Chapter 2
The terms of item 16525
Introduction
2.1
In this chapter the committee canvasses the terms of item 16525
including the basis on which payments are made and the procedures under the
item. The data available on the use of this item is provided together with a
discussion on the limitations of that data.
The terms of item 16525
2.2
The Health Insurance Act 1973 provides that regulations may
prescribe a table of medical services (other than diagnostic imaging services
and pathology services) that set out items of medical services, the amount of
fees applicable in respect of each item and rules for interpretation of the
table. The Health Insurance (General Medical Services Table) Regulations 2007
currently prescribe such a table.
2.3
The items in the Medicare Benefits Schedule (MBS) relate to medical, optometrical
and, in some cases, dental surgical services, provided on a private basis. The review
of items already on the MBS is undertaken by the Medicare Benefits Consultative
Committee. This committee is an consultative forum with representation drawn
from the Department of Health and Ageing, the Health Insurance Commission, the
Australian Medical Association and relevant professional craft groups of the
medical profession. The reviews are designed to ensure that the MBS reflects
current medical practice and encourages best practice. Proposed listings of new
medical procedures and new technologies on the Schedule are assessed by the
Medical Services Advisory Committee on the basis of evidence of safety,
cost-effectiveness and of real benefit to patients.[1]
2.4
Item 16525 of Part 3 of Schedule 1 to the Health Insurance (General
Medical Services Table) Regulations 2007 is described in the Medicare Benefits
Schedule as follows:
MANAGEMENT OF SECOND TRIMESTER LABOUR, with or without
induction, for intrauterine fetal death, gross fetal abnormality or life
threatening maternal disease, not being a service to which item 35643 applies (Anaes.)
Fee: $267.00 Benefit: 75% = $200.25 85% = $226.95.[2]
2.5
Item 35643 is described as follows:
EVACUATION OF THE CONTENTS OF THE GRAVID UTERUS BY CURETTAGE OR
SUCTION CURETTAGE not being a service to which item 35639/35640 applies,
including procedures to which item 35626, 35627 or 35630 applies, where
performed (Anaes.)
Fee: $196.85 Benefit: 75% = $147.65 85% = $167.35.[3]
2.6
An item number for the management of second trimester labour was first
introduced on 1 October 1976 under the then Medical Benefits Scheme. On 1 November 1995 the current descriptor was introduced following a review of the
obstetric services in the MBS. The Department of Health and Ageing (the
department) informed the committee that the change was 'to ensure that it
reflects and supports current obstetric practice'.[4]
2.7
Practitioners caring for private patients use these item numbers when
providing services for women in private hospitals or alternatively for private
patients being cared for in public hospitals. Medicare benefits are paid under
item 35643 for procedures that may involve the termination of pregnancies in
the first trimester and under item 16525 for procedures in the second
trimester. The second trimester is generally considered to range between 13 and
26 weeks gestation.[5]
As might be expected, fewer claims are processed under item 16525 than under
item 35643 – 794 compared with 71,957 in 2007–2008.[6]
The services provided under item 16525 are discussed further below.
The basis on which payments of benefits are made
2.8
The payment of Medicare benefits are made under the Health Insurance
Act 1973 (HI Act). Subsection 10(1) of the HI Act provides:
Where, on or after 1 February 1984, medical expenses are
incurred in respect of a professional service rendered in Australia to an
eligible person, medicare benefit calculated in accordance with subsection (2)
is payable, subject to and in accordance with this Act, in respect of that
professional service.
2.9
The department noted that:
The term 'professional service' is relevantly defined in
subsection 3(1) of the HI Act as meaning, 'a service (other that a diagnostic
imaging service) to which an item relates, being a clinically relevant service
that is rendered by or on behalf of a medical practitioner'.
A 'clinically relevant service' is relevantly defined in
subsection 3(1) of the HI Act as a service rendered by a medical practitioner
that is generally accepted in the medical profession as being necessary for the
appropriate treatment of the patient to whom it is rendered.
