1.      Executive summary

The Medicare Benefits Schedule (MBS) Review Taskforce (the Taskforce) is undertaking a program of work that considers how more than 5,700 items on the MBS can be aligned with contemporary clinical evidence and practice and improves health outcomes for patients. The Taskforce will also seek to identify any services that may be unnecessary, outdated or potentially unsafe.

The Taskforce is committed to providing recommendations to the Minister for Health that will allow the MBS to deliver on each of these four key goals:

Δ Affordable and universal access.

Δ Best-practice health services.

Δ Value for the individual patient.

Δ Value for the health system.

The Taskforce has endorsed a methodology whereby the necessary clinical review of MBS items is undertaken by Clinical Committees and Working Groups. The Taskforce has asked the Clinical Committees to undertake the following tasks:

1. Consider whether there are MBS items that are obsolete and should be removed from the MBS.

2. Consider identified priority reviews of selected MBS services.

3. Develop a program of work to consider the balance of MBS services within its remit and items assigned to the Committee.

4. Advise the Taskforce on relevant general MBS issues identified by the Committee in the course of its deliberations.

The recommendations from the Clinical Committees are released for stakeholder consultation. The Clinical Committees will consider feedback from stakeholders and then provide recommendations to the Taskforce in a Review Report. The Taskforce will consider the Review Report from Clinical Committees and stakeholder feedback before making recommendations to the Minister for Health, for consideration by Government.

The Dermatology, Allergy and Immunology Clinical Committee (the Committee) was established in 2016 to make recommendations to the MBS Review Taskforce on the review of MBS items in its area of responsibility, based on rapid evidence review and clinical expertise. The Taskforce asked the Committee to review prenatal pathology testing as a priority review. The Committee did not consider items that had previously been addressed in the skin services review, nor did it consider skin patch-testing items, which are expected to be amended in November 2016.

1.1        Areas of responsibility of the Dermatology, Allergy and Immunology Clinical Committee

The Committee reviewed 38 MBS items, and all recommendations relating to these items are included in this report. A full list of items and descriptions are listed in Appendix A. A broad set of stakeholders is now engaged in consultation on these recommendations. Following this period of consultation, the recommendations will be presented to the Taskforce. The Taskforce will consider the report and stakeholder feedback before making recommendations to the Minister for Health for consideration by the Government.

It should be noted that recommendations that are eventually made for consideration by the Government will not necessarily reflect the final recommendations made to the Taskforce by the Committee after consultation. As stated, the Taskforce will consider these recommendations, and it may alter recommendations to bring items in line with broader changes that are being made. Additionally, the wording or structuring of item descriptors and explanatory notes may be changed to ensure consistency with the language and structure of the MBS. It should also be noted that the recommendations focus on the services provided by the items. Specific item numbers may be altered during implementation of the eventual recommendations proposed by the Minister for Health. For example, where the Committee has requested that services for item A be consolidated under item B, the actual item number for item B may be changed in some circumstances.

1.2        Key recommendations

The Committee has highlighted its key recommendations below. The complete recommendations and the accompanying rationales for all items can be found below. A complete list of items can be found in Appendix A, along with a brief description of the nature of the recommendation.

The Committee’s recommendations for stakeholder consultation are that seven items should be deleted (and their services no longer provided under the MBS); 28 items should be changed; and three items should remain unchanged. The changes focus on encouraging best practice, improving patient care and safety, and ensuring that MBS services provide value for the patient and the healthcare system. Some of this can be achieved by:

Δ Deleting items that are obsolete, or that provide questionable clinical value or low-value care;

Δ Consolidating or splitting items to address potential misuse;

Δ Modernising item descriptors to reflect best practice; and

Δ Providing clinical guidance for appropriate use through explanatory notes.

The most important recommendations are summarised below.

Δ Item for treating benign neoplasms of skin (other than common warts). Address safety concerns that malignant neoplasms may be missed or misdiagnosed, as well as suspected inappropriate cosmetic use, by deleting item 30195. Neoplasms suspected of malignancy would instead be sent for pathology using biopsy item 30071. Any cosmetic treatment—which the MBS does not fund—would need to be provided privately.

Δ Allergy testing items. Improve quality of care and address concerns about potential misuse by encouraging best-practice allergy testing. This involves:

 Removing the specific item for testing more than 20 allergens, as there are relatively few circumstances in which this is required, and the presence of the item may be encouraging misuse.

 Restructuring item 12000—which would now cover testing for more than and less than 20 allergens—into three new items that cover testing for three distinct groups of allergens and their required scope of practice: (a) aeroallergens, (b) food and latex allergens, and (c) medication (antibiotics and non-general anaesthetic agents) and venom allergens.

 Moving the anaesthetic allergy-testing item (21981) to the same section of the MBS as the above items, and changing the item descriptor to permit testing of all agents in the perioperative period.

