06/11/2015
Dr. Bruce Robinson Katie Lyndon
Chair Senior Industry Development Officer
MBS Review Taskforce Exercise & Sports Science Australia
Re: Medicare Benefits Schedule Review
Dear Dr Bruce Robinson,
Thank you for providing Exercise & Sports Science Australia (ESSA) with the opportunity to submit feedback as part of the Medicare Benefits Schedule (MBS) Review Taskforce
consultation on the reform of the MBS. ESSA is a professional association representing university trained exercise and sports science professionals, including the allied health profession of Accredited Exercise Physiologists (AEPs). AEPs frequently deliver MBS services, specialising in exercise prescription for individuals living with chronic disease and illness.
Please find below our responses to the survey questions as requested by the MBS Review Taskforce.
We look forward to hearing the outcome of the MBS Review. Please contact
[email protected] if you require any further information.
Yours sincerely,
Katie Lyndon Anita Hobson-Powell
Senior Industry Development Officer Chief Executive Officer
Exercise & Sports Science Australia Exercise & Sports Science Australia
Q1. Do you think that there are parts of the MBS that are out-of-date and that a review of the MBS is required?
ESSA advocates the review of MBS item processes that do not meet best practice service delivery through, limited access to allied health professionals (AHPs), costly inefficiencies and significant administrative burden.
Q2. Do you have any comments on the proposed MBS Review process?
ESSA advocates that MBS Review Clinical Committee memberships include an equal mix of medical and allied health professionals to ensure a well informed and balanced decision-making process in the evaluation of evidence.
Q3. How can the impact of the MBS Review be measured?
- What metrics and measurement approaches should be used?
Measurement of patient health outcomes will provide a foundation for continuous quality improvements (CQI) within the MBS. This will also provide a basis for funding incentives and support by Medical Services Advisory Committee (MSAC) during the application (or review) process of proposed MBS subsidised item numbers.
A national minimum dataset of population, care processes and health outcome key
performance indicators (KPIs) could be developed. This should include identification of what method information and data could be drawn from General Practitioners (GPs), AHPs and hospitals, and account for the following:
AHPs must be involved in an advisory team to oversee the development of a quality framework and KPIs for primary health carerelated MBS items.
A stepped approach is required, that accounts for the impact and processes of the whole care team, including the contribution of the patient on the health KPIs and outcomes achieved.
Consider the specific challenges faced by small business to avoid excessive administrative burden and onerous processes for providers.
Efforts to improve quality, efficiency and effectiveness must ensure patient safety,
whereby processes are introduced that ensure appropriate care is not neglected in order to meet KPIs for reward.
Effective financial support incentivising providers and institutions to use information communication technology and appropriate coding may enhance reporting.
A team-based approach to patient care requires a digital support platform that enables access for the entire team of professionals, including all allied health professionals. Currently, access and input is restricted for self-regulating allied health professions compared to professions registered with Australian Health Practitioner Regulation Agency (AHPRA).
- How should we seek to improve this measurement and monitoring capability over time?
Increased transparency through improving data dissemination to key stakeholders will promote and encourage quality service delivery and continuous quality improvement
(CQI). Sharing data with peak professional associations will help inform industry and business CQI, with dissemination to the professionals these bodies represent.
Real time access to data and results is needed to ensure that any KPIs are not superseded by the time they are implemented.
Investment will be required on an ongoing process ensure sustainability and support for providers participating in a measurement process.
Q4. Which services funded through the MBS represent low value patient care
(including for safety or clinical efficacy concerns) and should be looked at as part the Review as a priority?
It is widely established that arthroscopy procedures for knee osteoarthritis (OA) are not consistently clinically indicated, and indeed may fail to achieve positive clinical outcomes for the patient (Elshaug, 2012). In many cases, an alternative more cost effective and
evidence based approach would involve the patient undertaking an individualised functional exercise rehabilitation program.
Exercise therapy, education and weight loss are the cornerstones of long-term OA knee pain management (Bjordal et al, 2007). The Osteoarthritis Research Society International (Zhang et al, 2010) examined 64 systematic reviews, 266 randomised controlled trials and 21 economic evaluations. The study concluded that both strengthening and aerobic exercise are associated with relief of pain in the knee. A Cochrane review (Fransen et al, 2015) concluded that there is high-quality evidence for therapeutic exercise providing benefit in terms of reduced knee pain from OA that is sustained for at least six months after cessation of formal treatment. There was also moderate-quality evidence for improvement in physical function among people with knee OA. The magnitude of the treatment effect was comparable with estimates reported for non-steroidal anti-inflammatory drugs.
Miller and Block (2014) reported an intervention that combined physical rehabilitation combined with hyaluronic acid intervention achieved gains of $12,800 per Quality Adjusted Life Year (QALY)1 compared to normal care, which is highly cost effective. Participants had gained 0.138 QALYs at one year follow up, and WOMAC2 pain scores in the intervention group had improved by 45%.
Deloitte Access Economics (2015) identified exercise interventions for osteoarthritis are highly cost effective, calculating an average incremental cost effectiveness ratio per QALY of $46,595 (see table below).
1 Quality Adjusted Life Years (QALYs) are a common outcome measure used in economic evaluations. For QALYs, a disability weight of one represents full health, while zero represents death. Disability adjusted life years (DALYs) combine mortality and morbidity into a single numerical unit, whereby QALYs do not assess mortality. Interventions that cost less to produce a gain in QALYs (health gain) or avert a DALY (avert health loss) are deemed highly cost effective, (Deloitte, 2015).
Exercise interventions for osteoarthritis
Lead author
Year Country N Intervention Control $/QALY*
Coup 2007 Netherlands 200 8 * 1hr sessions over 8 weeks
TAU 104,727
Patrick 2001 USA 249 8 * 2hr group
sessions over 6 weeks
TAU 21,034
Cochrane 2005 UK 312 10 individual & 20 intensive group sessions TAU 14,024 Richardson 2006 UK 214 Home exercise Dominates Average $ QALY $46,595 TAU is ‘treatment as usual’. Source: Deloitte Access Economics (2015).
Addition of MBS items to support the delivery of clinically indicated exercise
rehabilitation programs for patients with knee osteoarthritis will achieve significant cost savings for the health system, and improved patient outcomes.
Importantly, this program will need to be developed by suitably qualified allied health professional, such as an AEP (Roine et al 2009).
Q5. Which services funded through the MBS represent high value patient care and appear to be under-utilised?
