5.      Recommendations to other committees

Introduction

The Committee has also developed provisional recommendations for the consideration of other committees. These recommendations 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. These recommendations will be submitted to the relevant committees for consideration as they formulate their own recommendations to the Taskforce. The recommendations will also be included in this Committee’s final report and may be considered directly by the Taskforce.

The item-level recommendations can be found below in Sections 5.1–5.4, and a summary recommendation table can be found in Appendix D. Recommendations are grouped by Clinical Committee.

5.1       Recommendation to the Consultation Services Clinical Committee

5.1.1        Healthy donor consults

Table 7: Item introduction table for items 132 and 133
 

Item

Descriptor

Schedule

Fee

Volume of services FY2014/15

Total benefits

Services average annual growth

132

Professional attendance of at least 45 minutes duration for an initial assessment of a patient with at least two morbidities (this can include complex congenital, developmental and behavioural disorders), where the patient is referred by a referring practitioner, and where

a) assessment is undertaken that covers:

 a comprehensive history, including psychosocial history and medication review;

 comprehensive multi or detailed single organ system assessment;

 the formulation of differential diagnoses; and

 b) a consultant physician treatment and management plan of significant complexity is developed and provided to the referring practitioner that involves:

 an opinion on diagnosis and risk assessment

 treatment options and decisions

 medication recommendations

Not being an attendance on a patient in respect of whom, an attendance under items 110, 116 and 119 has been received on the same day by the same consultant physician.

Not being an attendance on the patient in respect of whom, in the preceding 12 months, payment has been made under this item for attendance by the same consultant physician.

 

$263.90

 

790,316

 

$177,936,772

 

12.7%

 

133

Professional attendance of at least 20 minutes duration subsequent to the first attendance in a single course of treatment for a review of a patient with at least two morbidities (this can include complex congenital, developmental and behavioural disorders), where:

a) a review is undertaken that covers:

 review of initial presenting problem/s and results of diagnostic investigations

 review of responses to treatment and medication plans initiated at time of initial consultation comprehensive multi or detailed single organ system assessment,

 review of original and differential diagnoses; and

b) a modified consultant physician treatment and management plan is provided to the referring practitioner that involves, where appropriate:

 a revised opinion on the diagnosis and risk assessment

 treatment options and decisions

 revised medication recommendations

Not being an attendance on a patient in respect of whom, an attendance under item 110, 116 and 119 has been received on the same day by the same consultant physician or locum tenens.

Being an attendance on a patient in respect of whom, in the preceding 12 months, payment has been made under item 132. Item 133 can be provided by either the same consultant physician or a locum tenens.

Payable no more than twice in any 12 month period.

 

$132.10

525,184

$59,970,098

13.7%

Recommendation

Δ Amend the item descriptor for items 132 and 133 to include consultation with a healthy donor for transplant workup as an indication.

Rationale

The recommendation focuses on improving quality of care, and is based on the following observations.

Δ The Committee agreed that healthy donor workups are complex consultations. They are lengthy, and they require the nephrologist to share information about the donation process, including risks, long-term health implications, and the expected duration of admission and recovery (34). They also involve carefully managing patient vulnerability and ensuring informed patient consent (34), and decisions made during these consultations significantly affect the lives of prospective recipients and donors. (Live kidney donation has better short-term and long-term outcomes for the recipient than other treatment options, including deceased kidney donation.) (34) They also require complex estimation of long-term health risks, especially as growing rates of obesity, diabetes and associated co-morbidities increase the risk of future renal disease for the donor (35). The Committee agreed that a detailed and patient-focused approach to consent with a potential donor may increase a patient’s likelihood of proceeding with donation and allow the donor to make this decision in a more informed manner.

Δ The wording of item 132 does not clearly extend to cover healthy donor workups, as it requires the patient to have at least two morbidities—a condition not met by many donors as the assumption is that the donor is healthy.

Δ The expected economic impact of this change is unlikely to be significant, both because the Committee believes that many providers may be already using item 132 for these consults, and because the volume of healthy donor transplants is less than 270 a year nationwide (36).

Δ The Committee agreed that following the initial post-transplant period, it would be appropriate for the donor to be followed up using item 116 claims.

5.1.2        Claiming specialist attendances

Recommendations

Δ Amend the MBS section on General Rules for Professional Attendances to:

 Prevent nephrologists from claiming specialist attendances for the supervision of routine dialysis.

