Pathology - Endocrine Tests
Table of Contents
1. Executive Summary
The Medicare Benefits Schedule (MBS) Review Taskforce (the Taskforce) is undertaking a program of work that considers how more than 5700 items on the MBS can be aligned with contemporary clinical evidence and practice and improve 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 The Taskforce will also seek to identify any services that may be unnecessary, outdated or potentially unsafe.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:
- Consider whether there are MBS items that are obsolete and should be removed from the MBS.
- Consider identified priority reviews of selected MBS services.
- Develop a program of work to consider the balance of MBS services within its remit and items assigned to the Committee.
- 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 then provide recommendations to the Taskforce in a Review Report. The Taskforce will consider the Review Reports from Clinical Committees and stakeholder feedback before making recommendations to the Minister for Health, for consideration by Government.
The Chemical Working Group (the Working Group) is one of six clinical Working Groups established to support the work of the Pathology Clinical Committee (the Committee). The Committee was established in 2016 to make recommendations to the 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 chemical pathology testing.
1.1 Key recommendations
The recommendations of the Committee based on advice from the Working Group on endocrine tests are that two items be deleted, one added, 19 changed and 10 items remain unchanged. The Working Group is yet to review three items: Hormones and other tests (item 66686) and Adrenaline and other tests (items 66779 and 66780). Major changes to items are listed below; the remainders are found in the body of this report.
- ΔThyroid stimulating hormone (TSH) and thyroid function test (TFT) items
TSH tests and TFTs: items 66716, 66719, 66722–5, 66728, 66731 and 66734
The Committee recommends that, in accordance with Choosing Wisely recommendations of the Royal Australian College of General Practitioners (RACGP) and international guidelines, TSH should not be used as a screening test in asymptomatic patients. The explanatory notes for TSH should note this and provide advice about the indications for testing and repeat testing.
The item descriptor and explanatory notes for TFTs should be amended to enable pathologist-determinable (or requested) testing of TFTs when the most recently performed TSH is abnormal.
The TFTs item should be further amended to reflect that another indication for TFTs is in circumstances that make TSH testing of thyroid function unreliable. Advice about these circumstances is now set out in the explanatory notes.
The Committee recommends adding a new item for TFTs to include all three tests: TSH, free thyroxine and free T3, as this is clinically valuable and provides additional information in a subgroup of patients with markedly suppressed TSH.
- ΔOral glucose tolerance test (OGTT) and oral glucose challenge test (OGCT) items
The Committee recommends the obsolete item 66545 for OGTT be deleted to improve clinical quality. The item descriptor and explanatory notes of item 66542 should be revised to allow testing for patients when glycated haemoglobin (HbA1c) measurement is unreliable (recognising that for most patients HbA1c is the preferred test).
- ΔQuantitation of glycated haemoglobin
The Committee recommends item 66841 be changed to include specific indications for asymptomatic patients tested for diabetes mellitus in the explanatory notes. The maximum number of permissible tests under item 66841 should be increased to two per year to reflect current guidelines.
- ΔQuantitation of fructosamine
The Committee recommends the item descriptor for item 66557 be changed to stipulate that the test is only conducted when HbA1c is unreliable. The Committee also recommends that explanatory notes be added to specify the clinical circumstances in which testing is appropriate.
The Committee recommends that clinical requirements for testing be included in the explanatory notes for item 66560 and that testing is restricted to four times within a 12-month period. The Committee also recommended changing the name of the item descriptor to albumin: creatinine ratio.
- ΔElectrophoresis of serum for lipoprotein subclasses
The Committee recommends deleting the obsolete item 66539 to modernise the MBS.
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. After 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 Taskforce. The Taskforce will consider the recommendations as well as the information provided by consumers to make sure all the important concerns are addressed. The Taskforce will then provide the recommendations to government.
- ΔThe Committee brought together practitioners with experience in, and commitment to, the care of people with clinical diseases, to examine how well the description of Medicare items match current clinical practice and meet the needs of Australians. Consumer representatives were on the Committee and in every Working Group.
- ΔThere is a list of all the reviewed items, written in plain English, in Appendix B - Summary for consumers.
- ΔChanges have been recommended for some items that are no longer up to date. Some items are no longer used, and some should not be used because clinical best-practice has changed since they were originally described. These items have been recommended for deletion.
- ΔMost of the work conducted by the Committee focused on clinical issues and the provision of clinical services. As a result, the consumer representative relied frequently on the advice of the clinicians regarding how consumers would be affected.
- ΔThe consumer representative used the following framework to assess recommendations:
- – Safety: None of the recommendations negatively affect the safety of pathology services.
- – Quality: Many of the recommended changes are intended to improve quality, primarily by aligning the reimbursement system with evidence-based practice.
- – Access: The recommendations do not negatively affect appropriate access. However, some patient groups have been receiving services they do not need, which can result in either negative health impacts or unnecessary cost. Inappropriate access was restricted where possible.
- – Effectiveness: None of the recommendations reduce the effectiveness of chemical pathology services. The Committee did recommend that the Medical Services Advisory Committee (MSAC) consider allowing GPs to order TFTs comprising TSH, free thyroxine and free T3 in patients with suppressed TSH to assess the risk of ongoing medical condition and diagnose other medical conditions.
- – Cost-effectiveness: The recommendations will have a positive effect on cost-effectiveness because they make it easier to determine which patient groups should have access to specific tests and treatments.
- – Accountability: Many of the changes include wording that facilitates future auditing for quality purposes.
- – Data collection: Data collection for research, monitoring and auditing presents a huge opportunity for a revised MBS, and the recommendations should improve the opportunities to use this data for targeted research in the future.