Despite the overwhelming strength of evidence underpinning the efficacy and cost effectiveness of AEP interventions, clinical exercise interventions are a largely underutilised resource in the Australian health setting.
Almost 50% of Australians have some form of chronic disease (AIHW, 2014), and as many as 13 million Australians are at risk of chronic disease (Cheema et al, 2014), largely
attributed to ~63% of the population being overweight or obese (ABS, 2012). However, it has been estimated that less than 1% of people at risk of chronic disease are referred to an AEP (Cheema et al, 2014).
In 2012, the Australian Health Survey showed that over 747,000 Australians had known type 2 diabetes. These individuals are entitled to one Medicare Benefits Schedule (MBS)
assessment service per year. However, only 5,536 such services were conducted in 2012, indicating that less than 0.8% of eligible patients were referred for AEP interventions. Data from the Bettering the Evaluation of Health and Care(BEACH) initiative suggest that GPs only provide exercise counselling at a rate of around 1.2 per 100 encounters (Stanton et al, 2015; Britt et al, 2014). It is likely that a substantial proportion of services that may benefit from exercise are not referred, due to a lack of awareness.
Deloitte Access Economics has identified that exercise interventions delivered by AEPs are efficacious and highly cost effective in the Australian health care setting. Specifically, AEP interventions provide a high return on investment when treating people with chronic
conditions, notably pre-diabetes and type 2 diabetes, mental illness (including physical comorbidities) and cardiovascular disease (Deloitte, 2015).
Accredited Exercise Physiologists:
AEPs are 4 year university qualified allied health professionals specialising in clinical exercise interventions for persons at high risk of developing, or with existing, chronic and complex medical conditions and injuries. These interventions are provided by individualised assessment, evidence-based exercise delivery and prescription, including health and physical activity education, advice and support, and lifestyle modification utilising behavioural change strategies with the aim of optimising physical function, health and wellness. As part of a multidisciplinary team, AEPs work with clients with a range of medical conditions including cancer, diabetes, cardiovascular disease, mental illness, pulmonary disease, osteoarthritis and obesity.
To maximise outcomes for a given individual, exercise needs to be prescribed and delivered with regard for their functional and disease-related limitations, as well as any domestic, social, and occupational constraints. It is therefore important to integrate AEPs, who have specialist training and expertise in the many factors involved in exercise prescription and delivery, within the healthcare system (Cheema, et al 2014).
Clinical effectiveness of AEP led interventions for chronic disease
management
Evidence unequivocally demonstrates that individualised and appropriate exercise interventions aid in the management and impede the progression of many chronic health conditions and associated comorbidities, in some instances surpassing the benefits of costly pharmaceutical interventions (Stanton, 2013).
Importantly, optimal benefits are achieved when exercise is supervised, individualised, incorporates follow up, utilises a behavioural approach, and can be modified to
accommodate patient comorbidities – as provided by an AEP (Deloitte, 2015). For example:
A systematic review by Rosenbaum et al (2015) identified clear evidence from trials in clinical populations demonstrating superior outcomes from structured, supervised and progressive exercise compared with non-structured, unsupervised interventions.
Interventions that target specific groups or that are tailored to the individual, taking into account the participant’s age, gender, socioeconomic status, cultural background, health status, barriers to activity, and fitness level, were more effective in increasing levels of physical activity than more generic interventions (Richardson et al 2014).
Stanton and Raeburn (2013) reported all randomised controlled trials (RCTs) in their review were supervised to some degree, and all supervisors were well trained in the provision of exercise.
A systematic review by Chien et (2010) concluded that home-based exercise training did not improve the health related quality of life of heart failure patients, whereas supervised exercise did.
Overall, exercise interventions delivered by AEPs are efficacious and highly cost effective in the Australian health care setting for people with chronic disease (Deloitte, 2015). The benefits outlined below are not exclusive to the conditions listed, rather, it is well established that AEP interventions are both clinically and cost effective for a myriad of chronic health conditions.
1. Pre-diabetes
The clinical benefits of AEP-led exercise interventions for the prevention, treatment and management of type 2 diabetes mellitus (T2DM) and pre-diabetes are well documented:
Orozco et al (2008) reviewed eight trials involving interventions delivered by Exercise Physiologists, noting that exercise combined with diet is effective in reducing the incidence of T2DM in people with pre-diabetes, finding a 37% risk reduction.
Da Qing Study (Pan et al, 1997) randomised individuals diagnosed with impaired glucose tolerance (IGT) to a control group, or one of three intervention groups – diet only,
exercise only, or a combination of both. At 6-year follow up, the exercise intervention group was 46% less likely to develop T2DM than the control group. The lifestyle
intervention group (diet and exercise) was 42% less likely to develop T2DM than the control group.
The Diabetes Prevention Project involved 237 participants aged 40-75 years at risk of developing T2DM. The intervention involved diet and physical activity education with tasks to complete between sessions. Sessions were conducted fortnightly for 9 weeks, with one follow-up session after 8 months. The intervention was delivered by Exercise Physiologists, dietitians and nurses. After 12 months, weight was reduced by 2.7%, and waist circumference reduced by 4%, corresponding with a potential risk reduction of T2DM between 22% and 43%, respectively (Laatikainen et al, 2007).
Life! is a large-scale diabetes prevention program in Australia, comprising six group sessions over a period of 8 months and completed by more than 3,100 people by end of 2012. The program is delivered by a trained facilitator and incorporates one session by an AEPor other health professional and one session by a dietitian. After 8 months,
participants reduced weight by 2.4kg and waist circumference by 3.8cm, resulting in
T2DM risk reduction between 21% and 39% (Dunbar et al, 2014).
The Sydney Diabetes Prevention Program recruited more than 1,500 participants between 50-65 years of age at high risk of developing T2DM. The program comprised of an individual session and three group sessions designed to achieve behavioural change surrounding diet and exercise, delivered by Exercise Physiologists, dietitians, and nurses. Recent data suggests that the program achieved a weight reduction of 2.2kg after 12 months, translating into a T2DM risk reduction of 19%.
A community-based lifestyle modification program, Healthy Eating Activity and
Lifestyle (HEAL), targeted reducing risk factors for chronic disease in Australia in 2,800 adults. The intervention was designed and delivered by a team of (predominately) AEPs and dietitians. The program involved 2 hour education and physical activity sessions, running over 8 weeks. An individual consultation was also conducted at the start and end of the program. Results translated into a diabetes risk reduction of 9% and 25% for weight and waist circumference respectively (Hetherington et al 2015).