...
Medicare payments are payable under item 16525 (management of
second trimester labour) when performed in accordance with the item descriptor
under the Health Insurance (General Medical Services Table) Regulations...[7]
2.10
The department stated that a Medicare rebate is not available for second
trimester labour outside the restrictions of the item, namely, intrauterine
fetal death, gross fetal abnormality or life threatening maternal disease. The
department went on to state that:
It is a matter for the doctor's clinical judgment as to whether
a patient's condition meets these second trimester requirements.[8]
2.11
Lawful termination of a pregnancy is regulated by the States and
Territories and for a termination to be funded through Medicare it needs to be
provided in accordance with State and Territory law.[9]
The department provided the committee with legislative provisions and judicial
considerations on the lawfulness of abortion in the States and Territories at
Attachment A of its submission.[10]
Item 16525 descriptors
2.12
The three descriptors under item 16525 will be discussed in greater
detail in the next two chapters. However, whilst the term 'psychosocial
indications' is not included in the descriptor for the item, considerable
attention was given to 'psychosocial' grounds for pregnancy termination
throughout the inquiry and the committee sought further information on the
definition of this term.
2.13
The Perinatal Society of Australia and New Zealand Perinatal Death
Classification (PSANZ-PDC), which provides a uniform classification system for
Australia, lists 'termination of pregnancy for maternal psychosocial
indications' as classification 5.1 under 'maternal conditions'.[11]
The PDC does not provide a definition of 'psychosocial indications'. However,
the Victorian Consultative Council on Obstetric and Paediatric Mortality and
Morbidity (CCOPMM) reviews perinatal deaths in Victoria in accordance with the
PSANZ-PDC and considers 'psychosocial indications' as follows:
'Psycho-social' is a term in general use to encompass a range of
reasons/conditions why a woman might take the very serious decision to
terminate a pregnancy (with a normal fetus) at or beyond 20 weeks. Such reasons
could include for example, the late discovery of an unplanned or forced
pregnancy (maybe as the result of rape or incest), acute psychiatric disorders
including severe depression/suicidal intention, or abandonment or other grave social/cultural
problem. The term doesn't lend itself readily to precise definition or quantification,
except the word 'severe' would always apply to all these psychological and
social factors.[12]
2.14
The department noted that whilst the term 'psychosocial' was not defined
in the Health Insurance Act 1973 or the Health Insurance (General
Medical Service Table) Regulations 2007, the
Public Health Association of Australia provides some clarification:
The definition of psychosocial indications differs within the
legislation among different states. When psychosocial reasons for second and
third trimester abortion are cited, this generally refers to serious mental
illness of the mother.[13]
Procedures under item 16525
2.15
The explanatory notes to the MBS provide the therapeutic procedures
under item 16525. Note T4.4 reads as follows:
Labour and
Delivery (Items 16515, 16518, 16519, 16525)
Benefits for
management of labour and delivery covered by Items 16515, 16518, 16519 and
16525 includes the following (where indicated):-
- surgical and/or intravenous
infusion induction of labour;
- forceps or vacuum extraction;
- evacuation of products of
conception by manual removal (not being an independent procedure);
- episiotomy or repair of tears.[14]
2.16
Professor David Ellwood has stated that methods used for late
termination vary, depending on the indication, particularly the nature of a
fetal abnormality, the gestation and the preferences of the individual
practitioner and patient. Dr Ellwood went on to state that the most commonly
used method is induction of labour using prostaglandins and noted that:
A surgical procedure such as dilation and evacuation, although
possible, is less likely to be used at gestations beyond 20 weeks due to the
technical difficulties caused by fetal size and a higher rate of complications.
