on a series of landmark recommendations from specialist clinical committees established to examine areas as diverse as diagnostic imaging and maternity care.”

Sean Parnell The Australian

The new proposals include a requirement for mandatory health testing for pregnant women and new mothers, restrictions on GPs ordering expensive service such as low back scans, and a strict limit on surgeons ­ordering multiple MBS items for a single service.

But perhaps the most significant changes foreshadowed by the taskforce come from its 11-member MBS principles and rules committee, headed by former Royal Australasian College of Surgeons president Michael Grigg and including various ­specialists and a consumer representative.

The committee, tasked with safeguarding Medicare rebates and improving compliance, has called for medical professionals to be required to pass a test on their knowledge of MBS rules and billing requirements before gaining their Medicare provider numbers.

“Many providers have limited awareness of the rules and proc­edures involved in billing for MBS services, and may adopt questionable practices on the advice of colleagues,” the committee warns.

The committee has also seized on the problem of Medicare being billed for up to 18 MBS items for a single service, with flow-on costs to patients.

It recommends a three-item limit, which would ­almost certainly trigger separate examinations of the cost of ­providing a service.

While most services attract three or fewer MBS item number claims, surgical specialties in ­particular bill more frequently: 39 per cent of cardiothoracic surgery benefits, amounting to ­almost $10 million in 2014-15, ­involved four or more MBS items; as did 36 per cent of neurosurgery benefits ($15m), 26 per cent of urogynaecology ($402,019), 17 per cent of ear, nose and throat cases ($17m) and 13 per cent of plastic and reconstructive surgery ($9m).

“This practice is not transparent, (is) potentially unfair and ­appears to be a misuse of the ­intention behind the multiple ­operation rule, although it is ­partly a symptom of the out-of-date nature of many items and their descriptors,” the committee found.

It also concluded that — contrary to the argument that ­patients gained from a higher total of Medicare benefits being claimed — their out-of-pocket expenses were usually higher. It cautioned that “gaming of the MBS for any purpose, even the ostensible benefit of patients, is inappropriate”.

While the review was commissioned after the failure of the GP co-payment policy, there is no ­indication of the scale of potential savings to government. The recom­mendations are yet to be ­costed.

Health Minister Sussan Ley, however, continues to talk of making Medicare sustainable and the head of her department, Martin Bowles, told the taskforce it needed to help government “bend the cost curve”.

More patients are seeing more doctors, more often, and getting more referrals. Between 2004-05 and 2014-15, MBS benefits per capita rose from $492 to $843.

The Australian revealed last week that the taskforce’s interim report, delivered to government in January but not released publicly, showed health professionals nominated largely routine or ­administrative consultations as the most “low-value patient care”.

With medical professions questioning the value of seeing patients in person for repeat ­referrals or prescriptions and signing time-off-work certificates, the review was told other staff could play that role and communication with patients could be by email or text messages.

But the renewed focus on prim­ary care sparked an un­expected social media campaign against government cuts to ­general practice and perceived devaluing of the profession.

Ms Ley apparently felt compelled to respond on Twitter, where, over the weekend, she said health practitioners had nomin­ated the low-value tasks to the ­review, not the government.

When the interim report was released, including data on Medicare expenditure growth, the Royal Australian College of General Practitioners said it “vastly overstates the waste and in­efficiency in general practice” and was being used to fuel a government campaign against GPs.

The committee also sought to maintain the role of GPs as gatekeepers of the system, although recommending changes to time periods and criteria for referrals to specialists, ostensibly to reduce the opportunities for specialists to charge higher fees.

The committee also found fault with clinicians claiming for a consultation when also claiming for a procedure, despite little talking being done.

Taskforce head Bruce Robinson, the former dean of the Sydney Medical School, said health practitioners and consumers were invited to comment on the proposals. He hopes to make recom­mendations to the government by the end of the year.

“What we hope — what all the people who are taking part in this hope — is that by being more sensible about how healthcare dollars are spent we are able to spend them on services that are better value for patients and on more patients who need them,” he said.

Ms Ley previously promised to consider lifting the contentious freeze on Medicare rebate indexation if sufficient savings could be identified by the review and elsewhere, but no time frame was set.


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