Medicare Benefits Schedule
MBS review update
Since 2015, the Federal Government has been undertaking a review of the Medicare Benefits Schedule (MBS) to consider how medical services can be aligned with contemporary clinical evidence and practice. The work is being led by the MBS Review Taskforce and a number of clinical sub-committees and working groups have been established to review all 5,700 items.
The APA provided a submission to the Medicare Benefits Schedule Review Taskforce in July 2018. The submission reinforces our support for high-value physiotherapy that is safe, sustainable and grounded in evidence. Our submission reflects our continued commitment to pursuing an MBS that enables physiotherapists to increase consumer access to safe, high quality physiotherapy that cuts unnecessary red tape.
All reports have now been produced by the committees and are on the MBS review website. A full review of all 50 committee reports has been conducted and we have identified all recommendations that may impact physiotherapy. We have attended the Allied Health forum and have provided a submission, informed by the National Pain Group, to the Pain Management Committee.
The APA will be making further submissions to the Allied Health Reference Group, and the Aboriginal and Torres Strait Islander Clinical Committee. We are currently collecting feedback to inform our response to the recommendations in the Allied Health Report and would like to invite your feedback. A survey is available here.
Alternatively individual submissions can be made directly to Shelley.Crowther@australian.physio.
Update on the recommendations from the Taskforce Reports
We were pleased to see that many of our recommendations have been taken up across a number of committees; we will be providing further support for these recommendations to be approved by the Minister.
We called for the introduction of an initial assessment consultation under the CDM items for allied health professionals – this recognises that it is standard practice to conduct an initial assessment and supports the provision of high quality care. This recommendation for initial consultations to be 40 mins or more is welcomed as independent research commissioned by the APA in 2017 indicated that initial consultations last, on average, 40.29 minutes.
We recommend the Taskforce support payment of a fee/benefit when a physiotherapist participates in a case conference for which the GP or consultant medical specialist service is subsidised under the MBS. Currently when a physiotherapist provides a professional service by participating in such a case conference this service does not attract a fee/rebate. This recommendation has been taken up in the General Practice Primary Care Clinical Committee report and the Pain Management Clinical Committee Report. We will be providing further support in our submission to the Pain Management Clinical Committee.
We recommended the Taskforce support the inclusion of children in out-of-home care as a category of people eligible for health assessments and eligible for a GP Management Plan and as a result, children in out-of-home care are now eligible for health assessments and eligible for a GP Management Plan.
Our advocacy on the role of allied health practitioner in the health system and the need for more funding to support high quality research to build the evidence base has also been taken up as a longer term goal. We welcome the recommendation to conduct a review of the evidence for group allied health interventions to inform future models of care, as we believe this will highlight physiotherapy’s critical role. We are confident that there is a large volume of evidence available to support the current practice of physiotherapy, however note the current difficulty in accessing funding to conduct research that supports system change – such as cost-effectiveness studies – and welcome further investment.
We are pleased that the review has actively worked to enhance access to high quality allied health care for people with Autism Spectrum Disorder, Pervasive Developmental Disorder and complex Neurodevelopmental Disorder or disabilities.
We are particularly pleased with the recommendations from the Pain Management Report and we have voiced this strongly in our submission, supporting all of the relevant recommendations with sound evidence.
We recommended the Taskforce support a new MBS listing for an initial assessment for an interdisciplinary pain education and self-management program; and an interdisciplinary group service for pain management be introduced.
We support the Taskforce’s directions against recommendation to improve access to multidisciplinary pain management planning across the options (a to d) and the key shift that sees chronic pain recognised as a chronic disease (item b). We particularly welcome the extension of multidisciplinary assessment and case conferencing items for each member of the treating team (item d) to enable a stronger system response. We are pleased to see the recommendation to improve access to appropriately trained allied health services. The focus on enabling the allied health workforce through funded visits to support those living with chronic pain is welcomed.
