4.Emergency medicine recommendations and requests

4.1 Emergency Medicine Working Group membership

The Committee formed a Working Group to consider emergency medicine services. The Emergency Medicine Working Group (EDWG) included the members listed in Table 2.

Table 2. Emergency Medicine Working Group members

Name Position/Organisation Interests declared
Dr Michael Ben‐Meir*
(Chair)
Director, Emergency Department, Cabrini
Health
Chair, Private Practice Committee, Australasian
College for Emergency Medicine
None
Dr David Rosengren Director & Emergency Physician, Emergency
Centre, Greenslopes Private Hospital
Senior Lecturer, School of Medicine, The
University of Queensland
Chair, Queensland Clinical Senate
None
Dr David Ward* Emergency Physician, Brisbane Northside
Emergency Centre (Holy Spirit Northside)
Deputy Chair, Accreditation Committee,
Australasian College for Emergency Medicine
None
Ms Eileen Jerga AM * Consumer Representative None
Dr Greg McDonald* Director, Emergency Care, Sydney Adventist
Hospital
Member, Private Practice Committee,
Australasian College for Emergency Medicine
None
Dr Matthew Anstey* Intensive Care Specialist and Director of ICU
Research, Sir Charles Gairdner Hospital
Medical Advisor, Australian Commission on
Safety and Quality in Health Care
Board Member, Choosing Wisely Australia
None
Dr Paul Bailey Director of Emergency Medicine, St John of
God Hospital Murdoch
None
A/Prof Reza Ali* Director, Emergency Medicine Blacktown and
Mount Druitt Emergency Department
None
Dr Yusuf Nagree* Emergency Physician, Fiona Stanley Hospital
Chair, Scientific Committee, Australasian
College for Emergency Medicine
None
A/Prof Sally McCarthy
(Committee Chair)*
Senior Emergency Physician, Prince of Wales
Hospital
Medical Director, Emergency Care Institute
NSW
Clinical Lead, NSW Whole of Hospital Program
NSW Health
Former President, Australasian College for
Emergency Medicine
None

*Also a member of the Committee.

It is noted that the majority of Committee members share a common conflict of interest in reviewing items that are a source of revenue for them (i.e., Committee members claim the items under review). This conflict is inherent in a clinician‐led process, and having been acknowledged by the Committee and the Taskforce, it was agreed that this should not prevent a clinician from participating in the review.

The EDWG developed the following recommendations. Recommendation 2 has been amended by the Taskforce for consistency across the MBS Review. All recommendations have otherwise been endorsed unanimously by the Committee.

4.2 Emergency Department attendance items (501–536)

The MBS currently has 11 items related to ED attendances, of which five (501–515) relate to attendances tiered into five levels of complexity (Levels 1 to 5). The remaining six items (519–536) relate to prolonged attendances for critically ill patients with immediately life‐threatening problems (requiring resuscitation). These items are tiered by time into six categories: up to one hour, two hours, three hours, four hours or five hours, and five hours or more).

These 11 items relate only to services provided at a recognised ED of a private hospital by a medical practitioner who is an Emergency Physician. Emergency Physicians are medical practitioners who are Fellows of the Australasian College for Emergency Medicine (FACEM) and who participate in, and meet the requirements for, quality assurance and maintenance of professional standards by the Australasian College for Emergency Medicine (ACEM).

Table 3: Item introduction table for items 501–536

Item Descriptor Schedule
fee
Volume of
services
FY2014/15
Total
benefits
FY2014/15
Services 5‐year‐
average annual
growth
501 Level 1

Professional attendance on a patient
at a recognised Emergency
Department of a private hospital by a
medical practitioner who is an
emergency medicine physician in the
practice of emergency medicine.

Attendance for the unscheduled
evaluation and management of a
patient requiring the taking of a
problem focused history, limited
examination, diagnosis and initiation
of appropriate treatment interventions
involving straightforward medical
decision making.
$34.20 1,791 $55,379 8.0%
503 Level 2

Professional attendance on a patient
at a recognised Emergency
Department of a private hospital by a
medical practitioner who is an
emergency medicine physician in the
practice of emergency medicine.

Attendance for the unscheduled
evaluation and management of a
patient requiring the taking of an
expanded problem focused history,
expanded examination of one or more
systems and the formulation and
documentation of a diagnosis and
management plan in relation to one or
more problems, and the initiation of
appropriate treatment interventions
involving medical decision making of
low complexity.
$57.80 12,680 $712,539 ‐8.2%
507 Level 3

Professional attendance on a patient
at a recognised Emergency
Department of a private hospital by a
medical practitioner who is an
emergency medicine physician in the
practice of emergency medicine.

