4.      Recommendations for consultation

Introduction

The Committee reviewed seven assigned renal items and made recommendations based on evidence and clinical expertise, in consultation with relevant stakeholders. The Committee’s most important provisional recommendations for stakeholder consultation are as follows: (i) a new item should be created for dialysis services in very remote areas; (ii) two fee-for-service items should be restructured into a single weekly item; (iii) two items should be deleted from the MBS; and (iv) one item should remain unchanged. The changes focus on increasing access to medical services, encouraging best practice and simplifying the MBS to improve patient care.

The Committee’s assigned seven items all related to the 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).

The recommendations are organised by item type, with higher priority groups presented first.

4.1       Very remote dialysis item

Recommendation

Δ Create a new MBS item to fund the provision of dialysis in very remote areas by nurses, Aboriginal and Torres Strait Islander health practitioners and Aboriginal health workers. The proposed descriptor would contain the following elements:

 Management of haemo-dialysis, for each service provided to a person with end-stage kidney disease by or on behalf of a medical practitioner, who is employed by or contracted to a primary care organisation that provides haemodialysis services;

 The service is administered by a renal nurse, Aboriginal and Torres Strait Islander health practitioner or Aboriginal health worker with appropriate training to support dialysis patients under the auspices of a medical practitioner; and

 The patient is not an admitted patient of a hospital; and

 The community facility for delivering the service is in a very remote area, defined by Modified Monash Model 7; and

 The service is provided by a:

 Local primary care clinic or NGO; or

 By a health organisation with the support of the local primary care clinic; and

 The person administering the dialysis is employed by or contracted to the service described above; and

 The patient is under the care of a nephrologist affiliated with the local regional dialysis service, with review every 3–6 months:

 Physically, or

 Via telehealth if the patient is located:

 -Within a telehealth eligible area; and

 -At the time of attendance at least 15 kms by road from the specialist.

 

Δ The proposed explanatory notes for this new item are as follows:

 Primary Care Clinic refers to the first point of health care, usually provided in remote areas by nursing, health practitioner and health worker staff in community health clinics, including government, non-government and Aboriginal Community Controlled Health Services.

 Adequate training will be satisfied where the health care provider, such as a nurse, Aboriginal and Torres Strait Islander health practitioner or Aboriginal health worker, complies with state/territory requirements for the safe administration of dialysis in that role.

Rationale

The recommendation focuses on improving access to care, and is based on the following observations.

Δ Kidney disease is a significant and serious health issue that is considered a disease of disadvantage (5-7). In Australia, there is a steep gradient in the burden of kidney disease from urban to remote areas, with people in remote and very remote areas suffering much higher levels of disease (8). Indigenous people are also more likely to be affected, and those in remote and very remote areas have the highest rates of kidney disease (9). States and territories with large very remote areas have significant Indigenous populations living in those areas (Table 2). For instance, according to Australian Bureau of Statistics (ABS) data, 58 per cent of the Indigenous population in the Northern Territory and 32 per cent of the Indigenous population in Western Australia reside in very remote areas (Table 2) (10).

Table 2: Indigenous population and remoteness by state (ABS data, June 2011)

State

Indigenous

Total population

% population who are Indigenous

People living very remotely

% of people living very remotely who are Indigenous

People living very remotely who are Indigenous (n)

% Indigenous  population in very remote areas

NT

68,850

231,292

30%

53,469

75%

40,102

58%

WA

88,270

2,353,409

4%

63,042

32%

20,173

23%

SA

37,408

1,639,614

2%

14,816

33%

4,889

13%

QLD

188,954

4,476,778

4%

58,365

39%

22,762

12%

Δ Access to dialysis services is limited in very remote areas, which means that the majority of people must relocate to urban areas for treatment. The financial impacts of relocation on the patient, family and health service are currently unquantified (11), but it has undeniable social, economic and health consequences (12-17). For example, individuals may become dislocated from their family, community and support networks, and social consequences such as these have been identified as the second most important cause of death for Indigenous people on dialysis (24 per cent), after cardiac events (37 per cent) (18). Relocation can also be costly, and it can result in individuals losing their jobs and their housing. As a result of these social and economic costs, relocated patients often miss treatments, which has a negative impact on health outcomes. The permanent relocation of large numbers of people (and their families) for dialysis also has significant indirect impacts on other government services, including housing, social support services and education. These are often not considered in cost-effectiveness studies (19-22).

Δ The direct costs of providing a staffed dialysis service in a very remote location are likely to be more expensive than in an urban location, as accessible infrastructure—including transport systems and essential services, larger patient numbers and collocation of services—provide economies of scale. However, the Committee noted that studies to date have not considered the broader impact of relocating for treatment, as described above. As requirements for dialysis can extend over many years, it makes sense to provide services where people live, have support and can continue to contribute to their communities. The Committee also noted that emerging data (22) and anecdotal evidence suggest that facilities in regional and remote areas, which provide more accessible services, have better attendance rates and may improve health outcomes.

