Australian Association of Consultant Physicians

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MBS Review

Report of the MBS Principles and Rules Committee (PRC)

AACP response to PRC Report
 

The MBS Review is now well underway and a number of reports have been released over the past few weeks for comment. The AACP has been making representations at various times to the MBS Review and has made a number of nominations for consideration for membership of clinical committees.

Most recently the AACP has responded on the MBS Principles and Rules Committee’s (PRC) Report. This committee was established: “to consider matters falling within the scope of the MBS Review which are not of a strictly clinical nature. This includes the examination, and updating where appropriate, of the legislative and regulatory framework underpinning the MBS, but also involves consideration of broader questions about the principles, objectives and boundaries shaping the MBS’s conceptual approach and its impact in practice”.

The Committee has made recommendations on the following issues:

  • Provider education in MBS rules and processes

  • The ‘complete medical service’ and the multiple operation rule

  • Initial vs subsequent attendances and determining a single course of treatment

  • Removal of the differential MBS fee structure for remaining ‘G&S’ items

  • Co-claiming attendances with procedures

  • Aftercare

  • Specialist to specialist referrals

While it has responded on all the recommendations, the AACP has particularly focussed on the matter of initial vs subsequent attendances and determining a single course of treatment, because the PRC’s recommendations do not appear to recognise the broad range of situations applicable to consultant physician / consultant paediatric practice that would be affected by the PRC’s recommendations were they to be implemented.

The AACP is following this issue closely and the AACP is arranging for the President to meet with the Taskforce Chairman shortly to discuss these and other issues.

The AACP is concerned about the potential impact of this recommendation if implemented, and pointed out the importance of consultation between the various committees of the MBS Review to ensure that recommendations will not have unintended consequences. The committee dealing with CPP / specialist consultations has not yet been established.

Initial vs subsequent attendances and determining a single course of treatment

The questions of when an initial attendance item may be charged and what constitutes a “single course of treatment” were looked at by the PRC.

The PRC’s report included data that showed instances of billing for initial attendances with a “new referral”, but at the same time the PRC acknowledged that: “most specialists and consultant physicians who see patients on an ongoing basis do not claim a new initial attendance item (item 104 or 110) after a defined period”. The PRC noted the data support this. The PRC’s report also noted that it is not possible to ascertain from the data which are genuine new courses of treatment for different conditions.

In view of the above comments in the PRC’s report, it is therefore not clear why the committee has recommended:

That only one initial attendance item be claimed in relation to any single course of treatment for a particular patient, regardless of the duration of that course of treatment. All other attendances are to be considered subsequent attendances.

since this recommendation is not supported by the data the PRC has quoted.

Further, while the PRC noted that the current explanatory notes make provision for a range of reasons to support charging an initial attendance item, the PRC has determined that “there seems to be an excess of initial specialist and consultant physician attendances (items 104 and 110) being claimed” that it attributes “in part ... to confusion over whether initiation of a new referral is linked to the ability to claim an initial attendance”.

The AACP’s response was that what constitutes a “single episode of care” is not always clearcut. For example, we pointed out that a sub-specialist who deals with cardiac problems may only deal with that condition for his/her patients and thus the condition may be defined as a "single episode of care". However a sub-specialist consultant physician / consultant paediatrician who is dealing with patients with diabetes may also be managing a range of other related conditions such as heart disease, cerebrovascular disease, kidney disease and nerve disease and, at any stage, additional morbidities may present. The PRC’s recommendations suggested a lack of understanding of these situations.

Similarly, rheumatologists and nephrologists may also be dealing with multiple conditions. Therefore, restrictions which determine that only a subsequent item may be billed fail to acknowledge not only the ongoing complexity of the patient’s condition, but also the frequency with which the patient’s condition changes such that the CPP is no longer dealing with what might have originally been defined as a “single course of treatment”.

Accordingly, the PRC’s recommendation is not supported by the available data, nor does it reflect CPP practice.

The PRC has proposed other options for discussion:

  • Amending rules and definitions around the concept of a ‘single course of treatment’ to improve clarity

  • Introducing a time-tiered attendances structure for specialists and consultant physicians, as currently applies to GP attendances

  • Abolishing the initial/subsequent attendance structure and replacing it with a new single specialist attendance item, supplemented by an extended specialist attendance item where the attendance lasts for longer than, say, 40 minutes. The fee for the ‘new’ specialist attendance item would be designed to be cost neutral overall.

