MBS Review Renal Medicine and Dermatology

Transcription

1 MBS Review Renal Medicine and Dermatology 9 August 2017 Australian Private Hospitals Association ABN

2 Contents Introduction... 1 Renal medicine... 2 Dermatology... 4 Phototherapy... 4 Benign and Malignant Neoplasms... 4 Laser Photocoagulation... 5 Mohs... 5 Skin Lesion Hydrocortisone... 5 Vermilionectomy using laser... 5 Rhinophyma using laser... 6 Private Hospitals in Australia... 7 The Australian Private Hospitals Association... 7 Bibliography... 8

3 Introduction The APHA is appreciative of the opportunity to make a submission to the Medical Benefits Schedule (MBS) Review in response to consultations on recommendations regarding Renal Medicine and Dermatology. In this response, APHA has focused on issues which could arise for private hospitals if these recommendations were adopted. Many of these issues lie outside the scope of the terms of reference for the MBS Review, for example they pertain to potential implications for the regulations governing private health insurance. The Private Health Insurance (Benefit Requirements) Rules makes detailed reference to relevant MBS items and it is therefore essential to consider whether the recommendations of the MBS Review will give rise to the need for changes in private health insurance regulation. It may also be necessary to consider whether there will be a need for education or guidance to the private sector as a whole including hospital operators and health insurers so that unintended consequences are avoided. For example, APHA has at several points in this submission noted that it would be undesirable if recommendations from the MBS Review resulted in increased certification requirements. Certification refers to a process where-by clinicians are required to confirm that a hospital admission has been necessary for clinical reasons. Some of the recommendations released in this consultation round have identified the need for clinicians to keep additional clinical records, photos and pathology results for audit purposes. While such recommendations may be entirely appropriate in the context of the MBS, APHA would want to ensure that these requirements remain specific to the MBS alone. The issues in this submission are raised with the intention of informing implementation of the proposed recommendations should they be adopted by the Australian Government. In making these comments, APHA remains fully supportive of the objectives of the MBS Review and recommendations intended to promote sound, evidence based clinical practice. 1

4 Renal medicine Items and The Committee proposes that these two items be replaced by a new item that will remunerate the management of dialysis over a week irrespective of the number of treatments delivered. This recommendation introduced a new approach to MBS billing. If this approach is adopted there will need to be special consideration given to the manner in which claims are recognised for the purposes of private health insurance. It is essential that hospitals are able to claim for all dialysis services delivered within a private hospital even if only the minority of services delivered in that week were delivered in a private hospitals (ie in circumstances when the MBS item would not be claimed). The Committee recommends that a record of services provided would be kept in the clinical notes, this raised the question as to how private health insurance claims would be validated. APHA is of the view that while it is acceptable for clinical notes to be accessed for retrospective audit purposes, it should not be necessary for hospitals to be required to provide clinical notes to health insurers for each claim to a health insurer. While recognising the importance of clinical registries, it is of potential concern that additional costs may accrue to the hospital as a result of the requirement to provide data to the ANZDTR (or equivalent) even though the Committee notes that reporting levels are already quite high. Reporting of data should be made as efficient as possible. In principle, APHA is of the view that where the collection of registry data requires the support of hospitals, the hospital costs involved should be recognised and compensated and data should be made available to hospitals so that it can be used in the continuous improvement of service quality. The Committee has noted that home peritoneal dialysis is not available for many private patients. Costs of non-medical supervision for home dialysis are not covered by private health insurers. APHA supports further consideration of this issue in the context of private health insurance reform. The Committee has noted that it is important that this change does not inadvertently reduce the funding available for private dialysis services. The Committee has noted that some small facilities are already at the edge of financial viability. APHA supports this observation and requests that this specific issue is given further attention by the Federal Government before the Committee s recommendation (if adopted) is implemented. 2

5 The Committee has indicated that it is willing to consider the creation of differentiated items by access method in order to support the gathering of data on this basis. APHA would want to ensure that this differentiation did not result in added complications to the recognition of items under the Private Health Insurance (Benefits Requirements) Rules. APHA notes that both items are listed as Type B within the Private Health Insurance (Benefits Requirements) Rules and consequently APHA is of the view that any differentiated items would remain Type B. Items and The Committee proposes that these two items be combined as one item however the one entails insertion and fixation of a catheter and the other refers to the removal of a catheter. Consequently although the two procedures are related and of similar complexity (see rationale) they entail different costs for hospitals particularly in relation to the costs of the catheter and other consumables. This issue would need to be resolved for the purposes of referencing in the Private Health Insurance (Benefits Requirements) Rules. Item Item is not listed in the Private Health Insurance (Benefits Requirements) Rules. It may be advisable to remedy this. A number of other items currently listed in the Private Health Insurance (Benefits Requirements) Rules have been referred to other MBS Committees and so APHA will not be commenting on them at this time: 30390, and