Δ The Committee agreed that appropriately trained health care providers—including renal nurses, dialysis technicians, Aboriginal and Torres Strait Islander health practitioners and Aboriginal health workers — should be allowed to administer dialysis to patients. This conclusion reflects two key considerations. Firstly, the Committee noted that nurses already administer dialysis to patients in hospital. Nurses, Aboriginal and Torres Strait Islander health practitioners and Aboriginal health workers have also successfully administered and supervised dialysis patients in remote dialysis programs, such as those supported by the Western Desert Nganampa Walytja Palyantjaku Tjutaku Aboriginal Corporation. Secondly, the Committee noted that Aboriginal and Torres Strait Islander health practitioners, Aboriginal health workers and nurses are more readily available in remote areas, and that these providers are integral to creating a successful and sustainable workforce model. The descriptor recommends the broad term ‘health care provider,’ as the Committee noted that there have recently been regulatory changes to terms used to refer to Aboriginal and Torres Strait Islander health practitioners and Aboriginal health workers. This broad term also reflects the intent of this item, which is to allow appropriately trained health care providers to safely administer dialysis services in very remote areas. The Committee refers to nurses, Aboriginal and Torres Strait Islander health practitioners and Aboriginal health workers in this recommendation because these terms represent the current health workforce in very remote areas.

Δ Nurses, Aboriginal and Torres Strait Islander health practitioners and Aboriginal health workers do not have MBS provider numbers and cannot bill the MBS, and this item will therefore have to be claimed by a medical practitioner. However, the Committee agreed that should nurse practitioners be able to practise independently and without the direct engagement of a medical practitioner in the future, the item should be amended to allow claiming by nurse practitioners. This will ensure that clinics that transition to a nurse practitioner-supported model are able to continue providing access to dialysis services. The Committee noted that this would remain an administrative claim, with care provided by the renal-trained health care practitioner, with supervision from the local regional dialysis unit.

Δ The Committee specified that the item should only be available in very remote areas, as defined by the Modified Monash Model (MMM) level 7. People in these communities are generally unable to commute for dialysis, and they experience the most disruption as a result of relocation. It has not been extended to remote areas at this time, as it was noted that these areas (such as the eastern coast of Tasmania) are often within commuting distance of regional public hospitals, which are capable of providing a dialysis service. It is also not intended to replace in-hospital dialysis for patients within reasonable commuting distance. However, the Committee did acknowledge that commuting to regional areas from a remote location is disruptive for many patients, and that some remote areas are significantly further from a regional service than others.

Δ Importantly, the Committee noted that there is a risk that introducing this service may result in current state government funding for self-care dialysis ceasing to be available. This is expressly not the intent of this item, and the Committee is strongly supportive of the ongoing funding of patients suitable for self-care dialysis. The Committee agreed that although this risk exists, the new item is warranted because the current level of access for patients in remote areas remains very limited (despite extensive work over many years to address this), and because there are many patients for whom self-care is not possible or appropriate. The Committee strongly supports the creation of the very remote item, and it believes that there will be a significant net benefit to remote Australians and the Commonwealth, resulting from improved health outcomes and an associated reduction in the economic impact of end-stage kidney disease.

Δ The Committee agreed that the item descriptor has to be flexible in order to ensure that providers can afford to operate, and to allow for the creation of health care models tailored to the needs of local communities. Accordingly, the item was designed so that (i) the renal nurse, Aboriginal and Torres Strait Islander health practitioner or Aboriginal health worker could be employed by or contracted to a primary care clinic or organisation; and (ii) the new item could be claimed by local primary care clinics, non-government providers and private health organisations, with the support of the local primary care clinic. The Committee believes that the support of the local community and local primary care clinic is essential in order to ensure that the model appropriately meets the needs of very remote communities.

Δ The Committee introduced a three- to six-month mandatory review by the local regional dialysis service in order to maintain the connection between the patient and his or her local renal unit. This ensures that holistic care is provided for the patient across the complete patient journey, including continuity of care during hospitalisation and acute episodes.

Δ The Committee agreed that the review of a patient by the local regional dialysis unit could occur physically or via a teleconsultation. This is because some very remote areas are more than 500km from a local regional dialysis unit, and the Committee felt that a teleconsultation may be appropriate if a patient is stable.

Δ The Committee recommended using the MMM as it is the latest standard, with the understanding that the Department of Human Services (DHS) and the ABS will adopt this standard over time. Although estimates in Table 2 (above) have been taken using ABS data, the Committee did not regard this as a serious issue as it noted that both the MMM and the 2011 ABS census data draw on the same Australian Standard Geography Standard – Remoteness Areas (ASGS-RA). The Committee acknowledged that retrospective data may use an alternative model, and this should be considered when attempting to forecast usage.

4.2       Medical supervision of dialysis items: Items 13100 and 13103

Table 3: Item introduction table for items 13100 and 13103

Item

Descriptor

Schedule

fee

Services FY2014/15

Total benefits

Services average annual growth

13100

Supervision in hospital by a medical specialist of haemodialysis, haemofiltration, haemoperfusion or peritoneal dialysis, including all professional attendances, where the total attendance time on the patient by the supervising medical specialist exceeds 45 minutes in one day.

