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 in order to improve health outcomes for patients. The Taskforce also seeks to identify any services that may be unnecessary, outdated or potentially unsafe.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 the following key goals:

  • ΔAffordable and universal access.
  • ΔBest‐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 Intensive Care and Emergency Medicine Clinical Committee (the Committee) was established in June 2016 to make recommendations to the Taskforce regarding MBS items in its area of responsibility, based on clinical expertise and rapid evidence review. The Taskforce asked the Committee to review 29 items related to intensive care and emergency medicine. All recommendations relating to these items are included in this report for consultation.

1.1 Areas of responsibility of the Intensive Care and Emergency Medicine Clinical Committee

The Committee was assigned 29 MBS items to review, covering attendance and procedural services related to emergency medicine and intensive care. A complete list of these items can be found in the Appendix A ‐ Index of items.

In the 2014/15 financial year (FY), these items accounted for approximately 760,000 services and $93 million in benefits. Over the past five years, service volumes for these items have grown at 5.1 per cent per year, and the cost of benefits has increased by 7.6 per cent per year. This growth is largely explained by a 3.8 per cent increase per year in services per head of population (Figure 1).

Figure 1: Drivers of growth 1

Figure 1 is a graph that shows the increase in percentage for each of the drivers of growth from 2009-10 to 2014-15. The total benefits increased at 7.6%, due to a 5.1% increase on the number of services and 2.3% increase on the average benefits per service. The increase on the number of services was due to a 1.3% increase on the population and the 3.8% increase on services per 100,000.

SOURCE: MBS COGNOS data

1.2Key recommendations

The Committee has highlighted its most important recommendations below. Of the 29 existing items allocated to the Committee for review, 17 were found to require change or deletion. The majority of recommendations involve revising or restructuring items, and two items have been recommended for removal from the MBS. The Committee has also made recommendations for the Medical Services Advisory Committee (MSAC) to conduct an expedited review regarding the inclusion of new items on the MBS.

The complete recommendations and accompanying rationales for all items can be found in Sections 4 to 6. A complete list of items, including the nature of the recommendations and the page number for each recommendation, can be found in Appendix A ‐ Index of items. These recommendations are provisional and may be revised based on feedback received during consultation.

The recommendations focus on the objectives of the MBS Review: improve access to medical services, encourage best practice, increase value for consumers and the health system, and simplify the MBS to improve both patient and provider experience (for example, through improved transparency around services billed), as well as the efficiency with which the MBS is administered.

Section 4 – Emergency medicine recommendations
  • ΔRestructure Emergency Department (ED) attendance items (501–536) into three tiered base items with add‐on items.
  • – The three tiered base items reflect the differing levels of professional involvement required during emergency attendances, based on the number of differential diagnoses and comorbidities that require consideration.
  • – The add‐on items reflect the significant additional professional involvement associated with issues or tasks that may be performed in an ED context, but that are not a standard component of any particular base item. Specifically, these items cover resuscitation (for half an hour to one hour, one to two hours, or two hours or more), anaesthesia, minor procedures, procedures, fracture / dislocation management excluding aftercare, fracture / dislocation management including aftercare, care for patients above the age of 75 or below the age of two, chemical or physical restraints, and goals of care. Other MBS items should not be used for services (or components of services) provided in the course of an ED attendance (i.e., the proposed add‐on items should be used instead of all existing MBS procedural items).

  • This recommendation focuses on ensuring that ED attendance items accurately reflect the key patient complexity factors that determine the amount of provider skill, time and risk involved. It does so by making the item descriptors clearer, which will provide patients with greater billing transparency, reduce variability in item use for similar services and support ease of auditing.

  • ΔUse a consistent item framework for all emergency attendances, regardless of the provider type. Item descriptions for professional attendances in accredited private EDs should specify the provider type and applicable schedule fee but should otherwise be the same.
  • – A lower MBS benefit should apply if the provider is not an Emergency Medicine Specialist. This ‘scaled access’ to emergency attendance items should provide a fixed proportion of the benefit available for services provided by Emergency Medicine Specialists.
  • This recommendation focuses on improving billing transparency for patients and providers, by ensuring the item billed reflects the nature of the service provided.

Section 5 – Intensive care recommendations
  • ΔLeave items relating to daily management of a patient in an Intensive Care Unit (ICU; items 13870 and 13873) and invasive pressure monitoring (item 13876) unchanged.
  • This recommendation reflects the Committee’s view that these items are functioning as intended, and that item 13876 remains an accurate and appropriate scalable surrogate for the complexity of patients in an ICU.

  • ΔRemove the differential fees for the first day (item 13847) and subsequent days (item 13848) of managing counterpulsation by intraaortic balloon.
  • This recommendation simplifies the MBS and is intended to enhance value for the patient and the health system, recognising that there is no significant difference in the professional involvement required between first and subsequent days of care.