Attendance for the unscheduled
evaluation and management of a
patient requiring the taking of an
expanded problem focused history,
expanded examination of one or more
systems, ordering and evaluation of
appropriate investigations, the
formulation and documentation of a
diagnosis and management plan in
relation to one or more problems, and
the initiation of appropriate treatment
interventions involving medical
decision making of moderate
complexity.
$97.05 27,329 $2,576,136 0.9%
511 Level 4

Professional attendance on a patient
at a recognised Emergency
Department of a private hospital by a
medical practitioner who is an
emergency medicine physician in the
practice of emergency medicine.

Attendance for the unscheduled
evaluation and management of a
patient requiring the taking of a
detailed history, detailed examination
of one or more systems, ordering and
evaluation of appropriate
investigations, the formulation and
documentation of a diagnosis and
management plan in relation to one or
more problems, the initiation of
appropriate treatment interventions,
liaison with relevant health care
professionals and discussion with the
patient, his/her agent/s and/or
relatives, involving medical decision
making of moderate complexity.
$137.30 28,370 $3,806,402 7.4%
515 Level 5

Professional attendance on a patient
at a recognised Emergency
Department of a private hospital by a
medical practitioner who is an
emergency medicine physician in the
practice of emergency medicine.

Attendance for the unscheduled
evaluation and management of a
patient requiring the taking of a
comprehensive history,
comprehensive examination of one or
more systems, ordering and evaluation
of appropriate investigations, the
formulation and documentation of a
diagnosis and management plan in
relation to one or more problems, the
initiation of appropriate treatment
interventions, liaison with relevant
health care professionals and
discussion with the patient, his/her
agent/s and/or relatives, involving
medical decision making of high
complexity.
$212.60 19,395 $3,909,046 21.5%
519 Professional attendance on a patient
at a recognised Emergency
Department of a private hospital by a
medical practitioner who is an
emergency physician in the practice of
emergency medicine.

Attendance for emergency evaluation
of a critically ill patient with an
immediately life threatening problem
requiring immediate and rapid
assessment, initiation of resuscitation
and electronic vital signs monitoring,
comprehensive history and evaluation
whilst undertaking resuscitative
measures, ordering and evaluation of
appropriate investigations, transitional
evaluation and monitoring, the
formulation and documentation of a
diagnosis and management plan in
relation to one or more problems, the
initiation of appropriate treatment
interventions, liaison with relevant
health care professionals and
discussion with the patient, his/her
agent/s and/or relatives prior to
admission to an in‐patient hospital
bed…

…for a period of not less than 30
minutes but less than 1 hour of total
physician time spent with each
patient.
$146.20 71 $9,586 ‐3.1%
520 … for a period of not less than 1 hour
but less than 2 hours of total physician
time spent with each patient.
$280.85 470 $125,551 14.5%
530 … for a period of not less than 2 hours
but less than 3 hours of total physician
time spent with each patient.
$460.30 235 $99,299 11.4%
532 … for a period of not less than 3 hours
but less than 4 hours of total physician
time spent with each patient.
$639.75 68 $39,545 1.2%
534 … for a period of not less than 4 hours
but less than 5 hours of total physician
time spent with each patient.
$819.35 17 $14,298 -15.3%
536 … for a period of 5 hours or more of
total physician time spent with each
patient.
$909.10 19 $16,193 -9.3%
Recommendation 1
  • ΔRestructure ED attendance items into three tiered base items with add‐ons 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 are designed to 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., services rendered by an Emergency Physician in conjunction with an ED attendance). Add‐on items should be used instead of all existing MBS procedural items, such as anaesthetics items.
  • The proposed item descriptors and explanatory notes are provided below.

Item 50X:

STANDARD EMERGENCY ATTENDANCE

Professional attendance on a patient at a recognised Emergency Department of a private hospital by a medical practitioner who is an Emergency Physician in the practice of Emergency Medicine, for the consultation, investigation (if required) and management of a single system issue in a patient with no relevant comorbidities where the differential diagnosis is limited.

