Pearls and Irritations

The long-awaited Medicare Benefits Scheme Taskforce Review (MBSTR) Report has been released but brought little  joy for those seeking contemporary health care delivery, improved consumer choice, and outcome-based care.

The MBSTR was commissioned in 2015 to better align Medicare with “contemporary clinical evidence, practice and improved health outcomes for patients”. Unfortunately, the review has failed to deliver on all counts, reinforcing the current position of profession centric care.

Many countries around the world have embraced nurse practitioners (NPs) as a clear solution to the problem of expensive healthcare that does not encourage equity of access. Nurse Practitioners require extensive training to achieve their coveted title, with up to 8 years of university education combined with a minimum of a further 5 years of specialized and advanced clinical training. Nurse Practitioners can make diagnoses, request investigations, and prescribe medications. They manage the healthcare of our most needy and vulnerable Australians and importantly, they work well with other healthcare providers, including GPs, specialists, allied health, and of course other nurses.

Nurse Practitioners are not new to Australia, having been practising for 20 years and with more than 2000 nurse practitioners registered in Australia. They have been extensively researched and have made their presence felt through improved health outcomes and patient satisfaction. They are not here to replace the work of medical colleagues, but to add value to the entire healthcare team. The evidence consistently demonstrates that care by nurse practitioners results in processes and outcomes that are either equivalent to, or better than, those achieved by doctors. Patient satisfaction with the care delivered by Nurse Practitioners is high. We know that the highest value Nurse Practitioners contribute to our healthcare system is their ability to provide care in underserved areas and to help meet the demand for more accessible and cost-effective care. The RACGP has campaigned very successfully that investing in primary care reduces costs across the whole health care system. ‘If we are serious about focusing on preventive healthcare, we need to end the inequality of Medicare rebates compared to other clinical specialties.’ RACGP.

To provide a case study of the problems of demand for services, take the coastal stretch in northern New South Wales (NSW). The towns of Lismore, Ballina and Byron Bay are typical of many towns in regional Australia. Leafy locations that are home to families, retirees, and even major university campuses. This is not remote Australia with its well-known challenges: this area is home to Russell Crowe, Matt Damon and the Hemsworth’s and is often called the playground of Sydney’s elite.

But in terms of healthcare, it is not a playground, due to an overburdened primary healthcare system, typical of many towns like it, service gaps and lack of access to care are contributing to poorer health outcomes for the community. This stretch of idyllic coastline faces up to a 25% higher mortality for adults and infants alike, while recording some of the lowest immunisation rates in the nation. A 2017 report from the Royal Australian College of General Practitioners (RACGP) painted a stark picture of access to care in this region. In Ballina, none of the seven GP practices offer bulk billing, and in nearby Byron Bay only one out of 15 practices offer gap free bulk billing, in fact in the Northern NSW Primary Healthcare Network only 1 in 5 practices offers gap free bulkbilling.

Despite these startling statistics, getting access to affordable healthcare is not the biggest issue, it is getting an appointment. In this region, going up to the Queensland border, out of the 3.1Million episodes of GP care that are offered each year, almost a million of them wait longer than 2 weeks for an appointment. 2 weeks is a long time to wait when you are suffering with an illness or in pain.

So why have Nurse Practitioners been frozen out of the recommendations of Medicare Benefits Schedule Review Taskforce when we know that they are highly effective and cost efficient? The Medicare Benefits Schedule Review Taskforce is a lesson in how to fail to incorporate evidence to move toward the delivery of a contemporary and cost-effective healthcare system. We call for the appointment of panels that include clinical experts from across healthcare, instead of a taskforce made up of 14 medical practitioners with not a single psychologist, physiotherapist, pharmacist, or nurse practitioner among them.

To inform the panel of doctors who would decide the who and how of access to Medicare, reference groups of experts were commissioned to provide evidence-based recommendations that relied on an assessment of the literature and data with the goals to set aside professional bias. Largely these recommendations were then approved by the taskforce and forwarded to government. However, all 14 recommendations provided by the Nurse Practitioner Reference Group (NPRG) were entirely dismissed by the medically dominated taskforce. The evidenced based recommendations set out in the comprehensive NPRG report with the goal to enhance access to healthcare for all Australians, were set aside. The Taskforce, incredibly and indefensibly, ignored both the evidence of their own experts and arguably the terms of reference that the taskforce members were appointed under.

Allegations of anti-competitive conduct, professional mobbing and cartel behaviour have been levelled against medical colleges before. Professor Alan Fels and Professor Graeme Samuel, two former chiefs of the ACCC, have suggested governments needed to get over their fear of taking on powerful medical lobby groups and investigate these allegations. Professor Samuel reported to Fairfax that, when he wanted to investigate medical colleges in the 2000s, he was told to “back off” by federal and state health ministers. “Control over competition almost invariably results in lowering of quality or higher prices,” he said and further observed that most medical colleges in Australia were “closed shops” and that health ministers needed to “take charge” and open them up to more scrutiny to benefit patients.

Currently, patients of Nurse Practitioners have very limited access to Medicare funding. A handful of time-limited Medicare numbers are funded at such a low level that these expert clinicians are frequently forced to subsist on less than the minimum wage if they attempt to bulk bill. We need to support Nurse Practitioners to access Medicare funding for the nation to gain from the opportunity to obtain high quality, equitable care across Australia.

It is time to highlight, share and embrace the evidence-based recommendations from the NPRG that will create greater consumer choice, make care more convenient, effective, accessible and more affordable for all Australians

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