General lifestyle intervention programs that also combine structured education programs covering diet and behaviour modification in addition to exercise identify similar reductions in the incidence of T2DM. For example:
Lifestyle modification reduced the incidence of T2DM in patients with IGT, by 28.5% compared to the control group (a greater outcome than the group receiving metformin only), (Ramachandran et al 2006).
The Diabetes Prevention Program Research Group (2012) randomised people with IGT and impaired fasting glucose (IFG) to a control group, metformin, or lifestyle
intervention. Participants were provided education over 16 sessions, which covered diet, exercise and behaviour modification. The intervention was delivered by individual case managers, who were generally Exercise Physiologists or dietitians. At the end of 24 weeks, 50% of participants in the lifestyle intervention group had achieved 7% weight loss, which dropped to 38% at the most recent follow-up (average 2.8 years). Further,
74% met physical activity goals of 150 minutes of moderate exercise per week, which dropped to 58% at the most recent follow-up. The lifestyle intervention reduced the incidence of diabetes by 58% compared to the control group (placebo).
The Finnish Diabetes Prevention Study (Tuomilehto et al, 2001) randomised participants to a control group (general advice surrounding exercise and diet), while the intervention group received detailed advice on achieving specific goals to reduce weight by 5% or more, including dietary and exercise advice. Exercise advice included individual guidance on increasing physical activity, and supervised resistance training. The lifestyle
intervention reduced the overall incidence of diabetes by 58%.
See Appendix 1 for a summary of identified findings in the literature search.
Exercise interventions delivered by AEPs are estimated to reduce the incidence of type 2 diabetes in high-risk populations by 31% on average (Deloitte, 2015).
Importantly, these benefits are sustained for a number of years after the intervention finished:
13 years after the Finnish Diabetes Prevention Study commenced, lifestyle intervention reduced the risk of developing T2DM by 38% compared to the control group (Lindström et al, 2013).
20 years after the Da Qing Diabetes Prevention Study commenced, the risk of developing T2DM for the lifestyle intervention group was 43% lower than the control group (Li et al, 2008).
The expansion of MBS items to include patients with pre-diabetes will enable early
intervention by an AEP to reduce patient deterioration to T2DM and the associated clinical and financial impacts on the patient, community and health system as a result.
Please refer to Q6 for further information regarding this proposal. 2. Type 2 Diabetes
Benefits of specialised exercise prescription for people with T2DM include improved glycaemic control, body composition, cardiorespiratory fitness, physical functioning and well-being (Hordern et al, 2012). These benefits lead to reductions in microvascular (retinopathy, nephropathy and neuropathy) and macrovascular (coronary heart disease, myocardial infarction and stroke) complications of diabetes (Colagiuri et al, 2009). For example:
Church et al (2010) conducted a RCT to assess the effects of exercise training on HbA1c levels (marker of long term glucose control) in patients with T2DM. The intervention involved supervised exercise and compared with usual treatment, the combination training group reduced HbA1c by -0.34%.
Gordon et al (2008) reviewed 20 studies observing supervised resistance training to be more effective than unsupervised training. The reduction in HbA1c ranged between 0.5% and 1.2%.
Conn et al (2007) conducted a meta-analysis of 103 studies finding an overall mean
reduction in HbA1c of 0.45%. There was a larger effect size in studies that focussed on exercise only (0.45) than interventions targeting multiple health behaviours (0.22).
Thomas et al (2006) reviewed 14 clinical trials where exercise was prescribed as a
HbA1c decrease of 0.6%, reducing the patient’s need for other forms of treatment including medications.
There is sufficient data available demonstrating reduction in HbA1c due to exercise interventions (the primary outcome linked to health expenditure, cost effectiveness and complication outcomes). The average HbA1c reduction across the meta-analyses was 0.63%, significantly reducing microvascular and macrovascular complications of T2DM (Thomas et al, 2006). For example, a 1% reduction in HbA1c has been associated with a 10% reduction in diabetes-related mortality and a 25% reduction in
microvascular end-points(Health Quality Ontario, 2009).
Deloitte (2015) identified AEP exercise interventions can achieve a reduction in
microvascular end-points of 28% and macrovascular end-points of 14% in patients with T2DM.
Due to the clear evidence supporting the clinical efficacy of AEP-led exercise prescription for patients with T2DM, ESSA advocates greater support of AHPs within the MBS. Please refer to Q7 for further information regarding this recommendation.
3. Mental Illness
Clinical depression3 is the most common mental condition treated by AEPs (Stanton, 2013). There are a large number of meta-analyses demonstrating that exercise is highly effective and has strong anti-depressive and anxiolytic benefits for both the general population and those living with mental illness (Jayakody et al, 2014; Cooney et al 2013).
Individuals living with a mental illness are at higher risk of chronic physical conditions such as heart disease, diabetes, arthritis and asthma (Teesson et al 2011; De Hert et al 2009). Furthermore, some treatments for these patients may contribute to modifiable risk factors, with up to 86% of patients treated with antipsychotic medication experiencing a significant gain in weight (Álvarez-Jiménez et al, 2008).
Exercise appears to be as efficacious as cognitive behavioural therapy or anti-depressant medication in combatting depression, and is associated with a wide range of physical benefits including stress and weight reduction, decreased blood pressure, reduced risk of cardiovascular and metabolic diseases, and improvements in cognitive functioning (Josefsson et al, 2014).
In addition, no negative side effects attributed to exercise interventions have thus far been reported, as opposed to antidepressant medication (Josefsson et al, 2014). However, it is important to note that exercise is not a panacea for depression, but in conjunction with
3 Clinical depression refers to a Major Depressive Disorder as defined by the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-V).
psychological and pharmacological interventions, it can be very effective.
Evidence based practice warrants that the entire needs of a person living with mental illness is considered in delivering interventions. We advocate greater support for AEPs within the MBS to enable the delivery of exercise interventions targeting the frequent physical comorbidities in this population. In addition to existing psychological interventions, this will ensure the whole needs of the person is met.
Please refer to Q7 for further information regarding this recommendation. 4. Cardiovascular disease
Patients with chronic heart failure (CHF) experience marked reductions in their exercise capacity which has detrimental effects on their activities of daily living, health-related quality of life and ultimately their hospital admission rate and mortality. The efficacy of exercise interventions for cardiovascular disease (CVD) is well established by a large number of meta-analyses. For example, Georgiou et al (2001) reported that for CHF patients, exercise
interventions were more cost effective compared to usual care by $1,773 per life year saved. In the Piepoli et al (2004) meta-analysis of exercise in CHF, at two year follow up 22% of the original exercise participants had passed away compared with 26% of the control
participants, representing a significant reduction in mortality and a relative risk of 0.86. If the mortality rates for the control group had applied to the intervention group, there would have been 14 more deaths by the two year follow up.