Includes targeted history and examination, routine point‐of‐care procedures (such as ECGs, in‐ dwelling urinary catheterisation, venous and arterial blood gas sampling, ultrasound in conjunction with procedures such as vascular access or nerve block), interpretation of relevant investigations (if required), development and initiation of a management plan, relevant GP and specialist communication and associated documentation. These patients would typically be discharged home from the Emergency Department.

Item 50Y:

ADVANCED EMERGENCY ATTENDANCE

Professional attendance on a patient at a recognised Emergency Department of a private hospital by a medical practitioner who is an Emergency Physician in the practice of Emergency Medicine, for the assessment, investigation and management of an undifferentiated presentation or a presentation with a clear diagnosis that needs risk stratification and complication exclusion. Where the diagnosis is clear from the outset this item should be used when management is time consuming or more than one strategy is required. May include referral or consultation with alternate specialist(s). These patients may or may not be admitted.

Includes a period of observation in response to initial treatment and / or requiring results of investigations to inform an ongoing management plan, and includes any routine point‐of‐care procedures (such as ECGs, in‐dwelling urinary catheterisation, venous and arterial blood gas sampling, ultrasound in conjunction with procedures such as vascular access or nerve block).

Item 50Z:

COMPLEX EMERGENCY ATTENDANCE

Professional attendance on a patient at a recognised Emergency Department of a private hospital by a medical practitioner who is an Emergency Physician in the practice of Emergency Medicine, for the assessment, investigation and management of an undifferentiated ED patient with one or more comorbidities and more than one differential diagnosis.

This item may include time consulting with alternate specialists, liaising with community services and arrangement of admission, pharmacy reconciliation, communication with family, carers and general practitioners; and any routine point‐of‐care procedures (such as ECGs, in‐dwelling urinary catheterisation, venous and arterial blood gas sampling, ultrasound in conjunction with procedures such as vascular access or nerve block).

Item 51A:

RESUSCITATION, 0.5 – 1 HRS

Resuscitation of a critically ill patient with an immediately life threatening problem requiring immediate attendance by an Emergency Physician, for a period of not less than 30 minutes but less than 1 hour of total physician time.

Including all common procedures and processes involved in a resuscitation, such as rapid IV access, administration of fluid, vasopressors (via bolus or infusion), adrenaline nebulisers, use of point‐of‐ care ultrasound in conjunction with focused assessment with sonography for trauma (FAST scan), central line access, arterial puncture and or access, ventilation, nasogastric tube insertion and in‐ dwelling urinary catheter insertion.

Item to be used only in conjunction with Items 50X–50Z.

Item 51B:

RESUSCITATION, 1 – 2 HRS

Resuscitation of a critically ill patient with an immediately life threatening problem requiring immediate attendance by an Emergency Physician, for a period of not less than 1 hour, but less than 2 hours of total physician time.

Including all common procedures and processes involved in a resuscitation, such as rapid IV access, administration of fluid, vasopressors (via bolus or infusion), adrenaline nebulisers, use of point‐of‐ care ultrasound in conjunction with focused assessment with sonography for trauma (FAST scan), central line access, arterial puncture and or access, ventilation, nasogastric tube insertion and in‐ dwelling urinary catheter insertion.

Item to be used only in conjunction with Items 50X–50Z.

Item 51C:

RESUSCITATION, 2+ HRS

Resuscitation of a critically ill patient with an immediately life threatening problem requiring immediate attendance by an Emergency Physician, for a period of 2 or more hours of total physician time.

Including all common procedures and processes involved in a resuscitation, such as rapid IV access, administration of fluid, vasopressors (via bolus or infusion), adrenaline nebulisers, use of point‐of‐ care ultrasound in conjunction with focused assessment with sonography for trauma (FAST scan), central line access, arterial puncture and or access, ventilation, nasogastric tube insertion and in‐ dwelling urinary catheter insertion.

Item to be used only in conjunction with Items 50X–50Z.

Item 51D:

ANAESTHESIA OR EMERGENT INTUBATION

IV sedation, regional anaesthesia or emergent intubation by a second Emergency Physician.

In the case of sedation or regional anaesthesia, including pre‐anaesthetic consultation and the associated procedure (e.g., direct current cardioversion or hip enlocation).

In the case of emergent intubation, including all common procedures and processes involved in intubation, such as rapid sequence induction, insertion of an endotracheal tube under direct visualisation and / or video laryngoscopy (or alternative airway access procedures such as awake nasal intubation, or the creation of a surgical airway).