6 Dermatology Phototherapy Items and APHA would be concerned that the requirement of a specialist letter and review should not lead to more complex certification processes than those already required under the Private Health Insurance (Benefits Requirements) Rules. APHA notes that certification processes under the Private Health Insurance (Benefits Requirements) Rules relate solely to the question of whether hospital benefits are claimable or not. Certification does not allow the insurer to make a judgement regarding whether or not treatment was clinically appropriate. Benign and Malignant Neoplasms Item The Committee has proposed that this item be deleted and that item be used instead or a new item 3019X. Both these alternatives require referral for pathology. APHA considers it essential to ensure that hospital benefits are paid under the Private Health Insurance (Benefits Requirements) Rules irrespective of the pathology results given that the hospital costs will have been incurred irrespective of subsequent pathology findings. Items and The Committee has recommended consolidation of these two. They are currently given different recognition under the Private Health Insurance (Benefits Requirements) Rules is Type C and is Type A. The differentiation made in the Private Health Insurance (Benefits Requirements) Rules reflects different eligibility for different levels of funding and different certification requirements. This issue is financially material and may be sufficient argument for retaining two separate items with the same MBS fee level. This matter may require further consideration by the Department of Health and consultation with industry with respect to implications for the Private Health Insurance (Benefits Requirements) Rules. 4

7 Laser Photocoagulation Items 14100, 14106, 14109, 14112, 14115, 14118, The Committee has recommended that TGA licencing be required for the equipment used. APHA is concerned to ensure that this licencing requirement not impose an unreasonable cost burden on hospitals. The Committee has recommended that photo evidence be collected. APHA would be concerned that the requirement for photo evidence should not lead to more complex certification processes than those already required under the Private Health Insurance (Benefits Requirements) Rules. APHA would also want to ensure that patient privacy was protected in relation to the storage and use of photo images for audit purposes. APHA notes that certification processes under the Private Health Insurance (Benefits Requirements) Rules relate solely to the question of whether hospital benefits are claimable or not. Certification does not allow the insurer to make a judgement regarding whether or not treatment was clinically appropriate. Mohs Item 3100, and The Committee has recommended that each of these items be split into A and B reflecting the body part involved. APHA would want to ensure that this differentiation did not result in added complication to the recognition of items under the Private Health Insurance (Benefits Requirements) Rules. Skin Lesion Hydrocortisone Items and The Committee has recommended that an additional age criterion should be applied to these items such that administration under anaesthesia should only be offered to patients under 16 years of age. The two items attract different levels of hospital benefit under the Private Health Insurance (Benefits Requirements) Rules reflecting the different costs involved. APHA is concerned that this age specification should not lead to added complexity in the certification requirements involved particularly for item Vermilionectomy using laser Item The Committee has recommended that a biopsy be required. APHA would be concerned that the requirement for biopsy should not lead to more complex 5

8 certification processes than those already required under the Private Health Insurance (Benefits Requirements) Rules. APHA would also want to ensure that patient privacy was protected in relation to the storage and use of biopsy results for audit purposes. APHA notes that certification processes under the Private Health Insurance (Benefits Requirements) Rules relate solely to the question of whether hospital benefits are claimable or not. Certification does not allow the insurer to make a judgement regarding whether or not treatment was clinically appropriate. Rhinophyma using laser Item The Committee has recommended that photo evidence be collected. APHA would be concerned that the requirement for photo evidence should not lead to more complex certification processes than those already required under the Private Health Insurance (Benefits Requirements) Rules. APHA would also want to ensure that patient privacy was protected in relation to the storage and use of photo images for audit purposes. APHA notes that certification processes under the Private Health Insurance (Benefits Requirements) Rules relate solely to the question of whether hospital benefits are claimable or not. Certification does not allow the insurer to make a judgement regarding whether or not treatment was clinically appropriate. 6

9 Private Hospitals in Australia The Australian private hospital sector makes a significant contribution to health care in Australia, providing a large number of services and taking the pressure off the already stretched public hospital system. According to the most recent data available it treats: 4.33 million separations a year. It delivers: More than a third of chemotherapy 60% of all surgery 76% of rehabilitation 73% of eye procedures Almost half of all heart procedures 72% of procedures on the brain, spine and nerves. Australian private hospitals by numbers: Almost half (47%) of all Australian hospitals are private 630 private hospitals made up of: 289 overnight hospitals 341 day hospitals 33,074 beds and chairs (29,922 in overnight hospitals and 3,152 in free-standing day surgeries) 66,000 full time equivalent staff (AIHW 2017, ABS 2016). The Australian Private Hospitals Association The Australian Private Hospitals Association (APHA) is the peak industry body representing the private hospital and day surgery sector. About 70% of overnight hospitals and half of all day surgeries in Australia are APHA members. 7

10 Bibliography Australian Bureau of Statistics (ABS), 2017b Private Hospitals, Australia, , Accessed July 2017 Australian Institute of Health and Welfare (AIHW), 2017, Admitted patient care : Australian hospital statistics, Health services series no. 75. Cat no. HSW 185. Canberra. Private Health Insurance (Benefit Requirements) Rules 2011 Compilation 8 July Accessed July