$136.65

1,049

$107,513

-18.6%

13103

Supervision in hospital by a medical specialist of haemodialysis, haemofiltration, haemoperfusion or peritoneal dialysis, including all professional attendances, where the total attendance time on the patient by the supervising medical specialist does not exceed 45 minutes in 1 day.

$71.20

77,200

$4,162,558

8.1%

Recommendations

Δ Replace items 13100 and 13103 with new item 1310X—a consolidated item claimed weekly for care of a dialysis patient—on a 12- to 24-month trial basis, with defined objectives, a scheduled review and a sunset clause. The proposed descriptor for this item is as follows:

 Item 1310X: Supervision of private patient in a hospital or dialysis facility by a consultant renal physician, of haemodialysis/haemodiafiltration/ultrafiltration treatments occurring through the week including attendances in the dialysis unit for routine assessment of the dialysis treatment and the ongoing planning, care, and monitoring required between treatments as outlined in the explanatory notes.

A record of the services provided by the claiming provider is to be maintained in the patient’s clinical notes.

Claimable only where data is contributed (with patient consent) to the Australia and New Zealand Dialysis and Transplant Registry or where the provider engages in an equivalent, documented quality oversight activity.

Claimable once per calendar week (Mon to Sun) where the majority of dialysis services that week are supervised by the claiming practitioner in a private dialysis facility.

Δ Include the following proposed explanatory notes for this item:

 Supervision and attendances refer to the routine care associated with in-centre and satellite haemodialysis/haemodiafiltration/ultrafiltration patients. Attendances for non-routine consultations in consulting suites are eligible for the professional attendances item numbers where they meet the requirements of those items.

Ongoing planning, care, and monitoring would cover:

 Provision of a monthly care plan to the patient or the patient’s agent which outlines the care which will be provided to them by the claiming provider; and

 Regular discussions, at least monthly, with the patient and patient’s agent regarding their satisfaction with the care they are receiving and how that experience could be improved; and

 Regular ordering, performance and interpretation of appropriate biochemical and haematological studies (generally monthly); and

 Feedback of results to the patient and his or her treating general practitioner and other members of the health care team; and

 Adjustments to medications and dialysis therapies based upon these results; and

 Co-ordination of regular investigations required to keep the patient on active transplantation lists, where relevant; and

 Referral to, and communication with, other specialists involved in the care of the patient; and

 Being available to advise the patient or the patient’s agent; and

 Participation by the consultant physician in patient management discussions coordinated by renal centres.

Some elements of care may be reasonably provided by another health care provider such as a nurse or nurse practitioner, however no services should be charged in addition to this item for the routine care of the dialysis patient as described above.

It is expected that the item will be claimed once per calendar week for a patient, to a maximum of 52 claims per year. The patient must be informed that they will incur a charge for this service for which a Medicare rebate will be payable.

Δ Set an appropriate fee to reflect the work involved in the clinical care of the patient, as well as the reasonable practice costs—including education and quality assurance—of an efficient, full-time dialysis service.

Rationale

The recommendations focus on supporting best-practice care, and are based on the following observations.

Δ The Committee noted that the current item number only covers direct contact with a patient during a dialysis session. This does not account for the fact that much of the activity involved in caring for a dialysis patient does not require or involve direct physician–patient contact. For private dialysis patients, for example, activities such as phone calls to obtain authority prescriptions and the fortnightly recharting of medications can be time-consuming. The Committee acknowledged that many providers may be claiming item 13103 without physically attending the patient. In regional and remote clinics, for example, anecdotal evidence suggests that nurses and nurse practitioners provide services for months at a time without a medical practitioner being physically present.

Δ The Committee agreed that there is extremely wide variation in use of the current item number across physicians, which may reflect differences in clinical practice or differences in billing/claiming practices. Within the Committee, there was a lack of agreement about the appropriate frequency with which item 13103 (with the current item descriptor) could be reasonably claimed for a stable dialysis patient, with opinions ranging from every attendance for dialysis to less than once per week and only with physical attendance by the provider. The Committee agreed that the current fee-for-service model may incentivise some providers to provide more frequent dialysis services (up to six per week). Although this is not harmful to patients if the sessions are of an appropriate duration, there is no robust evidence to support this approach. MBS data showed that 4 per cent of providers claimed more than four dialysis services per patient in up to 7 per cent of patient treatment weeks. The remaining 96 per cent of providers did not claim more than four dialysis services in more than 1 per cent of patient treatment weeks (23).

Δ It was noted that the MBS data on item 13103 is also likely to provide an incomplete picture of MBS-supported dialysis, as there are providers who bill specialist attendance items (e.g., item 116) in place of item 13103 due to the higher rebate. It was agreed that it is appropriate to claim item 116 when a patient is reviewed, and a face-to-face consultation is performed and documented in line with item 116 requirements. However, the Committee felt that it is inappropriate to claim item 116 for routine dialysis supervision. Claims of item 116 can be seen in Figure 4. Co-claiming item 116 with dialysis supervision items 13100 or 13103 was also noted as a concern, although the Committee found that this occurred in less than 1 per cent of all dialysis supervision claims (23). This data may not capture all patients, however, as nephrologists who never bill renal-specific services (such as item 13013) may be classified by the DHS as “internal medicine” and therefore may not be included. The Committee noted that there are approximately 9,500 patients dialysing in Australia, and the data obtained accounts for approximately 12.5 per cent of this population. The Committee agreed that the majority of patients are likely to have been captured in this data.