This recommendation provides further detail relating to how the policy might operate through a tiered need-based approach under the current chronic disease items. The direct referral by a Specialist Pain Medicine Physician addresses a key system constraint. The current fragmented approach sees a patient returning to their GP for referral. The suggested approach offers a more streamlined approach limiting duplication and provides a more affordable outcome for the patient.
We are happy that our recommendation for access to appropriately spaced multidisciplinary review of the person and the management plan has been supported through the inclusion of a Multidisciplinary Chronic Pain Management Plan and patient review item with case conferencing provision extending to the full treating team is an important requirement to support the objectives of the framework.
The key recommendation to introduce a new item to support group treatment programs in allied health for patients to access on completion of their Chronic Pain Management Plan will provide further support in the interdisciplinary treatment of comorbid pain. Intensive pain management group programs have a significant positive impact on chronic pain patients. Ensuring appropriate reach across a broad range of accredited medical or allied health practitioners, specifically physiotherapists, is welcomed.
The APA supports the Pain Management Clinical Committee direction for the introduction of pain management specific telehealth items for multidisciplinary (medical, nursing and/or allied health professionals) assessment and review for pain management patients. As stated in our Supplementary Submission (June 2018), telemedicine is a proven cost-effective strategy for chronic pain management. There is a broad and rapidly increasing body of evidence that demonstrates that digitally-supported physiotherapy can be effective. The evidence-base for video consultations is rapidly expanding.
We recommend that the new MBS listing for early intervention physiotherapy services for people at risk of persistent pain be introduced as an interim measure (for two years) to enable an application for long-term funding to be considered by the MSAC, however this has not been directly addressed and we will highlight this in our submission.
A number of recommendations closely met our requests, but we would like to see some of the issues more fully addressed.
We recommended the Taskforce support five exclusive physiotherapy services in any one year in addition to five (non-physiotherapy) allied health services.
Although the recommendation from the Allied Health Reference Group is to increase the number of allied health appointments under team care arrangements by stratifying patients to identify those with more complex care requirement we are concerned that this may not sufficiently address the number required for physiotherapy. We will continue to advocate for five exclusive physiotherapy CDM services in any one year in addition to five (non-physiotherapy) allied health services. We are also concerned that the recommendation to add non-dispensing pharmacists to the list of eligible allied health professionals under the MBS may further reduce access. We will be requesting that there is physiotherapist involvement in any decision-making – not just GP – and that it is not administratively burdensome on either practitioner or consumer.
We were pleased to see that our recommendation to support the inclusion of video-consultations between a patient and their physiotherapist as a form of consultation and to expand the role of telehealth in allied health care has been included. The introduction of an interim number is supported but the provision for this to occur after two face to face session by the principle treating practitioner could make this unworkable. We have voiced this to the committee and we are confident that we will see this change.
Our recommendation to not limit telehealth access to rural areas was not taken up by the Allied Health Reference group but it was supported in the General Practice Primary Care Clinical Committee report and the Pain Management Clinical Committee Report which identify frailty and disability as criteria that support provision of services in urban metropolitan areas. We will be using this to support our argument in our submission to the Allied Health Reference Group.
The next steps
Our next step is to address our recommendations that have not been taken up in the draft reports.
We raised concerns about anomalies in the fees and benefits for patients in some cases of diagnostic imaging in our submission to the Taskforce. We were initially concerned that it did not appear to have been directly addressed in the reports, however, this has been raised directly with the taskforce, who recognised this as an anomaly. We understand that other such anomalies are being addressed, and we expect that it will be addressed following our next submission.
We raised the way in which direct referral from a physiotherapist to a consultant medical specialist could improve value in our initial submission to the Taskforce.
One in 20 Australians live in an area with severely reduced access to the services of a general practitioner (GP). In some of Australia’s most underserviced areas, only half the number of GP services per person are provided, compared with those provided to people living in metropolitan areas.
This means that the patients of physiotherapists in rural areas, who already have restricted access to consultant medical specialists, have an additional hurdle when accessing the most suitable medical practitioner.