Very infrequently, the method of choice may be either hysterotomy or caesarean
section, if there are valid obstetric reasons for choosing this approach.[15]
2.17
Professor Ellwood concluded that 'the various laws and court decisions
that guide practice in late termination do not really provide any direction as
to the method that should be used, and some practitioners have expressed
concern about the lack of legal clarity'.[16]
2.18
Information from Western Australia indicated that in 2005 the main
procedure used for induced abortions was vacuum aspiration (suction curettage)
(95.4 per cent) with dilation and evacuation accounting for 2.5 per cent and
other methods, including prostaglandin, intravenous or intra-uterine infusion,
another 2 per cent.[17]
The authors of the Western Australian report observed that the predominance of
vacuum aspiration as a method of inducing abortions is consistent with over 90
per cent of abortions taking place in the first three months of gestation.[18]
2.19
Terminations of pregnancy beyond 20 weeks gestation take place either by
dilatation of the cervix, followed by evacuation or extraction of the contents
of the uterus, or by inducing labour to deliver the fetus followed by injection
of potassium chloride into the fetus while it is in utero.[19]
Medicare claims under item 16525
2.20
The Department of Health and Ageing provided the following data on the
use of item 16525 from January 1994 to 31 August 2008 (calendar years).
Table 2.1: Number of Medicare claims processed under
item 16525 from January 1994 to 31 August 2008
Item/Year |
Total |
Total |
Benefit ($) |
Services |
16525 |
1994 |
145,786 |
936 |
1995 |
168,248 |
1,019 |
1996 |
113,768 |
697 |
1997 |
105,366 |
647 |
1998 |
100,349 |
605 |
1999 |
102,443 |
609 |
2000 |
111,719 |
655 |
2001 |
122,986 |
714 |
2002 |
109,435 |
624 |
2003 |
117,942 |
656 |
2004 |
126,418 |
683 |
2005 |
148,291 |
770 |
2006 |
150,583 |
777 |
2007 |
157,250 |
790 |
2008 |
113,132 |
540 |
Total |
1,893,716 |
10,722 |
Source: Department of Health
and Ageing, Submission 218, p.1.
2.21
The following tables show the number of Medicare claims processed under
item 16525 for the period July 1998 to June 2008; the cost of those claims;
claims per 100,000 of the Australian population; and the age of those making
the claims.
Table 2.2: Number of Medicare claims processed under
item 16525 - July 1998 to June 2008[20]
|
State |
Total |
NSW |
VIC |
QLD |
SA |
WA |
TAS |
ACT |
NT |
Services |
Services |
Services |
Services |
Services |
Services |
Services |
Services |
Services |
1998/1999 |
188 |
157 |
118 |
54 |
48 |
22 |
6 |
4 |
597 |
1999/2000 |
210 |
196 |
108 |
57 |
46 |
18 |
5 |
5 |
645 |
2000/2001 |
209 |
229 |
124 |
59 |
45 |
11 |
7 |
8 |
692 |
2001/2002 |
208 |
191 |
116 |
59 |
42 |
8 |
7 |
5 |
636 |
2002/2003 |
246 |
170 |
133 |
53 |
31 |
9 |
8 |
10 |
660 |
2003/2004 |
203 |
179 |
140 |
60 |
27 |
12 |
11 |
5 |
637 |
2004/2005 |
222 |
304 |
122 |
57 |
29 |
18 |
8 |
7 |
767 |
2005/2006 |
221 |
272 |
112 |
54 |
54 |
26 |
11 |
5 |
755 |
2006/2007 |
220 |
286 |
123 |
67 |
59 |
20 |
14 |
13 |
802 |
2007/2008 |
242 |
286 |
113 |
57 |
49 |
27 |
15 |
5 |
794 |
Total |
2,169 |
2,270 |
1,209 |
577 |
430 |
171 |
92 |
67 |
6,985 |
Source: Medicare Australia
Statistics.