 Prevent nephrologists from co-claiming dialysis supervision items 13103 and 13100 with consultation items.

Δ Monitor specialist attendance claim patterns in order to identify providers with high rates of item 116 claims per patient, who may be inappropriately claiming the item. This could be achieved using the MBS compliance function.

Rationale

The recommendations focus on ensuring appropriate use, and are based on the following observations.

Δ The Committee expressed concern that some providers are claiming consultation items, particularly item 116, instead of dialysis supervision items such as item 13103. The Committee noted that a consultation is distinct from supervision of dialysis. For this reason, there is a dedicated item for supervision of dialysis, which should be claimed when dialysis is being supervised. The Committee felt that providers were claiming consultation items because they are better remunerated. Committee members also expressed concern that providers who are claiming dialysis as consultation items (such as item 116) may not be complying with the requirements for these items, such as physical consultation and documentation of the consultation in the patient’s medical record. It was noted that such claims limit transparency across the MBS about the nature of services that are being provided, and that it is not possible to determine the actual number of dialysis services provided across the MBS when a portion are being claimed as miscellaneous items.

Δ The Committee agreed that although an acutely unwell dialysis patient may need frequent 116 reviews, a stable patient would generally require a 116 review every one to three months. Consistently higher claiming rates may indicate misuse of the items. Should the proposed consolidated weekly payment model (item 1310X) be implemented, this would include all routine reviews, including in consulting suites, and the creation of associated letters. However, if a patient is acutely unwell and admitted to hospital, it is reasonable not to claim the consolidated dialysis supervision item, and for provider(s) involved in the acute care episode to claim the appropriate professional attendance items.

5.2       Recommendations to the Nurse Practitioner and Participating Midwife Clinical Committee

Recommendations

Δ Consider increasing access to existing items or creating appropriate items for these services to reflect the scope of services provided by nephrology nurse practitioners and chronic disease nurse practitioners providing care for patients with kidney disease. Services that are currently provided by nephrology nurse practitioners—particularly in rural and remote areas and with Aboriginal Medical Services (AMS)—include procedures, referrals, and contributions to health assessments and management plans.

Δ Consider what steps could be taken to ensure that the extent and nature of the work performed by nurse practitioners is captured by the MBS. This could be achieved through various mechanisms, some of which are described below. The Committee acknowledges that this is a complex policy space that warrants detailed discussion.

Δ Consider creating a nurse practitioner attendance item for longer consultations, such as those required for complex patients with end-stage kidney disease.

Rationale

The recommendations focus on improving access to care and are based on the following observations.

Δ The Committee noted that nurse practitioners play an important role in the provision of care for patients with end-stage kidney disease and other chronic conditions, particularly in rural and remote areas. The Australian College of Nurse Practitioners estimates that there are over 130 nurse practitioners working in nephrology as a specialist field or providing care to nephrology patients under a chronic disease focus. More than half of these providers are practising in rural and remote areas. Many of these providers are employed by public hospitals and provide services to AMS and patients in other centres, which have an exemption from section 19(2) of the Health Insurance Act 1973. This allows the provider to bill MBS items despite receiving other government funding. It was felt that nurse practitioners provide a number of services for these patients but are not currently able to claim for these services under the MBS. Examples may include performing ECGs, referring for ultrasounds, suturing and contributing to health assessments.

Δ Any additional access to items granted to nurse practitioners would need to be within the scope of the individual provider. It was stated that many nurse practitioners are now graduating with a generalist scope, and many nephrology/chronic disease nurse practitioners are already trained in many diagnostic and procedural areas of care. Although an appropriately qualified nurse practitioner could perform some services fully, certain services (such as health assessments) are comprehensive and may not be able to be fully completed by a nurse practitioner independently. The Committee agreed that it may be reasonable to consider either an item that reflects a nurse practitioner’s contribution to a GP health assessment, or an item for nurse practitioner health assessments within the area of expertise of that practitioner. It was also noted that the Primary Care Clinical Committee will be reviewing the health assessment items, and that these reviews should occur in tandem.

