The effect of the introduction of Commonwealth Medicare Benefit Schedule: items 871 and 872 on cancer multidisciplinary teams in NSW
A multidisciplinary team (MDT) meeting is a regular meeting of all members of the treatment team – including medical practitioners, nurses and allied health personnel – to facilitate best practice management of patients with cancer.
by Mark Anns, Robyn Thomas, Sue Sinclair
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Background
In November 2006, the Commonwealth Government introduced two Medical Benefit Scheme (MBS) items (871 and 872) to encourage and support clinicians participating in cancer case conferences.
MBS item 871 covers attendance by a medical practitioner to lead and coordinate a multidisciplinary case conference on a patient with cancer to develop a multidisciplinary treatment plan. MBS Item 872 covers attendance to participate in such a case conference.
The new process allows private medical practitioners, and those staff specialists with the right of private practice, to claim a rebate from Medicare for services provided under these item numbers. Following its introduction in the period to January 2009, 10,952 services were billed by medical clinicians in Australia for item 871 and 7,782 for item 872 with NSW billing the highest for item 871 and third highest for item 872.
Anecdotal reports that clinicians were donating the rebates obtained for items 871 and 872 to assist the operation of their multidisciplinary team, led the Cancer Institute NSW, to examine the effects of MBS items 871 and 872 on cancer MDT meetings in NSW.
Methods
Twenty-one NSW cancer MDTs were asked to report on issues related to clinicians billing Medicare Australia for MBS items 871 and 872 using the following methods:
- MDT meeting administrators were asked to complete an audit tool on the processes and costs of running an MDT.
- MDT members were surveyed on their attitudes to the Medicare rebates 871 and 872.
- Staff undertaking the Cancer Institute NSW project on MDTs and use of MBS Items 871 and 872 were interviewed.
Results
Audit of MDTs
Nineteen of 21 MDTs completed the audit tool. These data showed the average annual cost of MDT meetings was $23,920. This increased to $28,769 when two low cost outliers ($200 and $4000) were excluded. The average annual cost of an MDT meeting exceeded the average collected Medicare rebates for 871 and 872 per MDT meeting over the same time period ($13,960). The average cost of collecting Medicare rebates for items 871 and 872 was $5,049 per annum, equating to an average 36 per cent of the rebates collected being expended through the process of collection.
Survey of MDT members
Fifty-nine per cent of MDT members supported the collection of Medicare rebates, with 27 per cent unsure and 14 per cent opposed to collection. The donation of funds collected by clinicians from Medicare rebates to supplement the operational costs of the MDT meeting was occurring for some specialists.
The average number of times item 871 was able to be claimed at a MDT meeting was 7.7 per meeting, with the actual average number of claims being 5.2.
The average number of times 872 was claimable among these MDTs was 28 times per meeting (reflecting that multiple clinicians can claim this item for the same patient, compared with item 871). However, the average number of times it was actually claimed was only eight per meeting. This reflects a reported claiming rate of 29 per cent of the potential claims that could have been made. If all MDTs providing data on the claimability of MBS item 872 were included, it would only be claimable 19 times per meeting, on average. It is also worth noting that some MDTs provided relatively high figures: for example, one site indicated that item 872 could be claimed an average of 90 times per meeting, although it was claimed only 23 times.
The majority of clinicians did not object to making modifications to administrative procedures to enable collection of Medicare rebates. However, they did not support reducing the time spent planning treatments to maximise Medicare claims.
The availability of Medicare rebates did not impact on attendance at MDT meetings. Of those respondents claiming for MBS items, 93 per cent stated that the availability of rebates ‘makes no difference to my attendance’ (the percentage for those not claiming for the MBS items was 96 per cent).
Interviews with staff undertaking the Cancer Institute NSW project on MDTs and use of MBS items 871 and 872
Administrative concerns raised by staff included: excessive time and effort required establishing a system to collect Medicare rebates and directing them back to the MDT meeting; difficulty identifying eligible patients and clinicians; and the collection of the required documentation/ signatures.
In addition, a philosophical issue was identified related to the expectation that doctors would ‘donate’ the Medicare rebate to a MDT. Some argued that the Medicare rebate was a payment for the time in attending a meeting and hence was normal income.
Conclusion
The availability of Medicare rebates for MBS items 871 and 871 was not a strong driver for practitioner attendance at cancer MDT meetings and did not impact upon decision making about whom should be prioritised for discussion at a MDT. Although there was support for the availability of the MBS items, others perceived the low level of rebate as not significant and associated with undue administrative burden.
A number of administrative issues were identified as potential challenges/barriers for the successful collection of the Medicare rebate, including:
- the time involved in setting up the system
- ongoing identification of eligible patients and clinicians
- collation of the required documentation, and follow-up efforts.
In no instance did the Medicare rebates collected meet all the costs of conducting a MDT meeting, but rather, after deducting costs, covered approximately 28 per cent of the average annual cost of running the MDT meetings.
To increase the utilisation of the MBS item numbers by medical personnel attending cancer related MDTs, a number of administrative changes to the scheme have been recommended by those surveyed. These include:
- Obtaining Medicare and Australian Tax Office (ATO) confirmation that a proposed billing approach was acceptable.
- The government providing the rebates retrospectively as a lump sum, perhaps on the basis of audit results per quarter, allowing for smoother administration rather than labour intensive chasing of small fees.
- Taxation implications to be clarified by the ATO, and appropriate solutions communicated, to ensure clinicians do not pay tax on rebates donated to the MDT.
- Administrative conditions to be simplified and processes streamlined, to reduce the administrative workload associated with collecting and/or redirecting rebates.
- Removing the requirement that a patient must be discussed for a minimum of 10 minutes to enable a Medicare claim to be lodged.
- Relaxing the restrictions on which clinicians can bill patients, or the number of clinicians required for billing to occur, particularly within rural settings.
- Increasing the value of the MBS item rebates.
As a result of the study, the Cancer Institute NSW has prepared additional resources for NSW Area Health Services on the availability of Medicare rebates for MBS items 871 and 871 and the tax implications of donating rebates to supplement the administration of MDT meetings.