MBS colonoscopy reforms haven’t worked: review

Medicopolitical

By Geir O'Rourke

10 Jul 2024

Medicare colonoscopy items need further reform because the changes after the MBS Review have failed to curb inappropriate and unnecessary procedures, the federal government has been told.

Fixes on the table include mandatory reporting of results to My Health Record, the creation of decision support tools for referring practitioners and a new MBS item for the positive FOBT indication.

The recommendations have been put forward by the government’s MBS Review Advisory Committee, which conducted a post-implementation review to examine the impact of reforms introduced in November 2019 that resulted in eight new MBS items and the removal of four existing items.

In a report dated February this year, and now published online, the committee’s review of three years of MBS data noted the revamp followed concerns raised by the MBS Review Taskforce about a surge in Medicare-funded colonoscopies, from less than 300,000 in 2001-02 to more than 600,000 in 2021-22 (link here).

This was coupled with major variations in access, with the rate of colonoscopies 3.2 times higher in the major cities than remote Australia, and 1.6 times higher in the highest socio-economic areas than in the lowest, it said.

More than four years on, these issues persist, and the changes had also failed to achieve their intended outcomes of improving access among Indigenous populations and curtailing the high out-of-pocket costs for private services, the report found.

“Modelling using MBS claims for colonoscopies from 2001 to 2019 shows that only 10-14% of MBS-funded colonoscopies in Australia (until 2030) will be generated by positive FOBT screening through the NBCSP,” they wrote.

“As such, it is likely that many colonoscopies performed to exclude colon cancer are occurring independently of the NBCSP.”

In addition, there were major concerns about the frequency and  appropriateness of repeat colonoscopies, particularly among patients at normal risk of colon cancer and with no diagnosis of IBD.

“More than 100,000 repeat colonoscopies were performed on people in this category in the past 3 years, with a large proportion of these repeats being performed by different providers over this period,” wrote the report’s authors.

“The Colonoscopy Working Group (CWG) were concerned that a lack of access to results of previous colonoscopy may be resulting in unnecessary repeat colonoscopy for people at low or normal risk of colon cancer.”

The authors added: “The CWG considered that the implemented changes had neither achieved their purpose nor were on track to do so.”

“Further, the benefits for patients and the healthcare system have not been realised at this stage.”

Recommendations included:

  1. MBS items for colonoscopy services are amended to require the reporting of results to platforms that enable ready access to results by all healthcare providers.
  2. The Conjoint Committee for Recognition of Training in Gastrointestinal Endoscopy amends the recertification approval process to require compliance with Quality Statement 9 of the Colonoscopy CCS.
  3. Improved education of both providers (including GPs, endoscopists and private hospitals) and patients is needed to promote high-quality colonoscopy.
  4. The Department to encourage health agencies to promote or develop clinical decision support tools that inform the absolute risk of colon cancer for different age groups, for both patients and clinicians.
  5. Improve equity of access for regional and remote populations by supporting ongoing development of the GP-endoscopist workforce through rural generalist training and expanding outreach models.
  6. Separate the positive FOBT indication from MBS item 32222 and make it a stand-alone item.

The authors said that the training and broadening of both the nurse endoscopist and rural generalist workforce should be supported, arguing this could be a way of improving access for disadvantaged populations in the future.

It was noted that both these workforce groups make up a very small proportion of the total clinicians performing colonoscopy in Australia.

Regarding potential new interventions, they noted that CT colonography was emerging, but it still required bowel preparation and could not provide histopathology. As a result, its role in screening assessment was yet to be fully defined, they said.

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