Figure 4: Dialysis and consult claim frequency per week

 Figure 4 is a bar graph which shows the dialysis and consult claim frequency per week. The y axis shows the count of patient weeks meeting a criteria. A patient week is a week of treatments for a single patient. The x axis shows the number of episodes per patient week. 

The figure shows counts for three items. Consults (item 116), standard dialysis supervision (13103) and long supervision (13100). There are very few 13100 services. Services for 13103 are predominately 1-3 episodes per week. Consult services decrease in count as the number of episodes per week increases from 1 to 7 or more. There is a callout on the chart which highlights that there are 23,840 episodes in which patients are receiving more than 4 consultations per week.

 

Δ The Committee found that service volumes for item 13100 were higher than expected. It was agreed that there was a financial incentive to claim this item, and that combining items 13100 and 13103 in a cost-neutral manner would remove this incentive without unfairly penalising providers.

Δ In light of this data and in-session discussions, the Committee agreed that the dialysis items should be re-drafted to achieve three outcomes: (i) the item(s) should reflect the ongoing care required by a dialysis patient, including between sessions; (ii) the item(s) should remove the financial incentives for specific treatment options, including in-centre versus home or community dialysis; and (iii) the item(s) should be linked to quality care or patient outcomes. The Committee also agreed that any change should be cost neutral, and should target the existing population of private patients who dialyse in the private setting.

Δ The Committee agreed that introducing an item that provides a weekly payment model could achieve the first outcome—reflect the ongoing care required by a dialysis patient—by facilitating ongoing planning, care and monitoring for patients receiving dialysis (see the proposed explanatory notes). It also agreed that the second outcome—remove financial incentives for specific treatment options—could be partially addressed through this weekly payment, which would remove the incentive to provide a specific number of services per week. However, the weekly payment model would not address the significant remuneration disparity between in-hospital and home dialysis supervision. It was noted that home peritoneal dialysis is not available for many private patients as this service requires transfer of care to a public hospital service. This is necessary to cover the non-medical supervision costs, which are not currently funded by private health insurers for home dialysis that does not require an ‘admission’ to a hospital or satellite service. It was noted that home dialysis (item 13104) currently attracts rebates of approximately $125 per month or approximately $1,500 per year, while in-centre dialysis (item 13103) attracts rebates of approximately $60 per service, which, if claimed three times per week for 40 weeks in a year, equates to over $7,200 per year (excluding payments by private health insurers for each service provided). It was noted that some in-centre patients are more acutely unwell and do have higher care needs. However, many stable in-centre patients do not have significantly higher complexity than home dialysis patients. The 40 weeks referenced in this example represent a very conservative estimate, reflecting that patients are acutely unwell for part of the year, and that some commence or cease dialysis part way through the year. The differential would be higher for a full year.

Δ The Committee agreed that a weekly consolidated payment for care of a dialysis patient would reduce inter-provider variability and simplify the billing and administration of dialysis, particularly for patients who were being reviewed and billed three times per week and would now be covered in a single claim. Practices utilising shared care models with multiple nephrologists would be required to implement appropriate fee-sharing models. Providers who currently claim fewer than 12 services per patient per year would need to bill patients more frequently, but this would involve a streamlined weekly billing process.

Δ Although weekly billing would simplify things for many providers, it may result in increased complexity and inconvenience for some patients. This is particularly true for patients of providers who do not offer claim delegation or automatic claiming. (Automatic claiming may also increase the inconvenience for patients who receive rebates via cheque.) However, the process would be simplified for patients who are billed three times per week, assuming their practices have not already implemented a process to simplify this for patients. The Committee agreed that the care of the patient should include regular assessment of patient satisfaction, which would allow for patient experience improvements to be made.

Δ The Committee noted that for a large number of patients, dialysis supervision items were claimed infrequently. It was agreed that the vast majority of patients undergo dialysis three times per week, every week. However, MBS data revealed that over a one- to two-year period, 32 per cent of patients received only one claim for dialysis, and 69 per cent of patients received less than 12 claims. The Committee considered a number of explanations for this disparity:

 The Committee felt that some of these patients may be accounted for by acute short-term dialysis, holiday dialysis of public patients in a private facility or other extraordinary circumstances. It was also considered that providers may be claiming item 116 instead of item 13103, although it seems unusual that a provider who routinely bills item 116 for the supervision of dialysis would periodically bill item 13013, except if he or she was unable to document in the patient’s notes, which is a requirement of a professional attendance.