Item to be used only for a patient receiving services under items 50X–50Z from a first Emergency Physician. The second Emergency Physician providing this service may not claim any other items in the management of the patient (including any other anaesthesia related items on the Medicare Benefits Schedule).

Item 51E:

MINOR PROCEDURE

Minor procedure performed by an Emergency Physician. Item to be used only in conjunction with Items 50X–50Z, and may be claimed for each minor procedure performed.

Item 51F:

PROCEDURE

Procedure performed by an Emergency Physician. Item to be used only in conjunction with Items 50X–50Z, and may be claimed for each procedure performed.

Item 51G:

FRACTURE / DISLOCATION EXCLUDING AFTERCARE

Fracture or dislocation diagnosis and management by an Emergency Physician, excluding aftercare. Includes all fractures and dislocations diagnosed and managed.

Item to be used only in conjunction with Items 50X–50Z.

Item 51H:

FRACTURE / DISLOCATION INCLUDING AFTERCARE

Fracture or dislocation diagnosis and management by an Emergency Physician, including aftercare. Includes all fractures and dislocations diagnosed and managed.

Item to be used only in conjunction with Items 50X–50Z.

Item 51I:

PATIENT ABOVE 75 OR BELOW 2 YEARS OF AGE

A patient receiving services as described in item 50X, 50Y or 50Z, who is above 75 years or below 2 years of age.

Item to be used only in conjunction with Items 50X–50Z.

Item 51J:

CHEMICAL OR PHYSICAL RESTRAINTS

A patient receiving services as described in item 50X, 50Y or 50Z, where an acute severe behavioural disturbance necessitates involuntary management with a team based approach and chemical and / or physical restraints (limited) and / or one on one nursing care to ensure the safety of the patient.

Item 51K:

GOALS OF CARE IN CONJUNCTION WITH ED ATTENDANCE

Professional attendance by an Emergency Physician for the discussion and documentation of goals of care:

(a) For a patient

  • Experiencing either a life‐threatening acute illness, or an acute illness in the context of a high baseline risk for end‐of‐life within the next 12 months, and
  • For whom alternatives to active management are reasonably thought to be an appropriate clinical choice, and
  • For whom an appropriate documentation of goals of care does not already exist or these goals are reasonably expected to change substantially due to new clinical circumstances;

(b) Including

  • Assessment of the patient’s capacity to make goals of care decisions, and
  • Comprehensive evaluation of the patient’s medical, physical, psychological and social issues, including identification of major issues requiring goals of care to be defined, and
  • Discussion with the patient (or surrogate), which must include proactive offering of treatment alternatives, including alternatives to intensive or escalated care; and, where appropriate, with the patient’s family, carers and other health practitioners, and
  • Agreement on the goals of care, between the provider and the patient or their guardian, and in relation to all major medical issues identified in the comprehensive assessment, and
  • Documentation of the goals of care in a way that facilitates timely retrieval by subsequent healthcare providers for the patient, and includes what interventions should and should not be pursued;

(c) Claimable

  • Once only per episode of care,
  • For the medical practitioner taking overall responsibility for the agreement and documentation of goals of care.

Item to be used only in conjunction with Items 50X–50Z.

Where this service is rendered by a provider who is familiar with the patient’s medical issues and circumstances (i.e., is rendered in conjunction with ED attendance items 50X–50Z), Item 51K should be used. Where this service is rendered by an Emergency Physician who is otherwise unfamiliar with the patient (i.e., where a prior ED attendance service has not been rendered by the provider), Item 51L should be used.

Item 51L:

GOALS OF CARE NOT IN CONJUNCTION WITH ED ATTENDANCE

Professional attendance by an Emergency Physician for the discussion and documentation of goals of care:

(a) For a patient

  • Experiencing either a life‐threatening acute illness, or an acute illness in the context of a high baseline risk for end‐of‐life within the next 12 months, and
  • For whom alternatives to active management are reasonably thought to be an appropriate clinical choice, and
  • For whom an appropriate documentation of goals of care does not already exist or these goals are reasonably expected to change substantially due to new clinical circumstances;

(b) Including

  • Assessment of the patient’s capacity to make goals of care decisions, and
  • Comprehensive evaluation of the patient’s medical, physical, psychological and social issues, including identification of major issues requiring goals of care to be defined, and
  • Discussion with the patient (or surrogate), which must include proactive offering of treatment alternatives, including alternatives to intensive or escalated care; and, where appropriate, with the patient’s family, carers and other health practitioners, and
  • Agreement on the goals of care, between the provider and the patient or their guardian, and in relation to all major medical issues identified in the comprehensive assessment, and
  • Documentation of the goals of care in a way that facilitates timely retrieval by subsequent healthcare providers for the patient, and includes what interventions should and should not be pursued, with
  • At least 60 minutes of dedicated professional involvement;

(c) Claimable

  • Once only per episode of care,
  • For the medical practitioner taking overall responsibility for the agreement and documentation of goals of care.

