01 JULY 2021

Painaustralia CEO Carol Bennett highlighted the issue of implementation of MBS item number changes in last week's blog. As she mentioned, the Pain Management Clinical Committee was chaired by Dr Chris Hayes, and while the bulk of the work of that committee was spent reviewing and updating item numbers related to pain management procedures, there were a number of other recommendations that were made by Painaustralia, the Australian Pain Society and Faculty of Pain Medicine among others that were specifically aimed at seizing the opportunity to review the state of Medicare funding for community-based care.

A number of specific anomalies in the current Medicare system were identified as particularly inhibitory of the provision of multidisciplinary team care outside of hospital pain clinics. These were, in no particular order, the lack of access to item number 132 by all Specialist Pain Medicine Physicians (SPMP), the lack of inclusion of SPMPs in the item number descriptor related to provision of a chronic disease management plan, and the lack of an item number for provision of group pain management services in an outpatient setting, both for allied health and medical practitioners.

The first of these has been highlighted directly with Health Minister Greg Hunt in a meeting when the review was first commenced. Faculty of Pain Medicine fellows who are not members of the Royal Australasian College of Physicians (RACP) are not able to access item number 132, which allows for up to an hour of complex consultation, including the generation of a plan to cover several comorbidities, and reimburses up to $234.85 to the patient. This number reflects the complexity of chronic pain patients, and their likelihood of having multiple medical and psychological issues to deal with. SPMP's who do not have access to this item number have to use item number 2801, which has a maximum reimbursement to the patient of $134.30. The laws of economics dictate that lower reimbursement means less time can be spent with the patient, or else the out-of-pocket costs are passed on to the consumer. The lack of an appropriate item number which captures the complexity of chronic pain consultations for all SPMPs regardless of background is arguably the single biggest barrier to establishing more community-based, consultative pain management practices. It means that expert knowledge stays locked up in the big hospital pain clinics because it is simply not economically feasible to do the same thing in private unless you also perform procedures to offset this disparity.

The second and third issues listed directly impact the financial viability of providing allied health services in the community for pain management. Effective multidisciplinary teams are incredibly beneficial assets and provide highly cost-effective care when given the resources to do so. I speak from personal knowledge in my own practice when I say that, at present, the costs of doing business far outweigh what can be recovered from Medicare in providing expert allied health care for pain patients. The MBS item number reviews provided a once in a generation opportunity to remedy this ongoing structural hindrance to widespread provision of appropriate care.

In the Budget papers announced in May this year, the MBS Review implementation dates for the pain management item numbers was given as March 2022. Anticipated savings of $40 million over three years were also announced. Absolutely no further information has been forthcoming about what this means, in particular whether any of the above issues are going to be addressed.

The fact that the notification of these changes was buried in the Budget papers as a one-liner reporting a one-off saving rather than announcing a revolutionary way of providing pain management care leads me to suspect that the government may have in mind changes which implement savings as recommended by the PMCC, without any of the beneficial offsets which were recommended as well. This amounts to a de facto defunding of pain management services in general. As has been seen with spinal surgery, and now the orthopaedic and cardiac surgery implementation, the lead-in time is short, and the critical details have not been supplied.

Far more concerning is the lost opportunity to address a major barrier to equitable access of quality pain care. The announcement of endorsement of the National Strategic Action Plan for Pain Management by all state and territory governments as well as the Commonwealth means little if this opportunity is allowed to pass by.

Assoc Prof Mick Vagg, Dean Faculty of Pain Medicine, Australian and New Zealand College of Anaesthetists.