  • ΔConsider an expedited MSAC assessment for listing MBS items for extracorporeal life support, and revise items 13851 and 13854 to clarify that they are intended to cover ventricular assist devices (VADs).
  • This recommendation focuses on addressing ambiguity in the current item descriptors for items 13851 and 13854, and on supporting access to best‐practice health services.

  • ΔRevise the item descriptions for item 13815 (central vein catheterisation) and item 13842 (intra‐arterial cannulation) to encourage ultrasound guidance where clinically appropriate. Where used, ultrasound guidance should not attract payment of benefits separate to those for items 13815 and 13842.
  • This recommendation focuses on supporting best‐practice health services and ensuring value for the patients and the community.

  • ΔIntroduce an MBS item for the discussion and documentation of goals of care by an Intensive Care Specialist. This service is for patients potentially nearing end of life, where alternatives to active management may be an appropriate clinical choice, and where relevant goals of care do not already exist. (See the proposed item descriptor in Section 5.6 for the appropriate clinical indications, required service components and restrictions on use for this item.)
  • This recommendation focuses on supporting access to best‐practice decision‐making services, with the aim of improving both the patient experience and enhancing value for the patient and the health system. The Committee noted that in ideal circumstances, goals of care are defined with a provider who is familiar with the patient, prior to admission to hospital or an ICU. However, if this has not occurred, it is important that patients (and, where relevant, family and carers) receive support to make informed choices prior to embarking on intensive and potentially prolonged treatment.

Section 6 – General recommendations
  • ΔRemove obsolete item 14200 (relating to the practice of gastric lavage in the treatment of ingested poison) from the MBS.
  • ΔConsider an expedited MSAC assessment for listing an MBS item for rapid response system / code blue attendances. This service is for attendances outside of EDs and ICUs by the medical practitioner taking overall responsibility for the patient in the course of the call or code response. It is not claimable in conjunction with ED attendance or ICU daily management items by the same provider.
  • This recommendation focuses on supporting access to this best‐practice health service. It recognises that such attendances require a higher level of professional involvement than other referred attendances because the patient is either unstable or critically ill, and because the provider is unfamiliar with the patient and must attend immediately.

1.3Consumer engagement

The Committee’s membership includes a consumer representative. The Committee recommendations have been summarised for consumers in Appendix B including a full list of all the items and their accompanying recommendations. The summary describes the medical service, the recommendation of the clinical experts and why the recommendation has been made for all major changes and proposed new items.

Importantly however, the Committee believes it is important to find out from consumers if they will be helped or disadvantaged by the recommendations – and how, and why. Following the public consultation the Committee will assess the advice from consumers and decide whether any changes are needed to the recommendations.

The Committee will then send the recommendations to the MBS Taskforce. The Taskforce will consider the recommendations as well as the information provided by consumers in order to make sure that all the important concerns are addressed. The Taskforce will then provide the recommendation to government.

1.4Key consumer impacts

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.

The Committee examined how well descriptions of the 29 MBS items matched current clinical practice and met the needs of Australians. The Committee brought together practitioners with experience in and commitment to the provision of emergency medicine and intensive care services, including Emergency Medicine and Intensive Care Specialists, as well as a Geriatrician and a Consumer Representative. All recommendations are provisional and may be revised based on feedback received during consultation.

The Committee made three recommendations that aim to improve consumer access to best‐practice health services and the consistency with which existing services are delivered in line with best practice:

  • ΔRevise the item descriptions for intra‐arterial cannulation (item 13842) and central vein catheterisation (item 13815) to encourage use of ultrasound guidance.
  • Cannulation and catheterisation of arteries or veins is a procedure that involves inserting a tube (‘catheter’ or ‘cannula’) into a blood vessel. This tube makes it possible to, for example, deliver fluids, obtain blood or measure blood pressure. The tube can be inserted with or without ultrasound guidance. Ultrasound guidance allows the provider to visualise the structures beneath the skin (such as blood vessels, nerves and muscles), which makes it easier to insert the tube accurately without damaging surrounding areas. In modern practice, the use of ultrasound guidance is considered best practice, and it is therefore an integral component of the cannulation / catheterisation service and should not attract separate MBS benefits. However, a blanket requirement for ultrasound guidance is not appropriate as there are circumstances where this is not possible, appropriate or necessary. For example, it may not be necessary for experienced providers, particularly those who were trained before ultrasound was introduced as part of the standard of care.

    This recommendation supports the safe and effective delivery of health services and ensures value for patients and the community.

  • ΔIntroduce MBS items for the discussion and documentation of goals of care by an Emergency Physician or Intensive Care Specialist for patients who are potentially nearing the end of their lives, where alternatives to active management may be an appropriate clinical choice, and where relevant goals of care do not already exist.