Table 2.3: Cost of
Medicare claims under item 16525 - July 1998 to June 2008[21]
|
State |
Total |
NSW |
VIC |
QLD |
SA |
WA |
TAS |
ACT |
NT |
$Benefit |
$Benefit |
$Benefit |
$Benefit |
$Benefit |
$Benefit |
$Benefit |
$Benefit |
$Benefit |
1998/1999 |
31,493 |
26,144 |
19,658 |
9,013 |
8,014 |
3,660 |
1,026 |
692 |
99,700 |
1999/2000 |
35,560 |
33,325 |
18,365 |
9,654 |
7,765 |
3,053 |
848 |
846 |
109,416 |
2000/2001 |
35,936 |
39,017 |
21,378 |
10,193 |
7,737 |
1,830 |
1,202 |
1,373 |
118,667 |
2001/2002 |
36,131 |
33,164 |
20,202 |
10,140 |
7,247 |
1,392 |
1,201 |
874 |
110,352 |
2002/2003 |
43,645 |
30,105 |
23,710 |
9,404 |
5,553 |
1,610 |
1,421 |
1,785 |
117,234 |
2003/2004 |
36,922 |
32,634 |
25,509 |
10,917 |
4,937 |
2,185 |
2,019 |
908 |
116,031 |
2004/2005 |
41,714 |
56,781 |
22,781 |
10,650 |
5,396 |
3,365 |
1,490 |
1,302 |
143,479 |
2005/2006 |
44,418 |
52,054 |
21,972 |
10,308 |
10,305 |
4,957 |
2,093 |
970 |
147,077 |
2006/2007 |
43,037 |
55,587 |
24,639 |
13,005 |
11,473 |
3,871 |
2,700 |
2,531 |
156,843 |
2007/2008 |
54,239 |
57,399 |
22,423 |
11,342 |
9,705 |
5,351 |
2,969 |
997 |
164,425 |
Total |
403,094 |
416,211 |
220,638 |
104,626 |
78,132 |
31,275 |
16,969 |
12,279 |
1,283,225 |
Source: Medicare Australia
Statistics.
Table 2.4: Claims per
100,000 population under item 16525 - July 1998 to June 2008[22]
|
State |
Total |
|
NSW |
VIC |
QLD |
SA |
WA |
TAS |
ACT |
NT |
1998/1999 |
3 |
3 |
3 |
4 |
3 |
5 |
2 |
2 |
3 |
1999/2000 |
3 |
4 |
3 |
4 |
2 |
4 |
2 |
2 |
3 |
2000/2001 |
3 |
5 |
3 |
4 |
2 |
2 |
2 |
4 |
3 |
2001/2002 |
3 |
4 |
3 |
4 |
2 |
2 |
2 |
2 |
3 |
2002/2003 |
4 |
3 |
3 |
3 |
2 |
2 |
2 |
5 |
3 |
2003/2004 |
3 |
3 |
3 |
4 |
1 |
2 |
3 |
2 |
3 |
2004/2005 |
3 |
6 |
3 |
4 |
1 |
4 |
2 |
3 |
4 |
2005/2006 |
3 |
5 |
3 |
3 |
3 |
5 |
3 |
2 |
4 |
2006/2007 |
3 |
6 |
3 |
4 |
3 |
4 |
4 |
6 |
4 |
2007/2008 |
3 |
5 |
3 |
4 |
2 |
5 |
4 |
2 |
4 |
Source: Medicare Australia
Statistics.
Table 2.5: Patient
Demographics under item 16525 - July 1998 to June 2008[23]
Item
16525 |
State |
Total |
NSW |
VIC |
QLD |
SA |
WA |
TAS |
ACT |
NT |
0-4 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
5-14 |
1 |
5 |
0 |
1 |
1 |
0 |
0 |
1 |
9 |
15-24 |
144 |
473 |
59 |
23 |
18 |
49 |
3 |
12 |
781 |
25-34 |
1,175 |
1,040 |
652 |
335 |
246 |
61 |
42 |
28 |
3,579 |
35-44 |
831 |
736 |
493 |
216 |
162 |
61 |
46 |
26 |
2,571 |
45-54 |
18 |
15 |
5 |
2 |
3 |
0 |
1 |
0 |
44 |
55-64 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
65-74 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
75-84 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
>=85 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
Unknown |
0 |
1 |
0 |
0 |
0 |
0 |
0 |
0 |
1 |
Total |
2,169 |
2,270 |
1,209 |
577 |
430 |
171 |
92 |
67 |
6,985 |
Source: Medicare Australia
Statistics.
