The Medicare Benefits Schedule Review Taskforce further curtails Nurse Practitioner practice – a case of unenlightened self-interest?
Published 14 December 2020, the Medicare Benefits Schedule (MBS) Review Taskforce (MBSRT) final report endorsed none of the 14 recommendations of its own Nurse Practitioner Reference Group(NPRG) Report. Instead, the report proposed three unrelated recommendations that further restrict the practice of NPs who provide services subsidised by the MBS: A decision not to endorse any of the 14 recommendations can only be viewed as a decision not to invest in nursing and the health of Australian communities.
The NPRG (one of five different professional groups established by the Taskforce) was multidisciplinary, comprising a range of practising nurse practitioners (NPs), both public and private; consumers; registered nurses; a medical practitioner from the MBSRT who was an ex-officio member and professional and industrial nursing group representatives. Many of the recommendations focussed on adjusting items that were already working well, or expanding recently introduced items through increased access or expanded scope. Fourteen evidence-based recommendations presented by the reference group sought to broaden the range of NP services subsidised through the MBS, and thereby encourage the growth of this much needed nursing workforce.
The review “drew on various types of MBS data, including data on utilisation of items (services, benefits, patients, providers and growth rates); service provision (type of provider, geography of service provision); patients (demographics and services per patient); co-claiming or episodes of services (same-day claiming and claiming with specific items over time); and additional provider and patient-level data, when required (p.20)”. The review also used evidence-based data from the literature and clinical guidelines from peer-reviewed nursing and medical journals and other sources, such as government reports and professional societies, to address its remit from the MBSRT. The main themes of the review focussed on the role and scope of the NP, and the differences between an NP and a registered nurse (RN). The 14 recommendations focussed on four key areas: supporting comprehensive and coordinated care for people with long-term health conditions and Aboriginal and/or Torres Strait Islander peoples; enabling nurse practitioner care for all Australians; addressing system inefficiencies caused by current MBS arrangements; and improving patient access to telehealth services .
Research evidence tells us that NPs provide quality care, that patients are highly satisfied with their care and that NPs have increased access to health services, particularly for marginalised populations in community settings. Other studies have demonstrated that NPs prevent representations to ED and that their expertise is drawn on significantly by the multidisciplinary teams.
The collaborative arrangements, introduced at the request of medical groups when NPs were given limited access to MBS items, have been repeatedly demonstrated to impede NPs’ ability to practise to full scope and to offer no benefits in terms of patient safety. Dr Sonj Hall, Editor in Chief of the Australian Health Review, made the observation, following on from an extensively peer-reviewed article by these authors
‘The available research literature shows nurse practitioners to be universally highly effective, with negligible patient complaints. The authors agreed with the Medicare Benefits Schedule Review’s nurse practitioner reference group that the collaborative relationship requirements should be scrapped ‘This would seem to be the best way to solve the barriers and difficulties experienced, especially in our current COVID-19 pandemic where flexibility of medical services is at a premium’.
In particular, in 2020, NPs have been at the forefront of emergency relief work during the NSW bushfires and in front line acute care, aged care services, quarantine camps and international Aid work in the Western Pacific during COVID-19. Indeed, during Australia’s Nurse Practitioner Week (7-11 Dec 2020), Minister for Health, Hon Greg Hunt, described nurses as ‘…the lifeblood of rural communities, responding to complex health needs away from major hospitals, and this year has exemplified the vital and necessary role they play.’
It is thus unfathomable why the MBSRT should reject all 14 recommendations of a Reference Group they chose and instructed, a set of recommendations that sought to expand the role of NPs and make their services more accessible to the underserved and underserviced. Instead, they recommended that there be a review of Collaborative Arrangements (CAs) because they “strongly endorses collaborative arrangements in ensuring patient safety”.
The second recommendation is that scope of practice and credentialing frameworks for nurse practitioners be established. They recommend the establishment of a “clinical governance framework”, based on the Nursing and Midwifery Board of Australia’s (NMBA’s) professional practice framework. This seems to be superfluous to the intent of the review and suggests that the MBSRT is micro-managing the legitimate and well established work of the professional regulatory body for nursing and midwiferyrather than focussing on their own remit.
Recommendation 3 thankfully suggests reviewing alternative pathways to fund NP services, but not to improve their access to MBS. The MBSRT states that “exploration of alternate funding models outside the MBS is regarded as a more appropriate pathway”. Given that the NPRG was established specifically to examine NP access to MBS payments (as presumably was the MBSRT) one can only wonder why on earth the MBSRT established a reference group for NPs in the first place.
Of 48 members of the MBSRT, only one represented nurse practitioners and one represented midwifery. Yet both of these groups of professionals need to access MBS in order to obtain adequate remuneration for their services, and in order to provide services to the under-served and underprivileged. It is acknowledged that the other 45 (mainly medical – one of the 46 identifying as a consumer) members of the MBSRT had the same need to access MBS funding and happily there seems to have been a more direct recognition of their need than that of the patients treated by the NP community.
There is little to be said that can enable any comprehension of this perverse, offensive and oppressive rejection of the diligent and evidence-based work of a specifically commissioned reference group. In the International Year of the Nurse and Midwife, when the value of NPs has been demonstrated over and over again as they have provided services in difficult, challenging and unpopular clinical settings, this report of the 14th December can only be described as irrational and contrary to the interests of more accessible patient care.
Membership of the Medicare Benefits Schedule Review Taskforce
The membership is:
- Professor Bruce Robinson – Chair
- Dr Steve Hambleton – Deputy Chair; representative of PHCAG
- Dr Matthew Andrews – Clinical member (Diagnostic imaging)
- Professor Michael Besser – Clinical member (Neurosurgery)
- Dr Eleanor Chew – Clinical member
- Dr Michael Coglin – Clinical member (Private provider)
- Professor Adam Elshaug – Health economist
- Dr Tammy Kimpton – Clinical member (General Practice)
- Professor Paul Glasziou – Clinical member (General practice)
- Professor Michael Grigg – Clinical member (Surgery)
- Dr Lee Gruner – Clinical member (Medical administration)
- Ms Rebecca James – Consumer representative
- Dr Matthew McConnell – Clinical member (Public health)
- Dr Bev Rowbotham – Clinical member (Pathology)
- Dr Joanna Sutherland – Clinical member (Anaesthetics)
- Professor Nick Talley – Clinical member (Medicine)