Time to speak up about remuneration for sleep and respiratory diagnostics


By Amanda Sheppeard

16 Sep 2016

The use of spirometry and sleep studies in thoracic medicine are set to change under proposed changes to a raft of MBS items relating to these commonly accessed diagnostic tools.

The Thoracic Medicine Clinical Committee tasked with reviewing the MBS items hopes the changes will address problems of under-utilisation of spirometry and over-utilisation of sleep studies as well as better remunerate health care professionals.

The committee, set up by the Medicare Benefits Schedule (MBS) Review Taskforce in 2015 to review relevant MBS items, released its recommendations for consultation this week.

The committee is chaired by Professor Christine Jenkins, senior staff thoracic medicine specialist, at Concord Hospital and head of Respiratory Trials at The George Institute.

Fellow committee member, Professor Matthew Peters, told the limbic that too much lung disease was being diagnosed without the use of spirometry, in particular the before and after bronchodilator test in patients suspected of having asthma.

“The low remuneration was part of that,” he said.

The committee has recommended that the MBS rebate for undertaking diagnostic spirometry before and after bronchodilator be increased.

“We think spirometry is a very important tool to measure airway disease,” Professor Peters said.

“There is a long held belief that a large number of people are being treated for asthma without confirmation of a diagnosis.”

Professor Peters is head of Respiratory Medicine at Concord Hospital; Professor of Respiratory Medicine at Macquarie University; and past President of the Thoracic Society of Australia and New Zealand (TSANZ).

He said that while asthma puffer medication was viewed as “generally harmless”, it was concerning that people without asthma are being treated for the disease with subsidised medicines.

“Medical waste is not a victimless crime,” he said.

According to the report, in Australia and internationally it is accepted that well performed spirometry is underused in primary care.

“Pre and post bronchodilator spirometry (“reversibility testing”) has an important role in confirming the diagnosis of asthma, COPD and other causes of airflow limitation,” the committee wrote.

“Underuse of testing means that these conditions are both under and over diagnosed and as a consequence, patients are under and over medicated. Both situations generate avoidable healthcare costs.”

Concern that sleep studies are over-used

On the flip-side, the committee noted the high number of sleep studies used to diagnose obstructive sleep apnea, especially those undertaken at home.

“OSA is a high prevalence condition and the addition of Level 2 sleep studies has enabled better access to testing for adult patients which provides a basis for evidence-based therapies and in particular CPAP,” the report states.

“However, there is concern that better access to testing has been associated with diminished quality for many patients.”

Furthermore, the committee noted that a very high proportion of sleep studies are provided by relatively few providers.

And they also found a high proportion of patients – 67% of patients undergoing home studies and 28% of patients undergoing laboratory studies – do not have a MBS-funded consultation with a specialist physician in the 12 months before or after a sleep study.

“For these patients, specialist sleep physician input into the assessment and management of patients is limited to remote authorisation of testing and then providing a diagnosis, sometimes with advice about therapy, but without direct clinical assessment,” the authors wrote.

“There is concern that in some sleep study facilities authorisation of testing has occurred in retrospect, often by reporting physicians, and not based on objective clinical assessment or a face to face consultation in clinically uncertain cases.”

The committee agreed that all patients with OSA should have a personalised treatment plan that is directed to managing risk factors as well as, if indicated, appropriate therapies such as CPAP, oral appliances or other measures.

However, there was concern about the high volumes of testing in some practices. The Australasian Sleep Association (ASA) has developed guidelines about clinical aspects of testing and also practice standards. The ASA supports practice accreditation noting that currently there is no industry wide assurance that the quality of testing is high.

Professor Peters said that both over diagnosis and non-diagnosis were problems.

“Clearly there are a large number of people doing home sleep studies who don’t need them,” he said. “And there are some people who may be having full centre studies when they might be able to have a home-based study.”

The committee also touched on the need for a “degree of arms’ length between clinicians and suppliers of equipment such as CPAP machines.

Meanwhile, Professor Peters urged clinicians to read the report and make a supported comment, even if they were against the recommendations.

“Everyone needs to reflect on that and try in the next few weeks to respond,” he said.

The committee will consider feedback from stakeholders and then provide recommendations to the taskforce in a Review Report. The Taskforce will consider the Review Report from Clinical Committees and stakeholder feedback before making recommendations to the Minister for consideration by Government.

Submissions on the report can be accessed here. They close on October 7.

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