Soan et al (2014) reported that cardiac rehabilitation programs designed and facilitated by AEPs have been highly successful in:
changing exercise and physical activity behaviours;
preventing or delaying subsequent cardiac arrest;
improving exercise tolerance, muscle atrophy, and circulation;
improving quality of life; and
Cost effectiveness of AEP led interventions for chronic disease
management
ESSA commissioned Deloitte Access Economics to identify the economic benefits of employing AEPs in chronic disease management, relating to:
avoided health system costs;
avoided productivity costs;
years of life saved.
Deloitte Access Economics identified that exercise interventions delivered by AEPs are estimated to be efficacious and highly cost effective in the Australian health care setting.4 Specifically, Deloitte identified that AEP interventions provide a high return on investment in treating people with chronic conditions, notably pre-diabetes and T2DM, mental illness (including physical comorbidities), and cardiovascular disease.
For a complete overview of Deloitte’s economic analysis refer to the Appendix 1. Type 2 Diabetes
Through comparing health service utilisation for those implementing exercise into their daily routine to help manage their diabetes with those that do not, Deloitte estimated the number of services averted due to implementing exercise, demonstrated in the table below.
Health system expenditure averted due to exercise in people with T2DM, 2015
Health Service Average cost ($)
Visits averted per person with T2DM
per annum
Total costs averted per person with T2DM per annum ($) GP consultations 37.05 2.68 99.28 Specialist consultations 85.55 0.00 -0.12 Admitted to hospital as inpatient 8,756.22 0.54 4,767,85
Visited outpatient clinic 304.93 -0.11 -34.70
Visited emergency department
722.88 0.33 239.44
Visited day clinic 304.93 0.12 35.49
Total $ 5,107.24
Source: Deloitte Access Economics (2015)
The total costs averted for people with type 2 diabetes receiving an exercise intervention, as delivered by an AEP, are estimated to be $5,107 per person annually.
4 Deloitte Access Economics’ analysis identified that efficacy results translate from clinical settings to community
interventions with approximately 50% effectiveness. This is largely dependent on intervention design, and may be a conservative estimate of economic impacts of AEP interventions as a result.
As outlined in the ‘Clinical Effectiveness’ section above, HbA1c is reduced on average by 0.63% following exercise interventions for people with T2DM, strongly linked with reduced incidence in complications of T2DM.
Deloitte identified the expected cost savings due to a reduction in complications of diabetes are expected to be $477 per person annually.
Costs of secondary complications averted due to exercise, 2015
Complication Prevalence amongst people with T2DM (A) Health system costs per person per annum (B) Expected cost per person (C=A*B) Reduction from glycaemic control (D) Expected savings (E=C*D) Visual loss (incl. retinopathy) 10.7% $5,167 $552.86 18% $98.52 Chronic kidney disease 6.0% $5,926 $355.57 8% $30.12 Amputations 4.1% $11,126 $456.18 8% $38.64 Coronary heart disease 10.0% $27,327 $2,732.68 8% $231.49 Myocardial infarction 10.0% $8,087 $808.75 8% $68.51 Stroke 5.0% $2,237 $111.84 8% $9.47 Total $476.77
Source: Deloitte Access Economics (2015)
Productivity losses are the cost of production lost when people are unable to work because of a health condition or illness. They may work less than they otherwise would (either being employed less, being absent more often or being less productive while at work) or may die prematurely. The amount of productivity lost due to T2DM is equivalent to 13.2 days per person per year.
Deloitte identified the productivity loss avoided as a result of exercise intervention in people with pre-diabetes is estimated to be $1,520 per person annually and for people with type 2 diabetes is ~$760 per person annually.
The annual per person lifetime burden of disease savings resulting from Australians receiving exercise interventions, as delivered by an AEP, is estimated to be $2,860 and $2,617 for a person with T2DM and pre-diabetes, respectively. Combining the direct costs with the burden of disease avoided annually, the total annual wellbeing gains due to AEP interventions in Australia for people with pre-diabetes and T2DM are estimated to be $6,115 and $7,967 per person, respectively.
Pre-diabetes
Deloitte identified the total costs averted per person with pre-diabetes receiving exercise intervention, as delivered by an AEP, are estimated to be $1,977 annually, outlined in the table below.
Health system expenditure averted due to exercise in people with pre-diabetes, 2015
Health Service Average
cost ($)
Visits averted per person with pre-diabetes per annum
Total costs averted per person with pre-diabetes per
annum ($)
GP consultations 37.05 6.5 239.81
Specialist consultations 85.55 1.9 161.53
Admitted to hospital as inpatient 4,914.00 0.3 1,456.18
Visited outpatient clinic 304.93 0.1 31.54
Visited emergency department 222.00 0.0 3.22
Visited day clinic 304.93 0.3 85.00
Total 1,977.27
Source: Deloitte Access Economics (2015)
The World Health Organisation (WHO) considers an intervention to be highly cost effective if it saves one QALY for less than gross domestic product (GDP) per capita. In Australia, GDP per capita is ~$67,000. Exercise interventions are estimated to cost around $5,373 per QALY gained depending on the population and intervention frequency (pre-diabetes is $5,611 per QALY or T2DM is $5,135 per QALY), demonstrating high cost-effectiveness according to this criteria.
The annual per person lifetime burden of disease savings resulting from Australians receiving exercise interventions, as delivered by an AEP, is estimated to be $2,860 and $2,617 for a person with T2DM and pre-diabetes, respectively.
Combining the direct costs with the burden of disease avoided annually, the total annual wellbeing gains due to AEP interventions in Australia for people with pre-diabetes and type 2 diabetes are estimated to be $6,115 and $7,967 per person, respectively.
For an AEP to deliver an intervention similar to the Life! diabetes prevention program, which comprises 6 sessions lasting up to 1.5 hours, the cost would be approximately $635 per person receiving the intervention. This assumes that AEP interventions are primarily delivered on an individual basis. A predominately group-based program similar to the Healthy Eating Activity and Lifestyle (HEAL) program, which comprises 2 sessions for 8 weeks and 2 individual sessions at program commencement and follow-up, would cost approximately $525 per person receiving the intervention.
