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 The Taskforce will also seek to identify any services that may be unnecessary, outdated or potentially unsafe.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.

1.1       MBS Review process

The Taskforce has endorsed a process whereby the necessary clinical review of MBS items is undertaken by Clinical Committees and Working Groups. The Taskforce asked all committees in the second tranche of the Review process to review MBS items using a framework based on Appropriate Use Criteria accepted by the Taskforce (1). This framework includes the following steps: (i) review data and literature relevant to the items under consideration; (ii) identify MBS items that are potentially obsolete, are of questionable clinical value, are misused and/or pose a risk to patient safety; and (iii) develop and refine recommendations for these items, based on the literature and relevant data, in consultation with relevant stakeholders. In complex cases, full appropriate use criteria were developed for an item’s descriptor and explanatory notes. All second-tranche committees involved in this Review adopted this framework, which is outlined in more detail in Section 2.3.

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

1.2       The Renal Clinical Committee

The Renal Clinical Committee (the Committee) was established in April 2016 to make recommendations to the Taskforce regarding MBS items in its area of responsibility, based on rapid evidence review and clinical expertise. The Taskforce asked the Committee to review renal-related items.

The Committee was assigned seven items to review, all relating to initiation and supervision of haemodialysis and peritoneal dialysis. In 2014/15 these items combined provided for 97,864 services and $6.8 million in benefits. The average growth in services is 5.8 per cent per year, though item 13103 for supervision of dialysis accounts for 78 per cent of services and is growing at 8.1 per cent per year. There were 12,000 patients on dialysis in Australia in 2014/15, of which approximately 4,400 received dialysis supervision services under the MBS. There are an estimated 3,600 patients currently receiving home dialysis of which, 73 per cent (n=2,663) claimed supervision (item 13104 planning and management of home dialysis) under the MBS (2,3).

All recommendations relating to these items are included in this report for consultation. The Committee also provided input on items that will be referred to their primary reviewing Clinical Committee to assist with their recommendations for consultation.

An inclusive set of stakeholders is now engaged in consultation on the recommendations outlined in this report. Following this period of consultation, the recommendations will be finalised and 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.

1.3       Recommendations

The Committee has highlighted its most important recommendations below. The complete recommendations (and the accompanying rationales) for all items can be found in Section 4. Recommendations developed for referral to other committees are presented in Section 5. A complete list of items, including the nature of the recommendations and the page number for each recommendation, can be found in Appendices A and B (in table summary form).

Recommendations for consultation

The Committee’s provisional recommendations for stakeholder consultation are that a new item should be created for dialysis in very remote areas, two renal dialysis items should be restructured into a single weekly item, two items should be deleted from the MBS, and one item should remain unchanged. These changes focus on increasing access to medical services, encouraging best practice and simplifying the MBS to improve patient care by (i) consolidating item numbers; (ii) improving the clarity of descriptors (with support from explanatory notes); and (iii) providing clinical guidance for appropriate use through explanatory notes. The most important recommendations are summarised below.

 Very remote dialysis item. Address the access gap by creating an item to fund the provision of dialysis in very remote areas, including nurse supervision. At present, most Indigenous patients from very remote areas are forced to relocate for dialysis services (4). The proposed item would help to address this problem by funding the ongoing costs of providing dialysis in very remote areas.

 Weekly dialysis supervision item. Create a consolidated weekly payment to replace items 13100 and 13103. This would reduce variability in the billing of items, encourage best-practice care and remove incentives to over-service patients. Consultations and supervision of dialysis in the routine care of a patient on in-centre dialysis would be included. This item would be introduced with a provisional MBS fee and an economic review after 12 months to ensure cost neutrality.

 Paediatric–adult transition. Consider measures to better address the transition from paediatric to adult services for patients with complex kidney disease, particularly the significant allograft loss that occurs during this period. This recommendation will be considered by the Taskforce and if endorsed, the issue will be referred to an appropriate government or inter-governmental body or group, such as the Council of Australian Governments.

Recommendations for referral to other committees

The Committee’s provisional recommendations for the consideration of other Clinical Committees concern items that were assigned by the Taskforce to the Urology Clinical Committee (UCC), the Nurse Practitioner and Participating Midwife Clinical Committee (NP&PMCC), the Aboriginal and Torres Strait Islander Clinical Committee (ATSICC), the General Practice and Primary Care Clinical Committee (GPPCCC) and the Consultation Services Clinical Committee (CSCC) for primary review. The most important recommendations are summarised below.

Δ Specialist attendances claim. Amend the General Rules for Professional Attendances items to prevent medical practitioners from claiming specialist attendances for the supervision of dialysis. It was noted that some providers currently claim consults (item 116) in place of the dedicated dialysis supervision item (13103). This results in a lack of transparency in MBS data and is not the intent of the items. The exception is when a consultation is performed for non-routine management in consulting rooms, or when admission to hospital is required due to deterioration in a patient’s condition or for non-kidney related reasons.

Δ Nephrology nurse practitioners. The Committee recommends that the NP&MCC consider ways to recognise and remunerate the services provided by nephrology and chronic disease nurse practitioners, particularly in rural and remote areas.

Δ Live donor nephrectomy. Create a new item for living donor nephrectomy to acknowledge that live donor nephrectomy is a complex operation, and to address the absence of a dedicated item for the procedure.

Δ Renal biopsy. Update the item descriptor to require ultrasound guidance, which reflects contemporary best practice.

Δ Health assessments. Recommend that the health assessment items be reviewed by the PCCC to close gaps that may result in high-risk patients being ineligible for assessments, and to ensure that all items are align with best practice.

1.4       Consumer Engagement

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 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.

The Committee has brought together practitioners with experience and commitment to the care of people with renal conditions and a consumer representative. This committee has examined how well the current descriptions of Medicare items match current clinical practice to meet the need of Australians with kidney diseases.

A part of the work of the Committee has involved making the descriptions of items more accurate, so that payment data can help track the patterns of care across the country. Some items are no longer used because techniques for dialysis have changed since they were originally described and these items have been recommended to be deleted.

The Review has also given the chance to more accurately describe the complexity and time required for the care of potential kidney donors, the needs of young people moving from care in children’s hospitals to adult hospitals, and the care needed for people needing health assessment. The Review has also recommended a new item to fund dialysis in very remote parts of the country which will significantly improve access to patients in these areas.

Recommendations fall into three categories with different next steps.

Δ Recommendations to the Taskforce. These will be considered by the Taskforce along with submissions from public consultation. The Taskforce will then 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.

Δ Recommendations to other Clinical Committees. These are areas where the Committee has made recommendations that are within the scope of another Clinical Committee. They 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 Government. These recommendations may take longer to be implemented as the timeline depends on the timing of the other Clinical Committees.

Δ Recommendations beyond the MBS. The Paediatric-adult transition recommendation is complex and reaches beyond the MBS. This will be considered by the Taskforce with any submissions from consultation and if endorsed, the Taskforce will recommend that this be considered by the appropriate body or group. This timeline is unknown, as the recipient group is unclear, however members of the Committee will work with the Department to ensure the recommendation is considered.

There is a list of all the items in plain English in Appendix D - Consumer Summary Table.