2.22
As may be observed from the above tables, the number of Medicare claims
processed annually under item 16525 remained relatively static for the first
six years of the ten year period; increased in 2004-2005 and have since
remained relatively static at the higher level. The same pattern can be noted
in Table 2.4 which shows that claims made per 100,000 of the population
increased from three to four in 2004-2005 and have since remained at that
level.
2.23
According to recent evidence provided by Medicare Australia, the
national average for 2007, for example, was 3.7 item 16525 services per 100,000
population. Comparatively, the average for the first eight months of 2008 (to
31 August), was 2.5 item 16525 services per 100,000 population.[24]
2.24
Table 2.3 demonstrates that the cost of benefits paid in relation to the
claims also increased in 2004-2005 from earlier levels.
2.25
Medicare Australia provided the committee with the number of providers
who claimed item 16525 during the full year of 2007 and part year of 2008 to 31
August. Data in three states have been aggregated to other states due to data
size.
Table 2.6: The number of providers that
have claimed item 16525 from Medicare
|
Number of providers |
|
NSW/ACT |
VIC/TAS |
SA/NT |
QLD |
WA |
Total |
January
to December 2007 |
110 |
91 |
33 |
53 |
22 |
309 |
January
to 31 August 2008 |
92 |
74 |
26 |
52 |
22 |
266 |
Source: Medicare Australia, Answer to Question on Notice
Services to which item 16525 applies
Limitations of the Medicare data
2.26
The above tables indicate the total number of services provided under
item 16525. However, the MBS data is only available for all services provided
under the item and it not available for each indicator or the circumstances of
the labour. The department informed the committee that:
...the services to which item 16525 relates includes both
spontaneous abortions (miscarriages) and medical or induced abortions
(terminations). It is thus not possible to determine how many services
receiving payment under this item were the result of either a spontaneous or
induced procedure.[25]
2.27
The Royal Australian and New Zealand College of Obstetricians and
Gynaecologists (RANZCOG) stated that 'it is known that 16525 is used for
services that manage fetal death in utero, miscarriage and life threatening
maternal disease in the second trimester, it is therefore difficult to
extrapolate the use of item 16525 for termination of pregnancy when it is not
known if the procedure is induced or spontaneous'.[26]
Indications for second trimester
terminations provided by other data sources
2.28
While it is not possible to breakdown the Medicare data on item 16525, an
indication of the reasons for terminations of second trimester pregnancies is
available for South Australia, Victoria and Western Australia. RANZCOG noted
that South Australia conducts the only reliable termination of pregnancy data
collection, recording all instances of termination of pregnancy.[27]
The data reported for South Australia for 2006 indicated that there were 78
late terminations (performed at 20 weeks gestation or later) with 51 per
cent of these were for 'fetal reasons'.[28]
Late term terminations accounted for about 1.5 per cent of all
terminations in South Australia.
2.29
RANZCOG noted that the data from Victoria suggested that termination
after 20 weeks gestation amounts to 1 per cent of all terminations
performed.[29]
The Victorian Consultative Council on Obstetrics and Paediatric Mortality and
Morbidity publishes data on perinatal deaths. The council's annual report for
the year 2006 reported, in relation to perinatal deaths from termination of
pregnancy, that:
As a result of increasing uptake of prenatal ultrasound and
diagnostic procedures, congenital abnormalities are now frequently being
diagnosed in mid trimester pregnancies leading on to terminations of pregnancy
(TOP). When the termination procedure occurs at or beyond 20 weeks gestation,
regardless of the method of termination, it is a legal requirement that these
cases be recorded as births and perinatal deaths. In 2006 there were 106
stillbirths and 42 neonatal deaths in this category, 17.7% of perinatal deaths.