The Benefit to Cost Ratio (BCR)5 with reference to direct health care expenditure and the average cost of exercise interventions per person with pre-diabetes is 6.0 to 1. When the burden of disease is accounted for, the indicated BCR becomes 10.5 to 1.
For people with T2DM, the BCRs are 8.8 to 1 and 13.7 to 1, respectively.6 Mental Illness:
Bartels (2015) identified that adults with serious mental illness represent the single greatest and least recognised health disparity in the nation, reflected in a 13-30 year reduced life expectancy. As a result, health care costs are two to three times greater in adults with serious mental illness compared with general patient populations (Deloitte, 2015).
Deloitte Access Economics (2013) estimated the financial costs per case of depression were $9,622 per year. Translating this to 2015 dollars indicates that each case of depression averted through exercise, as delivered by AEPs, saves society $10,062 per year.
McGlinchey et al (2002) found that for people with depression classified as ‘recovered’, 77% were still classified as recovered at two year follow up. Assuming a linear relapse rate, this implies that 89% would still be in recovery at one year follow up. This may be further optimised by the specialised behavioural modification skills of AEP workforce.
Adjusting the cost of the intervention for patients assumed to still be in recovery at one year follow up, and allowing for translational effects, the total savings due to exercise interventions, as delivered by AEPs, are estimated to be $2,239 per personannually with a mental health condition.
Quality Adjusted Life Years (QALYs7)are a common outcome measure used in economic evaluations. For QALYs, a disability weight of one represents full health, while zero represents death. A case of depression avoided or managed by exercise, as delivered by AEPs, will avert 0.127 QALYs over the course of the following year (Begg et al, 2007). Indicatively, if the exercise intervention costs $824 and saves 0.127 QALYs, then the implied cost is $6,485 per QALY gained, which is highly cost effective.
5 The BCR indicates the overall value for money of an intervention. A BCR greater than 1.0 indicates that every dollar invested generates more than one dollar of benefits. A BCR less than 1.0 shows that the intervention delivers less than one dollar of benefits for every dollar invested.
6 The BCR in people with type 2 diabetes is likely to be conservative as no estimation of the productivity impacts could be made for this group.
7 Disability adjusted life years (DALYs) combine mortality and morbidity into a single numerical unit, whereby QALYs do not assess mortality. Interventions that cost less to produce a gain in QALYs (health gain) or avert a DALY (avert health loss) are deemed highly cost effective.
Deloitte identified the incremental benefit to cost ratio of exercise interventions delivered by AEPs for people with depression is 2.7 to 1.
Cardiovascular Disease:
The efficacy and cost-effectiveness of exercise interventions for cardiovascular disease (CVD) is well established by a large number of meta-analyses. For example, Georgiou et al (2001) reported that for heart failure patients, exercise interventions were more cost effective compared to usual care by $1,773 per life year saved.
The total lifetime burden of disease savings resulting from exercise interventions in people with CHF, as delivered by AEPs, are estimated to be $11,847 per person annually.
As the costs associated with AEPs delivering this intervention are substantially lower at $1,903 per person, the estimated BCR of AEP interventions in people with CHF is 6.2 in community settings
Other
A summary of the benefits and costs of AEP interventions per person, for the conditions analysed by Deloitte, is outlined in the table below. It is worth noting that Deloitte also identified that clinical exercise interventions were also cost effective for chronic back pain, osteoarthritis and rheumatic diseases.
Estimated benefits and costs of AEP interventions per person
Condition Benefits ($) Costs ($)
(E) BCR Health system (A) Productivity & other financial (B) BoD (C) Total wellbeing (D=A+B+C) Pre-diabetes 1,977 1,520 2,617 6,115 580 6.0ˆ Type 2 diabetes 5,107 NE 2,860 7,967 580 ≥8.8 ˆ Mental health (depression) 330 1,909 NE 2,239 824 2.7 ˆ Chronic disease (cardiovascular) NE NE 11,847 11,847 1,903 6.2
Note: BoD is ‘burden of disease’, NE is ‘not estimated due to lack of available data’, ˆ BCRs for pre-diabetes, type 2 diabetes and mental health (depression) are reported as the ratio of financial benefits (health system and lost productivity savings) to costs. The BCR for chronic disease is relative to the burden of disease. BCRs which contain NE elements are reported on a ‘greater than or equal to’ basis, as it is assumed that the NE components would add to the benefits. Source: Deloitte Access Economics (2015)
Recommendation: Maintain funding for Group Allied Health service MBS items (81100-81125), in addition to existing Chronic Disease Management MBS items.
The existing group allied health service MBS items (81100-81125) for patients with T2DM are achieving positive patient outcomes in a cost-effective manner. This is supported by a substantial body of evidence identifying physiological, social and behavioural benefits of group sessions administered by AHPs (Herman et al, 2005). Group sessions improve self-management of T2DM through improved patient education and increased peer support, improvements in glycaemic control and quality of life, with benefits persisting long term (Herman et al, 2005; Crandall et al, 2008; Diabetes Prevention Program Research Group, 2009).
The success of this MBS group interventions is largely attributed to the specialised input of AHPs which ensure that the frequent presence of comorbidities in this patient population is accounted for, whereby 75% of adults with diabetes have at least one comorbid chronic disease and up to 40% have at least three (ESSA and Dietitians Association of Australia, 2014; Pedersen and Saltin, 2006). Without the specialised input of AHPs, patients are exposed to increased risk of adverse outcomes due to inappropriate and/or lack of specific medical nutrition therapy, exercise prescription and diabetes self-care education that meet their needs, risk factors and comorbidities (Hordern et al, 2012).
Additional benefits of these existing MBS group items for patients with T2DM include improved integration and interprofessional collaboration and reduced costs to the health system of ~20-30% (Tuomilehto, 2001). Deloitte (2015) clearly identified that good quality education reduces the number of GP visits. Additionally, the 2014 Royal Australian College of General Practitioners (RACGP) Guidelines on T2DM (2012) states “access to, and care delivery by different healthcare providers allows the patient to benefit from a broad perspective on their health and wellbeing”.
Q6. Are there rules or regulations which apply to the whole of the MBS which should be reviewed or amended? Please outline how these rules adversely affect patient access to high quality care.
Greater MBS support for preventative strategies to reduce the burden of chronic disease: Expansion of eligibility criteria for Group MBS Items (81100-81125) to include patients with pre-diabetes.