The PRC is referring these views to the Specialist/Consultant Physician Attendances Clinical Committee for consideration. The AACP has made a number of nominations for this committee.

Clearly any changes to the above would be significant and the AACP is developing submissions on these matters.

AACP members are encouraged to have their say on all the above issues and provide their input both directly to the MBS Review when these issues are being considered by the Specialist/Consultant Physician Attendances Clinical Committee and also to provide input to the AACP, together with any relevant data, to assist with our next round of submissions.

Finally, the PRC has acknowledged the importance of the referral system as a “key operational component of Australia’s healthcare system”; the AACP also strongly endorses the continuation of the referral system. A copy of the AACP’s recent submission on referrals (with data drawn from the AACP’s referrals survey) was attached to the AACP’s submission on the PRC’s recommendations.

 

 

 

 

 

 

 

 

Medical Board of Australia

Consultations about a proposal for revalidation
of medical practitioners in Australia

AACP Response 

(November 2016) 

The AACP council reviewed the proposals put forward by an expert advisory group of the Medical Board. In broad terms the AACP considers that the present CPD arrangements, generally undertaken in association with one of the clinical colleges, and linked to ongoing registration provide appropriate basis for the medical profession to maintain clinical currency and to practice quality medicine in a safe manner.

The council was concerned that the proposed integrated revalidation process as set out in the consultation document did not provide a compelling case that the proposed much more complex revalidation process would deliver significant improvements.  At the same time there has been concern that revalidation on the basis outlined would become unwieldy, complex, time consuming and costly. Therefore, an enhanced form of CPD that did not introduce significant additional costs would appear the more appropriate approach.

Having said that, it was noted also that many medical practitioners question the need for any revalidation process apart from the annual renewal process which is already linked to CPD and the AACP's view was that the evidence base to support the need for revalidation along the lines proposed needed to be more clearly articulated, as would the evidence to support the value of each different element.

Other concerns identified are that a comprehensive program such as that introduced in the UK have led to a high level of regulation and considerable administrative workload and significant time demands for medical practitioners. While it is understood the UK model is unlikely to be pursued, the experience of that model should convince the Medical Board that a much more practical approach should be undertaken in Australia if revalidation is to be pursued.

Medical practitioners work in a wide range of settings in Australia – in both public and private sectors – and under a range of governance arrangements. As such, any revalidation program that has reliance on audit and peer review must be adaptable to a wide range of circumstances. Much support for aspects of the proposed revalidation are based on practitioners working in settings where there are extensive clinical governance arrangements in place that can be utilised for revalidation activities; for medical practitioners in private practice the same governance structures are not available and they would potentially be disadvantaged by not having access to existing structures. Overall, there is significant potential for revalidation to become an undue financial burden on medical practitioners.

The issue of identifying “at risk” practitioners presents a range of challenges, not the least of which is that identification of medical practitioners aged 35 and older and particularly males as “at risk” has been seen as insulting by many specialists; it should be noted that at 35 a large proportion would have only recently completed their advanced training. The whole issue of how to identify an “at risk” practitioner needs to be further considered. Notifications and complaints, particularly under the mandatory reporting requirement, need to be seen in the context that only a proportion of these will subsequently be proved. The number of complaints does not provide an accurate picture of how many potentially “at risk” practitioners there are.

The AACP considers that the colleges and specialist organisations have the key role in supporting and assisting medical practitioners that are genuinely identified as having performance issues given their role in training, accreditation and credentialling.

The AACP reiterates that the proposed revalidation process appears overly complex, potentially costly and unreasonably difficult for those without ready access to hospital based governance structures or who work in non-metropolitan settings and would like to see a simpler process that acknowledges the professionalism of medical practitioners in maintaining their professional standards and builds on existing CPD arrangements.

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The Pomegranate

home croppedThe pomegranate originated in Iran and Afghanistan. In Persian writing, the pomegranate confers invincibility. In Greek and Roman mythology, pomegranates are linked to Persephone who, each year, returned from the Underworld to mark the start of spring. Spring is associated with regeneration, fertility and abundance. Hence, the pomegranate decorates the religious artifacts of many of the major religions. The medical profession has embraced the symbolism - that of health and life.