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Defining value in the MBS Review

In May 2015 the Federal Government announced a review of the Medicare Benefits Schedule (MBS) with a view to bringing the MBS up-to-date and increase the value derived from the more than 5,700 listed items.

The announcement of this review brings into focus the challenges regarding how the concept of ‘value’ applies to healthcare, as well as the methodological approaches that the MBS Review Taskforce may employ in order to determine whether or not an item listed on the MBS provides ‘value’.

The Consultation Paper released by the MBS Review Taskforce in September 2015 outlines that only a small proportion of the services funded through the MBS have undergone the same evidence-based assessment that newer services must go through before they can be added to the MBS.

However, the idea that it is feasible to retrospectively apply contemporary evidentiary requirements for the clinical assessment and economic evaluation of MBS items listed prior to the formation of MSAC’s part of the MBS review is unrealistic. Further, the way in which MSAC assesses ‘value’ may not be appropriate when considering if a medical service funded through the MBS is clinically appropriate and reimbursed at an appropriate fee.

Assessing the value of clinician consultations

Certain health care interventions lend themselves to quantitative value assessment through well-established methodological approaches – such as those applied to the assessment of pharmaceuticals and medical devices. This is because there is often clinical trial evidence reporting on the comparative efficacy and safety of a new intervention versus an alternative intervention.

Many items listed on the MBS support patients through funding clinician consultations. In these circumstances the value provided to a patient’s health is derived from the time a medical practitioner spends in consultation with them, and the subsequent course of patient management chosen, rather than a direct consequence of the consultation itself. This is distinct from assessing the value associated with a pharmaceutical product (or direct medical intervention) where a patient’s benefit is more closely linked with receiving the intervention.

The difficulty in assessing value associated with clinician consultations is particularly relevant for consultations that consist of patient discussions and education, rather than procedural interventions.

Case study: The value of addiction medicine and sexual health medicine consultations

A case study highlighting the challenge in assessing the clinical and cost-effectiveness of MBS items supporting clinical consultations is given by the application to have professional attendances provided by addiction medicine and sexual health medicine specialists listed on the MBS. The assessment of this request through the MSAC process commenced in February 2012, yet was not formally considered by MSAC until August 2013. The Public Summary Document for MSAC’s deliberation on this application indicates that:

  1. There was no specific evidence that a particular structure of consultation items will have a direct impact on health outcomes; and
  2. No formal assessment of the cost-effectiveness of addiction medicine or sexual health medicine consultations was considered by MSAC.

These observations highlight the methodological challenges associated with assessing the ‘value’ of clinical consultation items funded through the MBS.

Notwithstanding the difficulties associated with determining the overall ‘value’ of listing addiction medicine and sexual health medicine attendances, MSAC recommended that 16 new time-tiered addiction medicine items and 16 new sexual health medicine items be listed on the MBS in August 2013. These items are yet to appear on the MBS despite MSAC’s recommendation in 2013.

This case study illustrates the fact that even though many MBS items don’t lend themselves to assessment via widely-accepted Health Technology Assessment methodologies, it does not preclude a conclusion that they represent value for money.

The MBS Review Taskforce Consultation Paper outlined that “in many cases, the review of MBS items will require an evaluation of the evidence for the relevant service’s safety, clinical effectiveness and/or cost effectiveness. Given the Taskforce’s remit to review all 5,769 MBS items in a relatively short timeframe, it will be essential that these reviews are done efficiently” (p. 13). Notwithstanding the noble intentions of this statement, the feasibility of such an endeavour is unrealistic given that the review and implementation of addiction medicine and sexual health medicine consultation items is still not complete despite being commenced in February 2012!

The importance of the MBS review

Given that tax payer expenditure on the MBS is approximately $20 billion per year, it is important to ensure that the items listed on the MBS facilitate patient access to medical services required to deliver care reflective of modern clinical practice. However, it should not be assumed that the translation of methodologies developed for the assessment of health care interventions for which evidence directly informing patient benefit is more widely available represents the best approach.

Given the breadth of the nature and complexity of items listed on the MBS, it is simply not feasible to assess the ‘value’ of an MBS item using approaches such as cost-effectiveness or cost-utility analysis. Perhaps the MBS review taskforce should consider that for some MBS items, and especially items for clinician consultations, ‘value’ may be more appropriately determined by assessing the cost of efficiently delivering the service in the contemporary health care system.

The team at Commercial Eyes have extensive experience in preparing reimbursement submissions to MSAC and the PBAC. Call us on +61 3 9251 0777 to discuss your market access need in this area.

This article was written by Andrea Yates and Toby Gould of our Market Access team.

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