This item is not payable for the same patient on the same day as Items 50X–50Z.

Where this service is rendered by a provider who is familiar with the patient’s medical issues and circumstances (i.e., is rendered in conjunction with ED attendance items 50X–50Z), Item 51K should be used. Where this service is rendered by an Emergency Physician who is otherwise unfamiliar with the patient (i.e., where a prior ED attendance service has not been rendered by the provider), Item 51L should be used.

Explanatory notes for items 50X–50Z:

Items 50X to 50Z relate specifically to attendances rendered by medical practitioners who are holders of the Fellowship of the Australasian College for Emergency Medicine (FACEM) and who participate in, and meet the requirements for, quality assurance and maintenance of professional standards by the ACEM.

Other than for point‐of‐care ultrasound (see below), only modifying items 51A–51L may be claimed in conjunction with items 50X–Z.

Items relating to point‐of‐care ultrasound services are not separately payable from Emergency Department attendance items 50X–Z where performed for a reason that represents routine use as standard of care in an Emergency Department attendance. For example, the following four (non‐ exhaustive) reasons:

  • To identify nerves for the purposes of administering nerve blocks.
  • To identify vessels, including abdominal aortic aneurysms.
  • As part of a focused assessment with sonography for trauma (FAST) scan.

Where the “standard of care” principle does not apply, items relating to point‐of‐care ultrasound services are payable in addition to Emergency Department attendance items 50X–Z, where the following three criteria are met:

  • A formal report is provided and is stored in a manner that reasonably facilities future retrieval / access.
  • The images are stored in a manner that reasonably facilitates future retrieval / access.
  • The provider is appropriately credentialed to provide the particular service, by a recognised body for the credentialing of ultrasound services.

For the sake of clarity, hospitals do not constitute recognised bodies for the credentialing of ultrasound services. The Australasian College for Emergency Medicine (ACEM) has published policy on the appropriate credentialing for Emergency Medicine ultrasonography, such as the “Policy on Credentialing for Emergency Medicine Ultrasonography: Trauma Examination & Suspected AAA.” As noted by ACEM, examples of appropriate credentials include the Diploma in Diagnostic Ultrasound (DDU) and the Certificate in Clinician Performed Ultrasound (CCPU) offered by the Australasian Society for Ultrasound in Medicine (ASUM).

Explanatory notes for items 51A–51C:

Patients requiring resuscitation often require a second Emergency Physician to assist with access, airway or other procedures as required. Only one Emergency Physician (the Emergency Physician holding primary responsibility for the patient) may bill the Emergency Department attendance item (50X–50Z). The second Emergency Physician may bill a time‐based resuscitation add‐on (items 51A– 51C) and an emergent intubation add‐on (item 51D).

Explanatory notes for item 51D:

This item accounts for all services that would otherwise be billed under the anaesthetic items in the Medicare Benefits Schedule, including the pre anaesthetic consultation, the associated procedure, and any loadings / add‐ons (such as duration of anaesthesia or the ASA classification of the patient).

Anaesthesia under Item 51D assumes an average of 20 minutes anaesthesia, and an average ASA 3 classification, in an emergent and / or after‐hours context.

Patients requiring resuscitation or procedural sedation often require a second Emergency Physician to assist with access, airway or other procedures as required. Only one Emergency Physician (the Emergency Physician holding primary responsibility for the patient) may bill the Emergency Department attendance item (50X–50Z). The second Emergency Physician may bill a time‐based resuscitation add‐on (items 51A–51C) and an emergent intubation add‐on (item 51D).

Explanatory notes for item 51E:

Minor procedures could include foreign body removal (including from the eye or nose), burns dressing & consult, incision and drainage abscess / cyst / haematoma (including Bartholin’s), pulp space drainage, removal of nail of finger, thumb or toe, incision of thrombosed external haemorrhoid, superficial <7 cm laceration repair not of the face or neck, abdominal paracentesis, thoracic cavity aspiration for diagnostic purposes (without therapeutic drain), bladder aspiration (suprapubic tap), passage of urethral sounds, paraphimosis reduction, sigmoidoscopy, skin biopsy, removal of etonogestral subcutaneous implant, venesection.

