Disease-specific MBS items

1. Position

As specialist generalists, general practitioners (GPs) are trained to treat a patient as a whole person, not a specific illness or issue in isolation. Given the holistic nature of general practice care, the RACGP does not support the introduction of new disease/condition focused Medicare Benefits Schedule (MBS) items. While there may be appropriate exemptions, structuring the MBS in this way:

  • does not accurately reflect the way in which GPs provide person-centred care
  • treats the disease in isolation from any other aspects of health relevant for the patient
  • leads to fragmentation of funding and disintegration of the healthcare system
  • increases the complexity of the MBS
  • places GPs at greater risk of being targeted by Medicare compliance activities.

Health funding and MBS requirements should support patient access to comprehensive and continuous general practice care.

As an alternative to creating new MBS items, the RACGP is willing to explore opportunities to leverage off existing items to increase access to care for patients. The RACGP is also open to new MBS items that provide additional funding for GP services – for example, items that pay higher rebates than standard attendance items.

2. Background

Whole person care is a key characteristic of general practice. Therefore, the interplay between bio-psycho-social elements leads to a deep understanding of the whole person, assisting GPs to manage complex conditions and circumstances over a patient’s lifespan. The evolution of the MBS and increasing trend of introducing disease-specific items limits GPs’ ability to see and treat the whole person.

GPs are required to meet multiple complex criteria to claim MBS items. This process is often more onerous for disease-specific MBS items including mental health services and heart health assessments.

3. Ways in which private health insurers could support general practice

3.1. Fragmentation of funding

The RACGP does not support the introduction of single disease focused MBS items (eg heart health assessments, smoking cessation items), as they are not consistent with the generalist approach to care that GPs are trained to provide. Disease-specific items represent fragmentation of MBS funding and episodic care rather than comprehensive primary care, resulting in disintegration of the healthcare system. An ad-hoc, piecemeal approach to health funding is not conducive to integrated team-based care coordinated by a patient’s usual GP.

The creation of disease-specific items is largely historical and the RACGP recognises that some items (eg mental health services) are now firmly entrenched in the MBS and are unlikely to be removed.

Commitments to establish new MBS items are often made during election campaigns or as part of annual budget announcements. ‘Taking action’ on a particular topical issue can be politically rewarding. However, this can hamper the effectiveness, efficiency, equity, and sustainability of healthcare funding.1 There is an established process for the creation of new MBS items through the Medical Services Advisory Committee (MSAC) which is often bypassed for political reasons.

3.2. Complexity of the MBS

The MBS is unnecessarily complex, with frequent changes to items and billing rules a persistent feature. These issues were heightened during the COVID-19 pandemic, with GPs required to keep abreast of new items for telehealth and COVID-19 vaccinations.

The RACGP does not support changes that will add to the complexity of the MBS and complicate billing arrangements. We have long called for the simplification of GP MBS items.

While the RACGP is supportive of the MBS being regularly reviewed and updated to ensure that items remain clinically relevant, clearer education and communication must be provided regarding Medicare claiming rules. Fact sheets must be clear and concise, with examples of scenarios where items can and cannot be claimed.

3.3. Medicare compliance

The RACGP has consistently argued that prescriptive requirements attached to MBS items place additional focus on processes rather than the quality of care. This discourages many GPs from using these items and creates complexity for those who may find themselves subject to Medicare compliance activities, such as targeted letters and audits. In many instances, failing to meet each requirement is not an indication that patients are receiving inappropriate and sub-optimal care, but rather a response to this complexity.

One example of how condition-specific MBS items can increase the scope of compliance activities is the Department of Health and Aged Care’s 2020 targeted letter campaign around co-claiming of professional attendance and mental health MBS items. Separating out item numbers creates confusion around co-claiming rules and gives rise to campaigns like this that threaten the ability of GPs to provide specialist generalist care.

The RACGP supports a more educative approach to compliance that gives GPs the opportunity to rectify any identified billing errors before being required to repay funds.

3.4. Collecting general practice data

Disease-specific MBS items may allow policy makers to collect data on specific services being provided by GPs to better allocate future funding.

While there is value in properly coded general practice data, this should be gathered via appropriate clinical software systems and not by further complicating the MBS.

4. Opportunities

A greater priority for allocation of health funding should be supporting patient access to comprehensive, continuous general practice care. This allows a patient and their GP to determine which assessments and interventions are required to support the patient to remain well.

As an alternative to creating new MBS items, the RACGP is willing to explore opportunities to leverage existing items such as time-based health assessments and GP Management Plans.

Examples of potential changes to existing items include:

  • expanding the list of patient cohorts eligible for time-based health assessments (eg children in out-of-home care, people released from prison)
  • expanding the list of eligible conditions for a GP Management Plan (eg expanding criteria to include those experiencing family violence)
  • allowing GPs to claim Level C and D general attendance items where the rebate for an existing condition-specific item (eg item 16500 [antenatal attendance]) does not reflect the time taken during the consultation.

The RACGP also supports additional detail being added to MBS item descriptors/explanatory notes to clarify when items can be billed. This will reassure providers that they are meeting their compliance obligations, particularly when billing longer consultation items.

The RACGP would potentially be open to new MBS item numbers that provide additional funding for general practice care, rather than simply duplicating or paying lower rebates than general attendance items. Patient rebates for disease/condition-specific items tend to be equal to or lower than rebates for standard consultations.

The RACGP’s preference, however, is for any additional funding allocated to general practice to go towards increasing rebates for standard time-based consultations that have a generalist focus, particularly longer consultations (>20 minutes) for patients with complex care needs.

5. Possible exceptions

The RACGP recognises disease-specific items may be necessary or beneficial in certain circumstances. One example is the Aboriginal and Torres Strait Islander peoples’ health assessment (item 715), which enables people of Aboriginal and Torres Strait Islander descent to receive a comprehensive annual preventive health check. A separate MBS item recognises the unique health challenges facing Aboriginal and Torres Strait Islander people and the need for culturally appropriate services for this cohort.

  1. The Royal Australian College of General Practitioners. Funding priorities – RACGP position statement. East Melbourne, Vic: RACGP, 2020. Available at www.racgp.org.au/advocacy/position-statements/view-all-position-statements/healthsystems-and-environmental/funding-priorities

Download this position statement

Disease-specific MBS items (PDF 224 KB)