TOP procedures undertaken for maternal psychosocial indications only at or
beyond 20 weeks gestation also require registration as births and perinatal
deaths (in 2006 there were 150 stillbirths in this category, which comprised
18.0% of perinatal deaths). 60% of TOPs =>20 weeks for maternal psychosocial
indications were undertaken for women whose place of residence was outside Victoria.[30]
2.30
Some Victorian data are provided for termination of pregnancy between
20 and 27 weeks gestation. In 2006, 144 terminations were performed for
congenital abnormality and 150 were performed for maternal psychosocial
indications with no fetal abnormality.[31]
2.31
Western Australian legislation also requires that terminations be
notified. A report of these notifications shows that in 2005 there were 507
induced abortions in the State after a gestational age of 13 weeks. Four-nine
(0.6 per cent) were carried out at gestation of 20 weeks and over.[32]
Nearly all of those terminations would have occurred in the second trimester
and should be reflected in the claims data for Medicare item 16525. However,
there were only 29 claims made from Western Australia in 2004-2005. The
discrepancy in the figures may be explained in that in 2005 there were 688
terminations in metropolitan and rural public hospitals[33]
and Professor Ellwood stated that all late terminations in Western Australia
are performed in that State's tertiary women's hospital.[34]
2.32
There is some information provided in the Western Australian data
concerning the reasons for terminations, but none of that information is provided
for various stages of gestation. The information that has been reported is as
follows:
In the four year period [2002-2005] 1.95% of all induced
abortions (622 cases) were carried out for
suspected or identified congenital malformations, with 14.6% of these (91 cases
in four years) due to suspected or identified Neural Tube Defects (such as
spina bifida and anencephaly).[35]
2.33
An estimate quoted in the final report of the Victorian Law Commission
on abortion law suggests that 4.7 per cent of abortions in Australia occur
after 13 weeks but before 20 weeks and that 0.7 per cent occur after 20 weeks.[36]
2.34
Other comments relating to the Medicare data were provided in evidence. It
was noted that services under item 16525 are provided on a private basis and
thus does not include services provided to public patients. RANZCOG stated:
In Australia most second trimester terminations are performed in
public hospitals, for these, the 16525 item is not used but the jurisdictions
and indirectly the federal government supports these services in that they fund
the public hospital system.[37]
2.35
Professor Ellwood in a 2005 article for the Australian Health Review
commented on late term terminations in the public sector and stated it is
highly probable that analysis of the data would confirm 'that the numbers in
the public sector are small and the indications are almost always for compelling
medical reasons to do with the fetal prognosis'. Professor Ellwood noted that
in Western Australia procedures 'are done for reasons of severe fetal
abnormality or serious maternal illness' in a tertiary women's hospital. In NSW
and Victoria processes in the major public hospitals are similar and that 'in
practice, late terminations in public hospitals are almost always for reasons
of severe fetal abnormality, or where the mother has a life-threatening illness
exacerbated by the pregnancy'.[38]
2.36
The MBS data also excludes women who have procedures in private settings
to which item 16525 may apply but who do not claim a Medicare rebate. In
addition, the department informed the committee that there is no Medicare item
for terminations in the third trimester.[39]
Thus the Medicare data does not include terminations conducted after
24 weeks (though the available evidence suggests that the number of these
is relatively small).[40]
Improving data reporting
2.37
As evidenced in the discussion above, there are limited data available
on second trimester terminations generally in Australia and in relation to the
services provided under item 16525.
2.38
Witnesses commented on these two aspects of data collection. RANZCOG stated
that 'rates of termination of pregnancy in Australia are poorly documented'.[41]
Ms Letitia Nixon from SHine SA commented:
Speaking from a South Australian perspective—and we are one of
the states that gathers data—there is not an adequate data reporting system in Australia.
That is clearly one of the issues you are struggling with around this item.