Allowing for direct physiotherapy referral to specialist medical practitioners will better utilise the existing workforce, cut red tape and free up GPs to dedicate more time to complex clinical care.
The rationale for retaining GPs as the primary source of referral has been the importance of continuity of care. However recent research suggests that a significant proportion of general practice care is delivered away from ‘usual’ or home practices, with over one-quarter of the study’s sample attending more than one practice in the previous year. This has potential implications for continuity of care.
Within their scope of practice, optometrists, dentists, midwives and nurse practitioners are able to make referrals directly to consultant medical specialists. The same principle needs to apply to physiotherapists.
Additionally, items 81105, 81115 and 81125 allow diabetes educators, exercise physiologists and dieticians to provide group diabetes education services for eligible patients. Physiotherapists are equally if not better qualified than exercise physiologists to provide evidence-based group exercise programs. We have argued that physiotherapists have comprehensive knowledge of the underpinning pathophysiology and use this knowledge to develop clinically appropriate diabetes education programs.
The inclusion of physiotherapists as a professional group able to assess a person’s suitability for group services for the management of Type 2 diabetes and then to provide these group sessions will be a priority in our subsequent report to the Taskforce.
New item number requests
We recognise that the introduction of new services was not in the remit of this review and we support the role of the Medical Services Advisory Committee (MSAC) in appraising new medical services proposed for public funding, and advising Government. However, using the MSAC process can be very problematic, especially when the proposal being made is auspiced by a not-for-profit organisation.
We are concerned that there will be an ongoing problem with the provision of low value services, or an absence of high value services, while the MSAC continues to operate in its current form, and while any review of its processes occurs. This delay is a substantial concern to us, as we see a range of Australians whose care is suboptimal as a result. We will continue to advocate for the following new services, if necessary, through the MSAC process:
- a pulmonary rehabilitation (PR) program by physiotherapists in primary care for patients with chronic lung disease has been proposed to MSAC but not supported. Additionally, a model of funding for pulmonary rehabilitation in Aboriginal communities through Aboriginal Community Controlled Health Services/Aboriginal Medical Services to be proposed on completion of the evaluation of the Breath Easy Walk Easy, Lungs for Life (BE WELL) program;
- a physiotherapy service for the assessment and treatment of pelvic floor disorders, restricted to physiotherapists who have undertaken specific post-entry education;
- a physiotherapy service for the management of complex lymphoedema, and an associated rebate for up to 10 sessions within a 12-month period, using the current Mental Health Care Plan as a model;
- a physiotherapy orthopaedic screening service for patients with specific conditions (e.g. degenerative knees, degenerative rotator cuff), indicatively based on a Level D consultation, on referral from a GP or consultant medical specialist
A number of recommendations that support access to physiotherapy service have been addressed in the Aboriginal and Torres Strait Islander report and we will be utilising the skills of our Aboriginal and Torres Strait Islander Committee to develop a submission to this report.
The following points were not addressed in any report so we will continue to strongly argue them as they impact the practice of physiotherapy:
- change of the relevant Determination such that physiotherapy students undertaking supervised clinical placements as a part of their pre-entry education can provide aspects of physiotherapy services described in the Medicare Benefits Schedule
- make no recommendation that supports a shift of subsiding physiotherapy services under the MBS to a payment model to GPs or general practices until public and professional consultation has occurred.
Duckett S Breadon P Ginnivan L. Access all areas: new solutions for GP shortages in rural Australia, Grattan Institute, Melbourne. 2013.
Haggerty JL Reid RJ Freeman GK et al. Continuity of care: a multidisciplinary review. BMJ. 2003 Nov 22;327(7425):1219-21.
Wright M Hall J van Gool K et al. How common is multiple general practice attendance in Australia? AJGP May 2018;47(5):289-96.
How this helps
This submission is our opportunity to continue advancing the profession by strengthening our position as a highly educated, skilled workforce, well placed to provide high value healthcare services. We are working to ensure members receive adequate and appropriate remuneration for their time and expertise, and consumers receive appropriate benefits for physiotherapy care.