Approximately 32% of Australia’s total burden of disease can be attributed to modifiable risk factors (Australian Institute of Health and Welfare, 2012) such as physical activity and overweight/obesity. Specifically, low cardiorespiratory fitness due to inadequate physical activity has the greatest contribution to all-cause mortality over and above obesity, hypertension, smoking, high cholesterol and T2DM (Blair, 2009).
At least 2 million Australians have pre-diabetes and are at high risk of developing T2DM (Gerstein et al, 2007), where the annual incidence of developing diabetes is 5–10% in this population compared to 1% in the general population (Gerstein et al, 2007; Shaw and Tanamas, 2012). However, current eligibility criteria for the MBS CDM items (10950-10970) and Allied Health Group service items (81100-81125) require diagnosis of T2DM.
ESSA, Dietitians Association of Australia (DAA) and Australian Diabetes Educators Association (ADEA) collectively advocate for the expansion of MBS criteria to include patients with pre-diabetes. ESSA (~6,000 members), DAA (~5,800 members) and ADEA (~2,000 members)provided this stance as part of the 2015 pre-budget government joint submission and to the National Diabetes Strategy Advisory Group. This strategy will increase access to early intervention, slow the rising prevalence of T2DM and co-morbidities and associated impact on healthcare spending, demonstrated by the following:
There are established criteria published by authoritative bodies in Australia and internationally for determining pre-diabetes (RACGP, 2012).
Specifically, pre-diabetes is diagnosed as IFG in a person presenting with random blood glucose levels of 5.5-11mmol/L or fasting 5.5-6.9 mmol/L, or IGT in a person presenting with an oral glucose tolerance test of 7.8-11mmol/L (American Diabetes Association, 2014). Evidently, these patients are easily identifiable and can be risk stratified with the use of evidence based tools such as AUSDRISK (Australian T2DM risk assessment tool)
(Department of Health, 2014). Consequently, the success of an intervention can be clearly measured and quantified with objective measurements such as blood glucose levels.
There is a clear evidence-based clinical pathway for this cohort, with peer reviewed evidence supporting the efficacy of lifestyle intervention on delaying disease
progression, with benefits persisting long-term (Colberg et al, 2010; Lindstrom et al 2006; Coghlan, 2012; RACGP, 2012; RACGP, 2014).
Patients with pre-diabetes are not yet dependent on pharmaceutical interventions and are more responsive to lifestyle modification (Shaw and Tanamas, 2012), when delivered by appropriately qualified health professionals such as AEPs, Accredited Practising Dietitians
(APD) and Credentialed Diabetes Educators (CDE). For example, The Diabetes Prevention Project involving 3,234 participants with pre-diabetes showed a 58% reduction of IGT in the group undertaking 30 minutes daily moderate physical activity for 5 weeks compared with 31% in the pharmaceutical treated group. Physical activity also resulted in 5-10% reduction in body weight.
This is further supported by the 2015 Royal Australian College of General Practitioner’s (RACGP) Smoking, Nutrition, Alcohol, Physical Activity (SNAP) guidelines and the 2014 guidelines for the management of T2DM, recognising the specialist skill and expertise of AEPs, APDs and CDEs for the prevention and management of T2DM.
Allied health group interventions for patients with T2DM are highly cost effective.
Effective funding of lifestyle interventions has the potential to mitigate rapidly increasing government expenditure attributed to T2DM:
- Refer to above section on cost-effectiveness of AEP interventions for patients with pre-diabetes and T2DM, as identified by Deloitte Access Economics (2015).
- An intensive lifestyle intervention conducted on people with pre-diabetes, involving 30 minutes of physical activity daily and a 5-7% loss of initial body weight resulted in an estimated reduction in lifetime healthcare costs by $1087 per person within the Australian health care setting (Shaw and Tanamas, 2012).
- A 2014 meta-analysis of 12 studies, consisting of 7,400 women and 5,500 men identified that successful prevention of T2DM has a positive economic impact. Cost effectiveness analysis indicated that lifestyle interventions are the most cost-effective approach compared to pharmaceutical interventions (Glechner et al, 2015).
- A meta-analysis of 28 studies identified a median incremental cost effectiveness return for diet and physical activity promotion programs of $13,761 per QALY saved. Group-based diabetes programs were more cost-effective (median, $1819 per QALY) than those that used individual sessions (median, $15 846 per QALY) (Li et al, 2015).
Expand Telehealth provisions to enable MBS payment to all allied health professionals.
There is a forty-fold difference between MBS-funded utilisation of AHP services in metropolitan areas, versus rural areas, largely attributed to a lack of service availability. Telehealth consultations are currently limited to specialist and selected medical and health care professionals, imposing barriers for patient access to the specialised input of AHPs. We note that MBS benefits are not currently payable for non-face-to-face care (some exceptions). Expanding Telehealth MBS items to include all AHPs will extend the reach of services into rural and more remote areas, addressing inequality in health care access, patient compliance and subsequent adverse health outcomes in this population and enhance the prevention, early detection and treatment of chronic diseases in Aboriginal and Torres Strait Islander people.
Q7. Are there rules which apply to individual MBS items which should be reviewed or amended? If yes, which rules and why? Please outline how these rules adversely affect patient access to high quality care.
ESSA applauded the introduction of MBS Chronic Disease Management (CDM) items and the intended goals of fostering interdisciplinary care. However, there are processes with these items that could be improved to achieve improved patient outcomes.
Constrained access to AHPs, regardless of the severity or complexity of a person’s condition, is the most serious gap within the MBS.
For example, the current MBS funding model:
requires a significant out of pocket contribution and delayed access to treatment in public services for many people with chronic/complex health conditions.
promotes crisis decision making, for example, a GP may refer all MBS CDM items to a Podiatrist because their patient has poorly managed T2DM and is at risk of amputation. Rather, a model encouraging a multidisciplinary approach with a focus on behavioural change (through diet, exercise, social support and psychology) is most effective in positively changing future patient outcomes (Colberg, 2010; Coghlan, 2012; Soan et al, 2014; Taylor et al, 2010).
supports episodic care by individual providers, rather than coordinated team-based care that extends over time. ESSA advocates the importance of patient access to a range of AHPs that can provide specialised input, which may entail an intensive period of interventions, timely access during exacerbation of symptoms, and monitoring and evaluation over an extended period of time when the patient is capable of independent self-management.