 Adding explanatory notes for the items to guide doctors and patients regarding the appropriate providers of the different items.

Δ Wart removal items. Improve quality of care and modernise the MBS by deleting items 30185–6. These items provide sub-optimal treatment compared to other modern treatment methods (such as cryotherapy).

Δ Items for removing more than 10 malignant neoplasms using curettage, laser or cryotherapy. Improve patient safety and address potential misuse by consolidating items for removing more than 10 malignant neoplasms (items 30197 and 30203) under the equivalent items for removing 1 or more malignant neoplasms (items 30196 and 30202). Furthermore, proof of malignancy under item 30196 will require histopathology – a procedure that already requires taking skin tissue, while either histopathology or AMC recognised dermatologist opinion will be required for item 30202.

Δ Phototherapy (PUVA/UVB) items (often used when treating conditions such as psoriasis and vitiligo). Address safety concerns about excess treatment leading to higher risks of skin cancer, and simplify the MBS. This involves (i) combining items 14050 and 14053 into one item number, (ii) setting an upper treatment limit of 150 treatments per patient over a 12-month period, and (iii) requiring initiation and ongoing involvement by a specialist dermatologist.

Δ Laser photocoagulation items (often used to treat vascular abnormalities or malformations). Address safety concerns and modernise and simplify the MBS to improve ease of use and encourage best practice. This involves (i) mandating Therapeutic Goods Administration (TGA) listing for laser equipment; (ii) updating descriptor terminology to reflect modern medical language; (iii) including intense pulsed light (IPL) treatment within item 14100; and (iv) consolidating item numbers 14106, 14109, 14112, 14115 and 14118 into three item numbers, using more intuitive treatment area specifications.

Δ Mohs surgery items (Micrographically controlled serial excision of skin tumours). Address concerns about potentially inappropriate use, which may occur when under-qualified doctors use items 31000–2, or when mohs surgery is performed on inappropriate areas of the body. This involves (i) restricting use of the items to appropriately qualified providers, in cooperation with the Australasian College of Dermatologists; and (ii) changing item descriptors to include specific areas of the body (for example, item 3100-A for head, neck, genitalia, hand, digits, leg (below knee) and foot, and item 3100-B for all other areas) to enable data collection for monitoring purposes. These recommendations also include updating the item descriptor to recognise the term “mohs surgery”, which replaces the previous words “micrographically controlled serial excision”.

1.3        Consumer engagement

Consumers rarely engage directly with MBS item numbers unless they are following up on out of pocket expenses. However, the descriptions of and restrictions on item numbers can have a major impact on consumer health experiences. This section summarises the report’s key recommendations from a consumer perspective. It aims to make it easier for health consumers and members of the general public to understand and comment on the report’s recommendations. Additional information for consumers can be found in Appendix B - Summary for consumers and Appendix C - Glossary.

The Committee considered 38 MBS item numbers relating to dermatology, allergy and immunology. The majority of these items cover the treatment of potential skin cancers and associated conditions. A small group of allergy testing items were also included. In recommending changes, the Committee focused on encouraging best practice treatment, improving consumer care and safety; and ensuring MBS services provide value for consumers and the healthcare system. The Committee’s membership included specialists, GPs and a consumer representative.

The Committee considered that no changes were required to three items, which provide current and medically appropriate treatment.

A further seven items have been recommended for deletion. In particular, this includes deleting several outdated items covering the removal of warts, skin cancers and other lesions by cutting, which are no longer considered best practice. Alternative treatment options, such as freezing, are already covered in the MBS. In many cases, these items are no longer used, with no or almost no claims made against them in recent years.

The Committee recommended changes to 28 items. Generally, these changes include updating the item descriptions to reflect best practice medical treatment, and providing more detailed guidance for medical practitioners on appropriate use of the items. In some cases, this included providing more stringent safety guidelines, such as requiring specialist medical opinion prior to treatment, or limiting the number of times an item can be claimed for safety reasons (such as limiting potential radiation exposure for patients). One particular area where changes are recommended to reflect best practice treatment include modernising and updating laser-based treatments for skin cancers and other lesions to include additional types of lasers, and to ensure that laser equipment is appropriately certified.

Some items were also recommended for removal and/or consolidation with existing items because they were considered to be potentially misused or to provide low value care. This included bulk treatment items (covering procedures such as the removal of more than 10 malignant lesions, or the conduct of more than 20 allergy tests at one time), where evidence suggested that these items were being used more often than expected. The Committee was concerned that these items were potentially being used because they allow treatment providers to claim larger rebates, and has recommended that these bulk treatments be merged with existing non-bulk item numbers.

Finally the Committee also recommended that certain items should be split to better reflect the true scope of practice. An example of this are the proposed changes to the allergy items. They would now specify different types of allergy testing that can be conducted, and provide guidance around the qualifications and experience that medical practitioners need to be able to provide the more technical, complex and potentially risky allergy testing items.