Explanatory notes for item 51F:

Procedures could include lumbar puncture, thoracic cavity aspiration with therapeutic drainage, removal of foreign body from the ear or subcutaneous tissue (incision / closure), excision of skin lesions / cysts, sinus excision, superficial laceration repair of the face / neck (including ear, eyelid, lip, nose) or of >7cm, management of deep, contaminated wound requiring debridement under general anaesthetic or field block, femoral nerve block, epistaxis cautery / packing, suprapubic cystotomy / catheter, cardioversion / defibrillation, intercostal drain insertion, PEG tube replacement, laryngoscopy (including fibreoptic), priapism decompression.

Explanatory notes for items 51K and 51L:

  • Patients could be assessed for “high baseline risk” (and suspicion that alternatives to active management may be an appropriate clinical choice) through the use of tools that assist in predicting end‐of‐life, such as the SPICT tool.
  • “Proactive offering of treatment alternatives” means that the patient must be provided with reasonable alternatives to continued intensive / active treatment or escalation of care, including where the patient has not directly asked for such information (in recognition that patients may not ask if they are not aware of such alternatives).
  • “Documentation” should be undertaken using standard forms (where available) appropriate to the facility in which a patient is receiving care.
  • Providers of this service should be appropriately trained to provide end‐of‐life care options and goals of care discussions.
  • The item should not be claimed where the goals of care are defined only in relation to a sub‐set of the patient’s major issues.

Rationale

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 aims to do 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.