Furthermore, government acknowledges the vital role allied health play in helping people to manage mental illness through the Access To Allied Psychological Services (ATAPS) and Better Access programs. However, these programs do focus on traditional mental health workers and do not allow access for AHPs who are more likely to contribute to the physical health improvements of people with mental illness (i.e. AEPs and Dietitians). ESSA recommends when these items are reviewed consideration is given to including a whole of person approach to care that incorporates both their psychological and physical health needs. Importantly, inclusion of providers who focus on physical health issues should not be at the expense of psychological interventions.
Remove barriers and inequity of rules applied to AHPs delivering services within the MBS.
Current processes within the MBS are unequally applied to AHPs, increasing administrative burden, slowing patient access to treatment and reducing sustainability of the workforce, for example, currently:
the AHP needs to check and ensure the GP has correctly completed their paper work (i.e. GPMP and/or TCA) to ensure the AHP is paid, whilst the GP is financially reimbursed automatically. This unfairly adds to the AHP administrative burden, in which case it should have been a shared responsibility between the GP and AHP.
Generally, rules are complex for access to MBS items and descriptors are not user-friendly.
Some of the provisions surrounding AHP reporting requirements are onerous,
burdensome and not completed in the private sector. For example, if a patient is referred 2 sessions to an AHP for CDM as per the MBS items, the AHP is required to provide an initial report to the GP following the first consult, and a post-intervention report to the GP following the second consult (despite the consultations often only being weeks apart). Additionally, if a client is returning to the same provider for the same reason, reporting should be as professionally/clinically justified or until the final appointment where a final report is required.
Increase support for individual Chronic Disease Management (CDM) item delivery by AHPs.
Currently, the allocation of 5 CDM items is inadequate for achieving sustainable clinical and behavioural outcomes in patients.
People with chronic disease frequently present with multiple comorbidities and
complications, requiring the professional input of a multidisciplinary team of AHPs. For example, a patient with T2DM may require the expertise of an AEP for a suitably prescribed exercise program, a podiatrist to address foot ulcers, a dietitian to address dietary issues and a credentialled diabetes educator to provide medication and other relevant advice. The
difficulties in distributing 5 sessions for this ‘typical’ patient presentation is clearly evident, notwithstanding the ability for these AHPs to deliver all the necessary advice and instil patient behavioural change within one (20minute) consultation.
It is also important to highlight that there is a high degree of correlation between chronic disease and low socioeconomic status (ABS, 2010). In the United States, a country with many behavioural similarities as Australia, there is a strong correlation between income and exercise levels. Moreover, this disparity is increasing, with the top four income quintiles increasing their exercise effort over time, while the poorest income quintile is increasingly undertaking less physical activity (Deloitte, 2015). Therefore, this limits the ability of AHPs to charge a gap fee to patients for service provision, because, as frequently reported anecdotally, this increases patient ‘no shows’, late cancellations and other logistical complications for the AHP.
Additionally, inadequate consultation time prohibits the delivery of AHP services to achieve the full patient benefit that could have otherwise been achieved with an appropriately allocated treatment time.
Currently CDM items are allocated and paid for by Medicare according to a 20 minute timeslot. Within this time an AEP is required to complete pre-exercise screening, discuss any injuries or conditions, complete initial assessment to monitor change, provide and instruct an individualised exercise program and deliver strategies to achieve behavioural change. Whilst many AEPs typically deliver longer consultations than the minimally prescribed 20minutes, remuneration does not change. Consequently, AEPs (like other allied health) frequently fulfil their reporting and other essential functions outside of this allocated timeslot in order to maximise service delivery whilst the patient is present (again, this is not remunerated).
Thus, to ensure the delivery of best practice care, and the sustainability and retention of the AHP workforce, the allocated treatment time per CDM item delivered should
increase to a minimum of 30 minutes (with a corresponding increase in the fee allocated to treatment time). Additionally, initial treatment sessions (which are more onerous due to screening, testing and rapport building requirements) should be increased to a
minimum of 45minute consultation time as per MBS CDM item criteria.
Remove duplication
There is duplication in the assessment of patients with chronic disease/injury. Currently, the GP or Practice nurses conducts an assessment in formulating the GP Management Plan (GPMP) and Team Care Arrangement (TCA), subsequently followed by an initial assessment conducted by the AHP receiving the referral.
ESSA advocate redirection of funding from GPMP and TCA items (MBS item numbers 721 and 723) into service delivery for patients. This could entail the introduction of a comprehensive biopsychosocial and risk assessment MBS item number (completed by a GP, Practice Nurse or AHP) that captures high-risk individuals who can be referred for lifestyle interventions to prevent progression of chronic disease or aggravation of
symptoms.
Support the direct referral between medical specialists and AHPs (and between various AHPs), within their scope of practice.
This strategy would achieve significant cost savings for Medicare and consumers, reduce GP administrative burden and ensure early access to appropriate health care. A pilot study indicated that the introduction of Medicare rebates payable for direct referral between medical specialists and one type of AHP alone, is likely to save Medicare ~$13.6 million annually (Tuomilehto, 2001).
For example, AEPs are widely recognised for specialist exercise prescription and behavioural change interventions for individuals with T2DM. Despite this, an Endocrinologist cannot directly refer their patient with T2DM to an AEP for an exercise program, rather, referral of the patient back to their GP is required first, upon which subsequent referral to an AEP can be made if this specialist recommendation is supported by the GP. Furthermore, if an AEP refers a patient back to a specialist medical practitioner the patient is not eligible to receive a
Medicare rebate, consequently most AEPs refer patients to a GP (to write a specialist referral) so that the patient receives a Medicare rebate. Evidently, this process is ineffective and
significantly increases costs to the patients and the government.
AEPs are highly trained and respected AHPs, qualified to provide appropriate assessment, management and referral of patients with T2DM as well as many other chronic health conditions and injuries. AEPs are equipped with the clinical reasoning skills to often determine when a specialist or GP referral is required to achieve best health outcomes for their patient.
Q8. What would make it easier for clinicians and consumers to understand or apply the rules or regulations correctly?
A fully functional digital support platform will act as an enabler for all health
professionals, including AHPs, to actively participate in team-based care, and assist with the application of MBS requirements.
AHPs have an essential role in team-based care and require full read and write access to digital records, EHR, shared care plans and clinical decision support tools, subject to patient consent.
A simple system that is not cost-prohibitive is needed (i.e. current compatible e-Health software requires an outlay of ~$20,000 by the health provider, which is not viable or a sole trader or small business).