 The Committee agreed that the majority of this unexpected data demonstrated that providers were claiming item 13103/13100 services infrequently, such as when they physically attended and reviewed the patient, rather than for all dialysis services the patient received. It was noted that as the items refer to a professional attendance (of up to 45 minutes for item 13013), many providers interpret this as requiring attendance for direct clinical involvement in the care of the patient—an interpretation shared by the Department of Health (the Department). However, it was noted that some providers consider attendance on a dialysis unit, or being available remotely, as fulfilling the requirements for this item.

Δ The Committee noted that introducing this weekly payment model would have a moderate economic impact on providers who are at the high and low ends of claim practices. However, it noted that reducing the variability in billing and the impact of this on both patients and providers, as well as recognising the non-face-to-face time of clinicians, were the main drivers for recommending the change. Although setting the fee for this item is not within the scope of this Review, analysis was conducted to estimate economic impacts. However, due to the marked variation in claim practices, and the Committee’s view that a significant proportion of patients are billed 116 services only, the Department did not have the resources to accurately model the impact of these changes on providers. High-level estimates indicate that the impact on the top 10 per cent of providers would be in excess of $20,000 per year (24). Unless a significant number of patients are being billed 116 services exclusively and at a high frequency, this is likely to be an under-estimation. However, it should be noted that this change is intended to be cost neutral, and as such there would be a commensurate positive economic impact for other providers (although not necessarily the current bottom 10 per cent, as these providers may have low patient volumes and thus may be minimally affected by any changes).

Δ The Committee did consider creating an item that included all specialist consultations (such as item 116) in addition to items 13100/13103 without exception. The final recommendation, however, was that routine attendance and reviews during dialysis services should be included in the weekly payment for care of the patient, and that where a non-routine consultation occurs in consulting suites, it would be appropriate to claim a professional attendance item such as item 116. When a patient is admitted to hospital for an acute deterioration or non-kidney-related reason, the attending doctors routinely bill specialist attendance items. The Committee felt that it was impractical to require in-hospital attendances to be covered by the primary nephrologist under the consolidated item, as would be the case in a full capitation model.

Δ The Committee also considered a monthly payment model, but it felt that this would be impractical due to the issues created by the retention of 116 access for some circumstances (as described above). As it is not reasonable to double pay for the care of a patient, the monthly payment would be inappropriate for any month in which a patient had an acute inpatient admission, and for that month, the fee-for-service dialysis items would need to be billed as appropriate. Given this complexity, it was agreed that a monthly payment model was impractical, but that a weekly model would provide a reasonable balance. It was also agreed that the consolidated item should only be claimed if the majority of dialysis services in the week (usually two out of three) were provided privately by the claiming provider.

Δ With regards to the third intended outcome of drafting this item—that the item(s) should be linked to quality or outcome measures—the Committee discussed the possibility of including an incentive for care quality and outcome tracking. It was noted that international examples of capitated or episode-based payment models generally incorporate robust quality frameworks to ensure appropriate care is provided, as there is a financial incentive for providers to provide cheaper care to patients. It was noted that the current fee-for-service model of the MBS assumes that simply because a service is provided, it is of sufficient quality due to self-regulation of the profession. However, it also noted that in some cases this may not be true. The Committee discussed potential quality assurance approaches and agreed that there are currently no widely accepted markers of high-quality care, and that existing metrics are significantly affected by factors such as patient mix.

Δ The Committee agreed that patients dialysing with a central venous catheter (CVC) are more susceptible to infections, hospitalisations and increased risk of death when compared to patients with an arteriovenous (AV) fistula or graft for vascular access (25). The Committee considered whether it would be appropriate to create differentiated items based on either commencement of dialysis with long-term access in place, or based on the type of access used for each service. Regarding commencement, it was agreed that unplanned commencement often occurs in patients who have not previously seen a nephrologist, or when an acute and unexpected deterioration occurs. As such, it was agreed that differentiating the items would be unlikely to affect these patient populations. The Committee also considered a separate item for any service provided via CVC, regardless of commencement access. However, the Committee ultimately felt that this was inappropriate for several reasons. Firstly, there are situations when it would be clinically appropriate to use a CVC—for example, in an elderly patient who only requires short-term access. In such patients, a lower rebate—whether passed on to the patient through increased out-of-pocket expense or absorbed by the provider—may create inequity in situations where appropriate patient-centred care was provided. Consideration was also given to the creation of split items without a fee differential for tracking purposes. This was not favoured, however, as it was noted that unique codes that carry equal remuneration are often not appropriately coded. Finally, it was noted that any differentiation based on access type would be very difficult to enforce. It was agreed that the majority of patients in Australia dialyse using long-term AV fistula or graft access. Any audit of providers in an attempt to identify CVC patients being claimed under the AV fistula item would require analysis of a high volume of records in order to have a reasonable probability of detecting a case if misuse had occurred. The Committee would be willing to consider the creation of differentiated items by access again, if this was felt to offer additional value to the health system.