  • ΔThe existing ED attendance items (501–515) warrant revision due to the ambiguity in the item descriptors, which creates a risk of misinterpretation. This is likely to result in inconsistency and variation between providers regarding what item (complexity level) is billed for similar services. The MBS benefit a patient receives may therefore depend on the billing practices of the provider, rather than the nature of the service rendered. The ‘resuscitation’ items (519– 536) also do not accurately reflect attendance complexity.
  • – In practice, three of the five complexity levels are typically used, with the vast majority of services categorised as Levels 3‐5 (Figure 3). The Level 1 (lowest complexity) ED attendance item (501) is rarely used, and use of the Level 2 item (503) is decreasing. However, growth in service volumes for the Level 5 item (highest complexity) is nearly three times larger than the growth for any other level. The ‘resuscitation’ items (519–536) are rarely used, with small and fluctuating service volumes of less than 1,000 instances per year (Figure 4).
  • – A submission from the Australasian College for Emergency Medicine (ACEM) noted that these items “are both confusing and open to variation in interpretation” and “do not reflect current ED practices … [Duration and qualitative complexity level] fail to capture the complexity involved.”
  • ΔThe Committee felt that creating three tiers represents the optimal balance of adequately differentiating levels of patient complexity while maintaining a manageable number of levels to support accurate allocation of complexity levels (i.e., MBS items) to services rendered.
  • – Including only one tier carries a substantial risk of providers “cherry‐picking” low‐ complexity patients and would not adequately reflect case‐mix variation between departments. For example, private EDs may differ in terms of the proportion of paediatric and geriatric cases, the admission rate and the clinical conditions seen (which may vary based on the specialist services available in the hospital to which the ED is attached).
  • – Including only two tiers would not allow enough specificity to adequately differentiate between levels of patient complexity.
  • – Including four or more tiers would create opportunities for misinterpretation, increasing the risk of miscategorising the complexity level of ED attendances (i.e., the risk of miscoding or upcoding).
  • ΔThe word “standard” is preferable to the word “simple” for items covering ED attendances. Attendances where diagnosis and management are clear (for example, for otitis media, a simple rash or simple injuries such as small lacerations or wounds) are uncommon, representing only 7 per cent of ED attendances, and Emergency Physicians are unlikely to view a consultation as straightforward. An item for a “simple” ED attendance is therefore unlikely to be used.
  • ΔSome procedural services form part of the standard of care received in an emergency attendance and should be considered an integral component of the attendance item. Billing these services separately adds to the administrative burden and creates a potential incentive to over‐service, and it should not occur.
  • – These procedures include electrocardiograms (ECGs), in‐dwelling urinary catheterisation, venous and arterial blood gas sampling, and point‐of‐care ultrasound for reasons including (but not limited to) the following:
    • Identifying nerves for the purposes of administering nerve blocks.
    • Identifying vessels, including abdominal aortic aneurysms.
    • Undertaking a focused assessment with sonography for trauma (FAST) scan.
  • ΔIn the case of resuscitation add‐on items 51A‐C, procedural services that form part of the standard of care involved in a resuscitation include rapid IV access, administration of fluid, vasopressors (via bolus or infusion), adrenaline nebulisers, use of point‐of‐care ultrasound in conjunction with a FAST scan, central line access, arterial puncture and/or access, ventilation, nasogastric tube insertion and in‐dwelling urinary catheter insertion. These should be considered integral components of the items.
  • ΔAdd‐on items cover the major sources of increased professional involvement. The Committee felt that use of these add‐on items (instead of other MBS items) would reduce the number of items that need to be billed for each patient and for each provider. This would reduce variation in the item combinations used by providers, which, in turn, would reduce variation in the Medicare benefits patients receive for similar services. It would also ease the administrative burden associated with using more than 100 items across the MBS.
  • – When providing safe and effective resuscitation of the critically unwell patient, anaesthesia and / or intubation, best practice requires the professional involvement of two medical practitioners.
  • – Fractures and dislocations were separated from other procedural add‐ons to support billing transparency for patients receiving these common procedures. This also allows aftercare requirements to be better articulated.
  • – The Committee noted that patients who are very young or elderly require a greater amount of professional involvement than is reflected in the complexity‐tiered base items.
    • Age is one determinant of the level of professional involvement required and is not simply a proxy for other factors (such as the number of differential diagnoses or comorbidities, or the period of observation time required). This is because differing physiological requirements affect drug dosing, there can be difficulties associated with communication and co‐operation, and there is greater complexity in pain and distress management.
    • Although the recommendation to reduce the number of tiers from five to three improves ease of comprehension and use (and therefore the consistency and accuracy of billing), it affords less discrimination between differing levels of complexity. However, age is a more objective measure of complexity than additional complexity tiers for base items, and it can be automatically verified during claims processing.
  • – Defining goals of care is an important service that is separate from the ED attendance and results in better quality and value for patients. However, the Committee noted the following:
    • Efforts to define patients’ goals of care are inconsistent and are often undertaken at a later stage than is clinically useful. Patients attended by Emergency Physicians or Intensivists often have not had goals of care defined by their primary General Practitioner (GP).
    • The lack of early decision‐making regarding goals of care may result in over‐treatment and / or excessive lengths of stay. In particular, there are patients who may not wish to proceed with active treatment but may feel that they have not been given alternative options to consider.
    • Emergency Physicians often bear responsibility for initiating discussion regarding the goals of care. This requires a significant level of professional involvement, due to the acuity of the situation and the importance of clarifying goals of care prior to admission to hospital or the Intensive Care Unit (ICU). It also requires complex discussions and decision‐making for a patient with whom the provider is unfamiliar.
  • – The level of professional involvement required in defining goals of care is greater if the patient is unfamiliar to the provider. Less professional involvement is required if the provider is familiar with the patient, having participated in the patient’s emergency attendance. (In the latter situation, the provider may have previously reviewed the patient’s medical records and history.) The Committee felt that separate items—with differing time requirements and schedule fees—were needed to reflect this.
  • ΔSchedule fees for the proposed items are expected to reflect the volumes of bundled procedural components, where benefits for these procedural components were previously separately payable under their respective items. For example, routine point‐of‐care procedures (such as ECGs, in‐dwelling urinary catheterisation, venous and arterial blood gas sampling, ultrasound in conjunction with procedures such as vascular access or nerve block), which are now bundled within proposed ED attendance items 50X–Z. This will require appropriate analyses / modelling to be conducted. Further, the Committee should be provided with an opportunity to engage with the Department in the process of determining Schedule Fees for the proposed items.

Figure 3: Level 1–5 ED attendance items

Figure 3 displays the number of annual emergency department attendance services over the five financial years from 2010-11 to 2014-15, broken down by the complexity level of the attendance. Namely, Level 1 through to Level 5. 

The greatest growth is shown in the high complexity Level 5 services, at 22% compound annual growth rate, while the lowest is Level 2 services at -8% compound annual growth rate. Overall, in 2014-15, Level 1 attendances accounted for 2% of services, Level 2 17%, Level 336%, Level 4 38%, Level 5 26%. 