    Defining goals of care is a service that involves a comprehensive evaluation of the patient’s issues (including medical, psychological, social and other issues), proactive offering of treatment alternatives (including alternatives to intensive or escalated care), and discussion of these alternatives with the patient (or surrogate decision-maker) and the patient’s family, carers and other health practitioners (where appropriate).

    This recommendation focuses on improving the quality of decision-making (thereby improving patient experience), as well as enhancing value for the patient and the community. The Committee noted consumer feedback that end-of-life decisions are often made without providing sufficient information to patients and their families about the alternatives available to them. At times, this can mean that patients do not realise they have alternatives, resulting in prolonged and futile treatment that patients may not want. The Committee noted that in ideal circumstances, goals of care are defined with a provider who is familiar with the patient, prior to admission to hospital or an ICU. However, if this has not occurred, it is important to support informed choices before embarking on intensive and potentially prolonged treatment.
  • ΔConsider an expedited MSAC assessment for listing an MBS item for rapid response system / code blue attendances.
  • ‘Code blue’ calls are requests for immediate medical professional attendance for medical emergencies such as cardiac arrest. Rapid response systems—such as the Medical Emergency Team (MET) call system—are designed to request immediate medical professional attendance to manage deteriorating patients. The aim is to provide earlier clinical intervention in order to stabilise the patient and prevent further deterioration that could lead to ICU admission or result in cardiac arrest.

    The proposed item is for attendances outside of EDs or ICUs by the medical practitioner taking overall responsibility for the patient in the course of the call or code response. It is not claimable in conjunction with ED attendance or ICU daily management items by the same provider.

    This recommendation focuses on supporting access to this best‐practice health service in order to improve patient health outcomes.

The Committee made one recommendation that aims to ensure that only safe and effective services are listed on the MBS:

  • ΔRemove obsolete item 14200 (relating to the practice of gastric lavage in the treatment of ingested poison) from the MBS.

The Committee made three recommendations that aim to ensure that the items patients are billed for more accurately reflect the services provided, and to clarify and simplify the item descriptors:

  • ΔRestructure ED attendance items into three tiered base items with add‐on items.
  • The three base items reflect the differing levels of professional involvement required in ED attendances, including the time required and the complexity of the service (based on the number of differential diagnoses and comorbidities that require consideration). The add‐on items reflect the significant additional professional involvement required to address additional issues or perform additional tasks (such as the management of a fracture, or the need to define goals of care for a patient potentially nearing the end of his or her life). These new items replace existing MBS items.

    This recommendation focuses on ensuring that ED attendance items accurately reflect the key patient complexity factors that determine the amount of provider skill, time and risk involved. It does so by making the item descriptors clearer, which provides patients with greater billing transparency, reduces variability in item use for similar services and supports ease of auditing.

  • ΔUse a consistent item framework for all emergency attendances, regardless of the provider type. Item descriptions for professional attendances in accredited private EDs should specify the provider type and applicable schedule fee but should otherwise be the same.
  • – A lower MBS benefit should apply if the provider is not an Emergency Medicine. This ‘scaled access’ to emergency attendance items should provide a fixed proportion of the benefit available for services provided by Emergency Medicine Specialists.
  • This recommendation focuses on improving billing transparency for patients and providers, by ensuring the item billed reflects the nature of the service provided.

  • ΔConsider an expedited MSAC assessment for listing MBS items for extracorporeal life support, and revise items 13851 and 13854 to clarify that they are intended to cover ventricular assist devices (VADs).
  • This recommendation focuses on addressing the currently ambiguous item descriptors for items 13851 and 13854, and on supporting access to best‐practice health services.

The Committee made one recommendation that aims to ensure that services funded by the MBS represent good value for the patient and the community:

  • ΔRemove the differential fees for the first day (item 13847) and subsequent days (item 13848) of managing counterpulsation by intraaortic balloon.
  • This recommendation simplifies the MBS and enhances value for the patient and the health system, recognising that there is no significant difference in the professional involvement required between first and subsequent days.

Recommendations fall into two categories, each of which has different next steps.

  • ΔRecommendations to the Taskforce. These will be considered by the Taskforce, along with feedback received during public consultation. The Taskforce will decide if these should be endorsed and recommended to the Government. The Government will then decide which recommendations to implement, and the Department of Health and other relevant agencies will work to implement them. This process may take some time.
  • ΔRecommendations to other Clinical Committees. These are areas where the Committee has made recommendations that are within the scope of another Clinical Committee. The relevant Clinical Committee will consider this advice and make a recommendation to the Taskforce. The Taskforce will be aware of the views of both committees when deciding what recommendation to make to the Government. These recommendations may take longer to implement as the timeline depends on the timing of other Clinical Committees.


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