Δ It was agreed that implementing an episode-based payment model without quality metrics presented a risk. However, the Committee felt that this risk was small due to the fragility of the patient population, who would deteriorate rapidly with inappropriate care. This risk is also significantly mitigated by the current near-universal participation of dialysis providers in the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA). ANZDATA provides quarterly haemodialysis key performance indicator reports to participating dialysis units, including metrics such as percentage starting with an AV fistula or graft, number of early referrals and percentage of early referrals with planned access. Hospital reports are also provided (which cover a rolling six-year window), and a transplant centre report summarises the outcome of transplant patients (patient and graft survival) over the six-year period. All reports compare the recipient unit or hospital to the average across Australia and New Zealand. ANZDATA also publishes public reports, including an annual report and annual dialysis and transplant hospital reports. These reports provide information on the incidence and prevalence of end-stage kidney disease, as well as the outcomes of dialysis and transplantation treatment performed in Australia and New Zealand. They contain comprehensive analysis of patient care outcomes, such as technique and patient survival, as well as trends and variations in the treatment of patients. The annual hospital reports (for dialysis and transplants) also include some of the outcomes of dialysis treatment performed in Australia and New Zealand, including a “standardised mortality ratio” for each hospital, which reflects the number of deaths over the number of “expected deaths,” based on the patient population of each hospital. The data collected by the registry is also regularly used for publications, with over 40 articles published in the last two years.

Δ Although nearly all dialysis units contribute to ANZDATA, the Committee noted that a very small number of providers elect not to participate, and that some patients at contributing units do not consent to their data being provided. For this reason, the Committee recommended that where registry data is not provided, an equivalent patient safety and quality assurance system should be instituted. Implementation of this aspect of the recommendation—including confirmation of participation, and appropriate use by the Department of the registry data to monitor quality of care by claiming providers—was not discussed. The Committee agrees that the quality of care currently provided under the MBS is already of a high standard. It is not expected that the move to a weekly payment model will have any material negative impacts on patient health outcomes or experience.

Δ The Committee discussed the broader implications of this recommendation for the MBS. It was noted that there is a risk that this item will be seen as establishing a precedent by other providers, both general practitioners (GPs) and specialists, who care for patients with complex chronic diseases. Generally, care coordination between consultations is considered part of the routine care of that patient.

Δ The Committee agreed that there was a degree of economic risk involved in implementing this weekly payment model due to a lack of data transparency, caused by providers claiming item 116 for the supervision of dialysis. The Committee therefore recommended introducing the change on a trial basis, for 12 to 24 months, with a subsequent economic evaluation. The primary end point would be decreased claim variability while remaining net cost-neutral. If the change is found to have increased or decreased dialysis funding, steps should be taken to correct this imbalance. The Committee emphasised that it is important that this change does not inadvertently reduce the funding available for private dialysis services. Consultations with some providers who practise predominately in private settings revealed that some small facilities are already at the edge of financial viability.

Secondary outcomes could be quite varied, including patient satisfaction, quality of care and provider satisfaction outcomes, and it is essential to confirm that there is no decline in patient health outcomes. The Committee noted that this could be done in partnership with an academic institution and ANZDATA in order to allow more robust research to be completed. The details of this should be discussed if this recommendation is to be implemented, noting that baseline data must be established prior to implementing the change.

 

4.3       Arteriovenous shunt: Item 13106

Table 4: Item introduction table for item 13106

Item number

Descriptor

Schedule fee

Volume of services FY2014/15

Total benefits

Services average annual growth

13106

Declotting of an arteriovenous shunt.

$121.35

6

$571

8.4%

Recommendation

Δ Delete this item from the MBS.

Rationale

The recommendation focuses on modernising the MBS and is based on the following observation.

Δ The Committee agreed that arteriovenous shunts are no longer part of contemporary clinical practice. This is reflected in the extremely low volume of items claimed. In FY2014/15, for example, only six services were claimed. All patients should now have venous access established, using either fistulas or grafts.

4.4       Insertion of temporary catheter: Item 13112

Table 5: Item introduction table for item 13112

Item number

Descriptor

Schedule fee

Volume of services FY2014/15

Total benefits

Services average annual growth

13112

Peritoneal dialysis, establishment of, by abdominal puncture and insertion of temporary catheter (including associated consultation).

$136.65

3

$508

-38.8%

Recommendation

Δ Delete this item from the MBS.

Rationale

The recommendation focuses on modernising the MBS and is based on the following observation.

Δ The Committee unanimously agreed that item 13112 covers a procedure that no longer reflects contemporary clinical practice and has been replaced by alternative procedures, such as insertion of catheters via laparoscopy (item 13109). This is reflected in the extremely low volume of items claimed. In FY2014/15, for example, only three services were claimed.

4.5       Indwelling peritoneal catheter for dialysis: Items 13109 and 13110

Table 6: Item introduction table for items 13109 and 13110

Item

Descriptor

Schedule

Fee

Volume of services FY2014/15

Total benefits

Services average annual growth

13109

Indwelling peritoneal catheter (Tenckhoff or similar) for dialysis insertion and fixation of.

$227.75

410

$70,354

4.7%

13110

Tenckhoff peritoneal dialysis catheter, removal of (including catheter cuffs).