The overall service volume was close to 90,000 attendances in 2014-15.



Figure 4: ‘Resuscitation’ ED attendance items

Figure 4 displays the number of annual emergency department attendance services for the 'resuscitation' items, over the five financial years from 2010-11 to 2014-15, broken down by the duration tier of the service. Namely, 0.5-1 hours, 1-2 hours, 2-3 hours, 3-4 hours, 4-5 hours and over 5 hours. 

There is an irregular pattern of total service volumes, with a peak in 2012-13, a trough the following year, and a slight rise to 2014-15. The overall volume was close to 900 attendances in 2014-15, with 8% at 0.5-1 hours, 53% at 1-2 hours, 27% at 2-3 hours, 88% at 3-4 hours, 2% at 4-5 hours and 2% at over 5 hours.

4.3Consistent item structure for all Emergency Department attendances

Recommendation 2
  • 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, regardless of whether the item is provided by a specialist Emergency Physician, a trainee in emergency medicine, a GP (whether vocationally registered or non‐vocationally registered), or another medical practitioner.
  • – A lower MBS benefit should apply if the provider is not a vocationally recognised Emergency Medicine Specialist (i.e., an Emergency Physician, defined by recognition as a Fellow of the ACEM). This ‘scaled access’ to emergency attendance items should provide a fixed proportion of the benefit available for services provided by Emergency Medicine Specialists.
  • The proposed item descriptors and explanatory notes are the same as those provided in Section 4.2 – Emergency Department attendance items, except that they also specify the provider type and applicable schedule fee. Specifically, in place of “medical practitioner who is an Emergency Physician in the practice of Emergency Medicine,” item descriptors should specify “medical practitioner who is not an Emergency Physician in the practice of Emergency Medicine”.

Rationale

This recommendation focuses on improving billing transparency for patients and providers, by ensuring the item billed reflects the nature of the service provided. It is based on the following observations.

  • ΔMBS benefits should maintain the primacy of vocational recognition as an Emergency Medicine Specialist by the Australasian College of Emergency Medicine as the professional gold standard in training to provide safe, effective, high‐value emergency medical care in Australia. Access to the higher MBS benefit should therefore be reserved for those who have attained this recognition.
  • ΔWhile encouraging providers other than Emergency Medicine Specialists to gain emergency attendance experience provides a valuable opportunity for these providers to up‐skill, such medical practitioners provide an important but substantively different skillset, and therefore an important but substantively different level of ED attendance service. The Taskforce felt that such services should attract a lower MBS benefit than those provided by Emergency Medicine Specialists.
  • – Such providers may include vocationally registered GPs (VRGPs), non‐vocationally recognised GPs (non‐VRGPs) and trainees in emergency medicine, among others. There are no substantive differences between emergency medicine services provided by VRGPs and non‐ VRGPs. Many non‐VRGPs have substantial experience in providing services in the ED context.

4.4MBS item use for Short Stay Units

Recommendation 2.1
  • ΔThe Committee requests that the Consultation Services Clinical Committee consider recommendations to allow referred in‐hospital attendance services provided by Emergency Physicians to attract a patient rebate equivalent to that received for attendances by Consultant Physicians.

Rationale

This request focuses on supporting access to best‐practice health services. It is based on the following observations.

  • ΔShort Stay Units (SSUs) provide care for admitted patients with a short anticipated length of stay (typically less than 24 hours) until they are discharged. These patients have usually received prior review in an ED, and they usually have a management plan that requires observation and medical practitioner attendance to review the patient’s clinical condition and investigation results, and to adjust the management plan appropriately.
  • ΔAttendances for patients in SSUs may be provided by Emergency Physicians, other Inpatient Specialists or Consultant Physicians, all of whom bring unique skills to bear in the given clinical context.
  • – If an SSU is located outside the accredited private ED, the ED attendance items do not apply, and Emergency Physician attendance services are instead covered by the MBS under inpatient referred specialist consultation items 104 and 105. ED attendance items may also not always appropriately describe SSU attendance services. For example, the nature of the service differs from that for the undifferentiated, acute patient first presenting to an ED, where a complete history must be taken, investigations requested and an initial management plan formulated.
  • – Emergency Physicians bring particular expertise in extended service provision and rapid turnover of patients, and provide a cognitive service similar to those provided by Consultant Physicians in the SSU context. Patients should not receive lower benefits for attendances by Emergency Physicians than they would receive for similar attendances by Consultant Physicians.


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