Δ Distinct from claiming additional services, the Committee noted that under the current items, it is not possible to identify the services provided by nephrology nurse practitioners under the MBS. The nurse practitioner consult items are time-tiered in the same way as medical consults, but the MBS does not currently record specialty areas for nurse practitioners. As such, it is impossible to determine the extent of nephrology or other services currently being provided. The Committee discussed potential solutions for this but acknowledged that this was a complex policy discussion with implications for all nurse practitioners, not only those specialising in nephrology. Three potential solutions were discussed and are included here for consideration.

1. Create specific duplicate items for individual specialties, with or without specific criteria for both patient eligibility and services to be provided—for example, a consult for kidney disease lasting more than 20 minutes, which includes a specified set of criteria.

2. Create items of negligible value that identify the specialty of the provider, and have them co-claimed with any service provided.

3. Recommend that nurse practitioners be attributed specialty designations based on their area(s) of practice.

Δ The Committee agreed that creating an item for more than 45 minutes may also be warranted, acknowledging that a consultation with a complex chronic kidney patient often takes considerable time if all appropriate aspects of care are reviewed and addressed.

5.3       Recommendations to the Urology Clinical Committee

5.3.1        Living donor nephrectomy

Recommendations

Δ Create a new MBS number for “Living donor nephrectomy, Laparoscopic and/or open,” including use of an assistant.

Δ When determining the schedule fee for the item, the MSAC should consider that item 36532 (for nephro-uretectomy, for tumour) is the most equivalent service on the MBS.

Rationale 

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

Δ Living donor nephrectomy is a unique operation performed to procure a kidney for transplantation. It is usually performed as a laparoscopic procedure, which is a standard procedure for live donor operations and has been widely used in Australia since 2007 (37). It is different and more complex than ablative nephrectomy for cancer or stone disease as it is very important to take the maximum length of the renal artery, vein and ureter, and to cause no damage to the kidney, in order to facilitate the transplant operation. For this reason, it is only performed by a small group of general transplant, vascular and urology surgeons who are specially trained in the procedure. Approximately 260 donor nephrectomies are performed in Australia each year (36).

Δ Donor nephrectomy, either open or laparoscopic, has never had an item number attached to it. For this reason, surgeons who perform donor nephrectomy use a variety of MBS numbers (for example, items 36516, 36531 and 30390). A dedicated item number would be helpful to clarify and adequately remunerate the operating surgeon.

Δ An assistant is required to complete a laparoscopic donor nephrectomy successfully, as three to four ports (requiring at least two pairs of hands) are essential for the procedure. For this reason, an assistant fee is also required.

5.3.2        Renal biopsy

Table 8: Item introduction table for item 36561

Item

Descriptor

Schedule

Fee

Volume of services FY2014/15

Total benefits

Services average annual growth

36561

Renal Biopsy (closed). (Anaes.)

$172.50

1,592

$220,437

10.1%

Recommendation

Δ Amend the descriptor for item 36561 to include a requirement that practitioners use ultrasound guidance when undertaking a renal biopsy. The proposed descriptor is as follows: “Renal biopsy (closed) performed with ultrasound guidance.”

Rationale

The recommendation focuses on ensuring best practice and is based on the following observations.

Δ Percutaneous renal biopsy continues to play an essential role in characterising and defining the processes involved in chronic and acute kidney disease. Although there are no global guidelines that outline when to perform a diagnostic renal biopsy, it remains an important diagnostic, prognostic and relatively safe test. Figures indicate that there are relatively few procedures undertaken in the private setting under the MBS, but there is a clear indication for its ongoing schedule. Although the procedure has historically centred on diagnosing parenchymal renal disorders, the procedure has also found increased utility in the diagnosis and subsequent management of small renal tumours. There are no guidelines on the utility of renal tumour biopsy, but it is recognised that biopsy of small renal tumours has a high diagnostic yield and low risk of complications.

Δ The Committee agreed that current best practice for renal biopsy involves the use of ultrasound (38), and that biopsy without ultrasound guidance should no longer be performed. The Committee felt that clinical practice had already shifted to reflect this. Services are provided under CT guidance, although there are specific items for deep organ biopsy under CT guidance.

Δ The Committee noted that when a nephrologist who has not been accredited under the Diagnostic Imaging Services Table (DIST) performs a renal biopsy, only item 36561 is claimable, and the ultrasound equipment may be sourced from areas equipped with them, such as an intensive care unit. However, when performed by an accredited provider, items 36561 and 55054 are claimable, as long as the provider complies with the formal reporting requirements under the DIST. Procedures performed by a radiologist, or in a radiology department with the assistance of another provider, attract a higher rebate for the same service. The Committee discussed creating a complete medical service, which would include imaging, but there was concern that the restriction on co-claiming of imaging may result in restricted access to ultrasound equipment or increased out-of-pocket costs for patients.