$228.50

178

$30,308

3.3%

Recommendations

Δ Change the item descriptor for item 13110 to align the descriptors of items 13109 and 13110. The proposed descriptor is as follows: “Indwelling peritoneal catheter (Tenckhoff or similar) for dialysis, removal of (including catheter cuffs).”

Δ Review the schedule fee for both items.

Rationale

The recommendations focus on ensuring best practice and are based on the following observations.

Δ The Committee felt that the discrepancies between the two item descriptors were unnecessary and confusing. Aligning the wording of the two item descriptors increases consistency across the MBS.

Δ The Committee agreed that the current fee attached to item 13109 ($227.75) does not reflect the skill and time required for the insertion or removal of a Tenckhoff catheter. Removal of a Tenckhoff catheter (item 13110), for example, requires careful dissection and removal of both the catheter and the incorporated cuffs, as well as repair of the abdominal wall (19-20). The fee also does not include an assistant fee, and the Committee agreed that an assistant is required to perform these procedures safely and accurately.

Δ Although surgeons associated with renal units usually perform insertion and removal of a Tenckhoff catheter as a specialised procedure, it is performed laparoscopically in some centres. Laparoscopic insertion or repositioning of Tenckhoff catheters are new techniques and have never had an item number. Increasing the fee for insertion and removal of a Tenckhoff catheter (whether open or laparoscopic) will better reflect the time, effort and expertise required to use these new techniques. A laparoscopy item number is currently also charged by some providers for these procedures, although the Department noted that this was not appropriate.

Δ The Committee considered whether it might be more appropriate for an alternative Clinical Committee to review this item, as only one Committee member had expertise relating to the item. However, acknowledging that this item is low volume and performed by providers from a variety of specialties, it felt that it was appropriate for the Committee to retain the item within its scope. The Committee noted that nephrologists may upskill to provide this service to their communities, particularly in rural and remote areas.

Δ The Committee agreed that the current service volume is not suggestive of a significant access issue as a result of the current schedule fee.

4.6       Paediatric–adult transition

Recommendations

Δ The Committee strongly recommended referring the issue of paediatric–adult transition of patients with complex kidney disease to an appropriate government or inter-governmental body or group, such as the Council of Australian Governments.

Δ The Committee proposed that an ongoing and sustainable service (or funding for a service) should be created to provide support for the care of adolescent patients with complex kidney disease. This service should:

 Be available for patients with complex kidney disease who are between 16 and 23 years old and within six months of transitioning from paediatric to adult services.

 Include funding to cover the cost of young adult complex care consultations, which involve history-taking, identification of the patient’s multi-disciplinary team (MDT) care needs and outcomes to be achieved by members of the care team, the execution of all tasks necessary to achieve these outcomes, and evaluation of patient progress against clear, patient-focused goals.

 Be attended by the following: at least one nephrologist; a youth worker; at least two other providers who provide a different kind of care or service to the patient (specifically, a specialist nurse, general practitioner or allied health professional) and are not the patient’s family/carers; and the patient (who should be physically present). Additional specialists (e.g., a paediatric nephrologist or urologist) may be in attendance as appropriate.

 Involve regular communication with and involvement of the patient’s usual GP.

 Take place in a youth-friendly location, generally a clinic or rooms designed for young adults, separate from a hospital.

 Provide care over a period of around two years, noting that cognitive development— particularly of executive functioning—is often somewhat delayed in complex chronic renal patients.

Rationale

These recommendations focus on improving patient outcomes and are based on the following observations.

Δ Teenagers and young adults have poorer outcomes than other transplant recipients, including a high incidence of late acute rejection episodes. Non-adherence to immunosuppressive regimens is a key contributory factor (28), which suggests that young people have poorer compliance and often miss out on adequate follow-up. These poor outcomes reflect a number of difficulties unique to teenage and young adult patients. For example, patients are transitioning from a paediatric system, where parents and the health care team assume great responsibility, to an adult system where they need to become responsible for their own care—a shift that can require upskilling. In addition, it is difficult to coordinate care as young adults with complex health care needs transition from paediatric to adult care, which involves many new providers. It is particularly challenging for patients with congenital renal disease and genetic or rare syndromes, many of which are unfamiliar to nephrologists who care for adults.

Δ Furthermore, it can be difficult to engage teenagers and young adults in their own health care in an unfamiliar health system that is geared towards mature and older patients. This is particularly true of cognitively vulnerable young adults, who may need additional help to understand their own medical/surgical history and their health care needs. This can result in psychological distress, anxiety, depression and poor health outcomes (29), which often lead to disengagement from health care services.

Δ Evidence suggests that introducing this service could improve outcomes for young adults with functioning renal transplants. In the United Kingdom, for example, a dedicated young adult clinic was established for patients aged 16–28 years with chronic kidney disease 4+. Among the small number of patients at this clinic (n=21), the rate of five-year graft loss fell from 67 per cent to 0 per cent during the first 10 years (30). Although the population in Australia is too small to allow for sufficiently powered sample sizes, a review of ANZDATA registry data from 1985 to 2010 showed that rates of graft loss due to late acute rejection and noncompliance were higher in young adult patients, while graft loss from other causes remained relatively flat (31). There is clinical consensus in both the Australian and international nephrology communities that this age group is at significant risk, and that steps should be taken to reduce this risk (32).

