If only fixing affordability and access was as simple as limiting doctor fees.
MBS distortions, private health arrangements, and low-volume services all pose threats to the smooth rollout of any kind of cap on non-GP specialist doctor fees, the AMA is warning the federal government.
A worst-case scenario would see doctors start charging outside of the Medicare framework entirely.
The AMA was responding to the Department of Health, Disability and Ageing’s September consultation paper, which laid out six potential options to address high out-of-pocket fees charged by specialist doctors.
It came in the wake of what the DoHDA called “increasing financial barriers to access”, which “undermine the universal nature of the Australian health care system”.
Reform options ranged from focussing on provider education to introducing a fee cap on each MBS item, alongside penalties for exceeding the fee limits.
The AMA remained strongly opposed to any potential cap which would use the MBS fee as a baseline for reasonableness.
“The MBS fee is the federal standard used to calculate a patient benefit,” the association wrote.
“It does not reflect the cost of service delivery, a market price, or a reasonable medical fee.
“The consultation paper itself acknowledges the schedule fee may not reflect costs, its relationship to charged fees varies by item, and a uniform ratio will have uneven effects. Those admissions are inconsistent with retaining schedule fee multiples as a central comparator or regulatory threshold.”
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One of the proposed mechanisms for defining an excessive fee was to measure total fees as multiples of the corresponding MBS item; if a doctor was charging, say, five times the schedule fee, they could be investigated or fined.
The AMA pointed out that the uneven relationship between MBS fees and actual fees would mean a uniform multiple rule would have different effects across specialties.
“Furthermore, an MBS-multiple approach may classify fees in the AMA Fees List or statutory schemes, including workers compensation schedules, as excessive,” it said.
“Private health insurer medical schedules also supplement the MBS amount because the base schedule fee does not represent the price of care.”
Measuring excessive fees by variation from the median charged by other doctors within that specialist field was also fraught.
The AMA argued that the methodology, in which the DoHDA included bulk billed claims and thus depressed the median, made some ordinarily billed services appear to be outliers.
A policy backfiring could be seen in emergency physician and clinical geneticist fees.
The specialist groups were ranked first and second in terms of variation from the median fee by specialty for out-of-hospital services.
“I saw that and thought well, that’s very strange, you know, that’s bizarre,” AMA vice president Associate Professor Julian Rait told The Medical Republic.
“But it turns out that what happens with emergency physicians is when they’re working in private emergency departments, they often bill a facility fee in with the consultation fee, and so they see very little of the final fee, but the facility actually takes a fair chunk.
“And similarly, with clinical genetics, … that is one of the most complex and intellectually rigorous subspecialties, and it’s only in recent times become a reality outside of public hospitals.”
Upon further investigation, Professor Rait found that the only item available to clinical geneticists to provide genetic services was item 132, which was designed to cover consultations of around 45 minutes in length.
The nature of clinical genetics often meant that a provider would be seeing multiple members of the same family in one consultation.
“Often when you have a whole family coming to get genetic counselling and to understand what’s wrong with their child, you might actually have to examine other children and spend quite a lot of time examining the genome sequence and that sort of thing, and it can last up to two, three hours,” Professor Rait said.
“And so, therefore, quite reasonably, the fee is not reflective of what’s in the schedule because it’s 45 minutes.
“Without careful thought, if [the government] were to attack that group [of practitioners], they would actually remove that service from private practice altogether.
“That would be a perverse outcome and one that emphasises that point that you can’t use the Medicare benefit schedule as any sort of measure against which to ascertain whether a service is excessively billed or not.”
The risk of implementing a poorly-designed fee cap, as the consultation paper itself acknowledged, would be to push doctors off the MBS entirely.
“As the MBS represents a smaller proportion of the total cost of care, extensive regulation linked to MBS participation may encourage some providers to charge outside Medicare arrangements,” the AMA said.
“This risk may be greater for highly specialised services. It must be assessed before imposing a framework tied to an inadequate benchmark.”