New and existing tools aimed at supporting team based care (e.g. web based information portals that schedule services and allocate responsibilities) need to enable AHP access.
ICT strategies need to incorporate a comprehensive approach to gathering consumer data, which will facilitate targeted allocation of funding and other resources for the benefit of consumers.
Improved financial incentivisation and reward systems
ESSA supports the concept of a flexible blended funding model, allocated according to patient risk assessment and needs, which accounts for the following:
Patients with multiple complex chronic conditions require increased access to an experienced and highly skilled care team that may include a range of AHP services. Complexity in the source of funding should align with the complexity of patient needs. For example, approximately 15% of Australians aged 40-59 years have two or more comorbidities, increasing to 39.2% for those over the age of 60 years (Taylor et al, 2010). This warrants the need for greater interprofessional practice and specialised input by AHPs, as a core component of all clinical interventions for prevention and management of non-communicable diseases (Soan et al, 2014).
The funding model needs to take into account the non-individual patient attributable proportion of health professionals’ time that is devoted to important functions such as mentoring and clinical oversight of less experienced health professionals, administrative functions (such as interprofessional communication), quality activities and career development. These functions are essential to the development and sustainability of a suitably experienced and skilled primary health workforce.
Bonus payments and funding should be allocated to the achievement of health outcomes and not processes (e.g. GP plans and reports).
Fair and equitable application of financial incentives and rewards to all members of the healthcare team involved with the provision of care and achievement of successful outcomes.
Ensuring perverse incentives do not dissuade health care providers from taking on more complex patients, or disproportionally focus on incentivised care. This may be overcome
through strategies such as providing increased financial incentives for treatment of higher risk or more complex patients.
A clinical advisory committee, including representation of AHPs, should assist in the development of KPIs by which funding incentives are assessed.
KPIs must account for those positive health outcomes that are not directly tangible and measurable, for example, improved patient self-management may be partly assessed through reduced GP visits.
Financial incentives must account for the fact that not all patients work to theory and they play a key role in their ‘performance’.
Q9. What kind of information do consumers need to better participate in decisions about their health care?
Health outcomes are the result of a highly complex interaction between patient and the health care team, including the influence of several variables such as:
the social determinants of health, meaning that not all people are capable of self-care.
relating health outcomes to the patient’s expectations and wishes, whereby some patients may choose not to undergo some types of treatment regimens.
performance measures and indicators for chronic disease may be hard to quantify. Responsibility and accountability should not be placed solely on the health care team. Patient self-management and consumer focus and choice now play central themes in patient care, therefore the consumer should be playing a central responsibility in their health outcomes.
Use of innovative information communication technology (ICT) as part of an overall suite of strategies to improve patient compliance with their care plan and enhance
self-management skills and health literacy.
Technology will enable patients to have immediate access to monitoring data, allowing patients to implement measures necessary to improve readings, with involvement of a health care team only necessitated if parameters are consistently beyond a set range (as an adjunct to strategies that improve or address health literacy and socioeconomic influencing factors). This will require increased resources and funding for education and secondary prevention. Patients should be encouraged to manage their condition, using the best available education programs and ICT to support the enhancement of health literacy and self-management efficacy. Effectively engaging the core skill sets of all AHPs, which include prevention and patient self-management, will facilitate this process.
Sharing performance information with consumers will help inform decision-making and empower self-management of their health care. However, we caution sharing information about a specific health care professional’s performance, such as feedback/ratings systems (e.g. NIB’s WhiteCoat system). This process may be ill informed, biased or prejudiced, and negatively impact the reputation and business of the professional involved, for example, businesses poorly rating the services of competitor businesses in an effort to generate increased market share. Additionally, according to Health Practitioner Regulation National Law and advertising standards imposed on regulated professions, these health professions are very limited in the advertising they can undertake. Therefore, it is unfair to subject them to rating systems when they are not able to promote their services as freely as other businesses in other industries that providing rating tools (e.g. restaurants).
Patients must have the option of actively choosing their provider to ensure continuity of care, patient-provider trust, and incentivise businesses to deliver quality services to attract increased opportunities.
Final Point of Consideration for the MBS Review Taskforce
Ensure MBS items account for self-regulating allied health professions.
The National Registration and Accreditation Scheme (NRAS) for health professions
commenced in July 2010, providing a national registration framework for health professions. The Australian Health Practitioner Regulation Agency (AHPRA) is the administering agency for NRAS. Prior to NRAS, health practitioners were registered through state-based agencies. Currently, only those professions that have historically been registered are included in NRAS. The national registration system, under the NRAS, was largely set-up to address safety
concerns, for the protection of the public. As a result of this, the Federal Government has seen no need to regulate many allied health professions, which are viewed as low risk to the Australian public. However, public expectation is that all health professionals are registered. Consequently, there is a disparity between public expectation and the legislated approach to regulation of health professions.
To address this disparity, seven allied health professions (including AEPs, Accredited Practising Dietitians, Speech Pathologists, Audiologists, Orthotics and Prosthetics, Sonographers and Perfusionists) have aligned through the National Alliance of
Self-Regulating Health Professions (NASRHP) to develop a comprehensive set of standards and provide governance across self-regulating health professions.That is, the peak professional body for the health profession administers functions equivalent to (and is some cases, to a higher standard) than those of the NRAS boards. These include formally
recognising qualifications, accrediting programs at universities, administering minimum entry practice standards, ensuring best practice standards and continuing professional development, providing a code of conduct, and investigating complaints. Protection to the public is
provided through practitioner accreditation through the peak professional body. Many people mistakenly believe that registration is an indication of a higher-quality or legitimate health service. Since the introduction of NRAS, quality self-regulation has been undermined by the perception that the professions registered under AHPRA are somehow better, safer, more credible, and more respectable. But this is not the case. Likewise, registration is not an indication of higher-quality education or educational attainment. This has led to discrimination on many fronts from individual registered practitioners ‘looking down’ on their self-regulated colleagues to systematic exclusion from opportunities at organisation and even government initiatives.
These matters do not just impact on the self-regulated professions, they can impact on trust within the health care team which can undermine the confidence of the people they are caring for, exacerbate existing public confusion about who is a safe, evidence-based health
professional and can lead to skewed, unbalanced decision making on health policy.
Currently, these self-regulating AHPs (such as AEPs, Dietitians, Speech Pathologists etc.) can deliver MBS items, we strongly advocate that the MBS Review Taskforce do not inadvertently exclude these AHPs through using NRAS as a benchmark.
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