Δ The Committee agreed that ongoing case management and the involvement of primary carers is important, and that this would vary by patient context. For example, care of a regional transplant patient would require the active involvement of the patient’s local supports and providers, in addition to specialist metro services. For high-risk patients, case management between visits may improve outcomes. The Committee agreed that for all patients, there should be a specific requirement to liaise with and communicate with the patient’s usual GP.

Δ The proposed service could be provided at a reasonably low cost due to the small number of potential patients. There are approximately 330 patients in Australia aged 15–24 with functioning renal transplants (3), and the populations for most other serious chronic paediatric conditions are expected to be similarly low.

Δ In addition to improving patient outcomes, the proposed service will make it possible to avoid the significant costs associated with graft loss. The healthcare costs of a patient with a functioning transplant averages $11,770 per annum, considerably lower than that of a patient on dialysis at $61,659 per annum. As such, each year of dialysis due to failure increases healthcare costs by $53,545p.a., with the year of transplantation costing $81,549p.a.(33). Data from the ANZDATA registry of all transplantations from 2005 to 2014 shows that the interval between graft failure and re-transplantation in young adults is 1,700-2,400 days (Figure 5). The resulting potential economic impact for each graft failure is $256,000-$351,000 in healthcare expenditure. In total there have been 101 re-transplantations between 2005 and 2014 (age at time of graft failure 15-19 n=39, 20-24 n=62), with an estimated cost of $31 million, or $3 million per year(31).

Δ Clinicians across Australia have been searching for sustainable funding for this model for several years, and it remains an ongoing challenge. Current models (Appendix C - Current Australian paediatric–adult renal transition models) are funded through grants and charitable donations, which may not be sustainable sources. Funding from public hospital services is generally unavailable, as the services require a youth-appropriate, off-site location, and hospitals do not generally consider off-site services to fall within their responsibility. Community sector funding has not been able to support this service due to limited resources for current services in this setting, such as community mental health care. Recurrent Commonwealth funding under the MBS was discussed, but this presented several challenges. Most notably, funding for the allied health services by unregistered providers, such as youth workers, may not be effective under the MBS, where there is no line-of-sight visibility to the claiming provider. It was agreed that funding these services would provide significant economic benefits for both state and federal governments, but a clear and sustainable funding model has yet to be identified.

Figure 5: Average time between graft failure and re-transplantation

Figure 5 is a bar graph which shows the average time between graft failure and re-transplantation. There are 5 columns: column 1: average time between transplant by age at time of failure of previous transplantation by number of days, column 2: cost without graft failure, column 3: cost of dialysis and re-transplantation, and column 4: savings per failure avoided. Column 1 shows in blue bars two of the highest age groups and their average time in days.The longest interval between failure and re-transplantation is between ages 20-24 at 2,428 days. In this age group, health costs without graft failure would have been $78,300, and with an average failure interval increases to $430,100, an additional $351,800 . The second highest is the age group of 15-19 years at 1,728 days. This age group's non-failure health costs would be $55,700 and with average failure interval inceases to $311,700 or an additional $256,000.

 

Δ The Committee discussed which provider generally holds overarching responsibility for the patient and the services during the adolescent years. It was acknowledged that for adolescents, the paediatric nephrologist often has additional expertise in working with younger patients, but during this period the focus is on transitioning away from paediatric services. It is imperative that rapport with adult providers and services is established during this time, and this is undermined if the paediatric providers remain the ‘lead,’ with services predominately occurring in the usual paediatric clinic. For this reason, the Committee agreed that overriding responsibility should rest with the adult providers.

Δ The Committee strongly supported consideration of other populations that fall between the gaps of state and Commonwealth funding, hospital and community care, and paediatric and adult services, where the significant lack of clarity in terms of accountability for funding care has negative health outcomes. Such populations would include adolescents with spina bifida, cystic fibrosis, complex urological conditions, cerebral palsy and other organ transplants. It is beyond the expertise of this Committee to recommend specific solutions for these populations, but the Taskforce should consider them when considering this issue.

4.7       Stakeholder impact statement

The new item for very remote dialysis is expected to address a significant access gap that currently forces very remote dialysis patients to relocate, with all the attendant individual and social costs. Adding this item is expected to have profound positive social and health outcome impacts for patients, as well as positive economic outcomes for patients, state governments and the federal Government.

The creation of a weekly dialysis supervision item is expected to redistribute funds between nephrologists, depending on current billing practices. For approximately 10 per cent of providers, billings are expected to decrease by more than $20,000 per year (24). There are no expected impacts on patient outcomes as a result of this change. However, there may be an improvement in care coordination activities among a small subset of nephrologists, whose attention is drawn to the level of ongoing care expected. This may also improve communication with primary care clinicians.

Patients and providers are expected to benefit from the recommendations to delete or change items. Fewer and clearer item descriptors, supported by clear explanatory notes, will minimise confusion for providers and incentivise best-practice clinical care for patients.