Δ The Committee discussed the potential for a fee review to account for the shift in practice to require ultrasound guidance. It was noted that the MSAC recently considered an application to remunerate point-of-care ultrasound guidance for other procedures, and that this application was rejected on the grounds that the guidance allows for faster and more efficient procedures, which offsets the additional cost. The Committee regarded this as a materially similar situation and determined that it was not worthwhile pursuing it.

Δ In Australia, renal biopsy using real-time ultrasound guidance is generally undertaken on the conscious patient using local anaesthetic. However, for the paediatric patient and some adult patients, general anaesthetic is required and this access should be retained.

5.4       Recommendations to the Aboriginal and Torres Strait Islander and General Practice and Primary Care Clinical Committees

Recommendations

Δ Review health assessment items 701, 703, 705, 707 and 715 in relation to both eligibility and content.

Δ Incorporate an integrated health assessment MBS item for vascular disease, diabetes and kidney disease, with eligibility and content that reflect evidence-based guidelines such as those contained in the Royal Australian College of General Practitioners’ (RACGP) Guidelines for Preventive Activities in General Practice.

Rationale

The recommendations focus on improving quality of care and are based on the following observations.

Δ The range of eligible population groups and the specific requirements of the current MBS health assessment items are not fit for purpose. For example, there are many individuals with one or more of the recognised risk factors for vascular and kidney disease who are not eligible for any of the health assessment items.

Δ The specific requirements for items 701, 703, 705, 707 and 715 do not reflect current evidence-based practice and in some instances deviate significantly from this. For example, Table 9 compares the renal-related requirements with the recommendations from the RACGP’s 2012 Australian Guidelines for Preventive Activities in General Practice (Edition 8). These guidelines provide explicitly evidence-based recommendations for health promotion and disease prevention in Australian general practice, categorised by sex, age and population group. They are revised every two to four years, and a new edition is currently in preparation. The only reference to such guidelines appears in the health assessment for patients aged 40–49 at high risk of type 2 diabetes.

Δ The two recommendations made by the Committee are consistent with recommendations made by other bodies. In 2015, for example, the Standing Committee on Health’s Inquiry into Chronic Disease Prevention and Management in Primary Health Care recommended “that the Australian Government examine the inclusion of an integrated health assessment check for cardiovascular, kidney disease risk and diabetes as per that developed by the National Vascular Disease Prevention Alliance, where a patient does not already qualify for an existing assessment and the treating practitioner suspects they are at risk of these chronic diseases.”

 

Table 9: A comparison table of items 701, 703, 705 and 707 and the relevant clinical guidelines

Item/eligibility

Renal-related requirements stated in Associated Notes

Red Book (Edition 8) recommendations

ACR = Urinary albumin creatinine ratio

eGFR = Estimated glomerular filtration rate

CKD = Chronic kidney disease

701, 703, 705, 707:

 

 

Aged 40–49 at high risk of type 2 diabetes (every 3 years)

“History… physical examinations and clinical investigations in accordance with relevant guidelines”

Blood pressure, ACR and eGFR every 1–2 years

Aged 45–49 at risk of a chronic disease (once only)

Clinical judgement

Blood pressure, ACR and eGFR every 1–2 years

Aged 75 and older (annually)

Blood pressure measurement

Blood pressure;

ACR and eGFR if at increased risk of CKD

Permanent resident of Residential Aged Care Facility (annually)

Clinical judgement

Blood pressure;

ACR and eGFR if at increased risk of CKD

Intellectual disability (annually)

“Comprehensively assess … physical, psychological and social function”

No specific mention of CKD or vascular screening

Not specified

Humanitarian entrants (once only)

Clinical judgement

Not specified

Former serving members of ADF (once only)

Blood pressure

Not specified

715

 

 

Aboriginal and Torres Strait Islander Peoples Health Assessment (annually)

Blood pressure (aged 15 yrs and older);

“Urinalysis (by dipstick) for proteinurea” (aged 15–54 yrs);

no requirement for eGFR

Blood pressure, ACR and eGFR from 30 years of age

(NB. Dipstick urinalysis not recommended)