Obviously this item is used overwhelmingly—and that data is further clear from
South Australia—around managing second trimester labour for a range of foetal
and maternal indications that have nothing to do with planned terminations of
pregnancy.[42]
2.39
Ms Nixon further noted that at times, as South Australia has good data,
'it gets extrapolated for the whole country'.[43]
The lack of national uniformity in data collection was also highlighted by Dr Janet
Mould of the National Foundation for Australian Women who noted:
There are of course a number of morbidity and mortality data
collections in hospitals but, unfortunately, to the best of my knowledge they
do not involve private hospitals. So this country could really do with a national
data collection on morbidity and procedures. Having said that, there are a
number of collections, and Victoria stands out here as having a collection that
you would be aware of in this area.[44]
2.40
Dr Edith Weisbert of Family Planning NSW held the same view:
I think that the major issue in Australia is that there are no
good data on the termination of pregnancies and there are no consistent data
throughout the country. It is high time that we set up a system whereby we had
accurate information and then we could look at whether this in fact is a
discussion that should be taking place.[45]
2.41
Some researchers have discussed options for collecting more reliable
data on terminations at the national level. In a brief compiled by the
Commonwealth Parliamentary Library three options for collecting more reliable
data were canvassed: changing the way that terminations are recorded by
Medicare; establishing uniform hospital data reporting to the Australian
Institute of Health and Welfare; and implementing nationally the South
Australian system of termination notification and data collection.[46]
Other researchers have suggested working towards a de-identified national
collection, perhaps coordinated through the Australian Institute of Health and
Welfare, of a list of agreed data from hospitals and private clinics.[47]
2.42
Options for improved data collection were also canvassed in evidence.
Catholic Health Australia commented on Medicare data and stated that there is
no way to reliably quantify the number of terminations funded by Medicare and
suggested that if a separate MBS item for pregnancy terminations were
introduced, women would be required to declare that they had had a termination
when claiming the Medicare rebate. Catholic Health concluded that:
This record of the termination would remain on their Medicare
record permanently. Whilst this may assist in better informing policy decisions
through improved data collection, such a move would more likely represent the
placing of an additional burden on a women who has undergone a termination and
potentially expose a women to a breach of privacy at the time of the
termination or at a later stage in her life.[48]
2.43
Dr Andrew Pesce also commented on complications that may arise if data
was reported against each descriptor of item 16525:
Data collection is always good. The more we know, the more we
can do what we want to do and avoid the unintended consequences of what we
might think we are doing. So I think it is high time we had much better
statistics and more robust data on this topic in Australia; it basically does
not exist.
The only cautionary note I would make is that I think it cannot
be linked to Medicare item numbers. Medicare item numbers are a claiming thing
for doctors so that we can pay for medical services. It is not a statistical
tool to try and find out the subtleties of why we are doing a medical treatment
or who we are doing it for. We must protect patient confidentiality. It would
be very simple for any institution which was able to claim for any of these
services—and they are always performed in institutions—to make it a requirement
that they had to, in a de-identified way, provide all of this data, which would
give us everything we wanted. We could go into the minutest details of what we
need and get exactly what we wanted to know, and not threaten the
confidentiality of the patient, who has to go to a Medicare office with an MBS
item number where they would say: 'Oh, you had an abortion. Ooh, you had a
psychosocial abortion.' Data is good, but you will get a lot better if you
actually think about what data you want and have it collected properly and
systematically in a de-identified way rather than mucking around with MBS item
numbers, pretending you are going to find out things that you do not currently
know.[49]
2.44
A further problem in relation to data collection is the lack of
consistent definitions. This problem was highlighted by Professor Ellwood in
his evidence:
One of the problems about data collection is definition. Is it a
termination of pregnancy if you are simply inducing labour early in pregnancy
when the baby has a condition that is incompatible with life? For example, anencephaly
in the foetus, which is incompatible with life after birth: should that be
classed as a termination of pregnancy if you end the pregnancy at 24 weeks as
opposed to waiting until 40 weeks?[50]
2.45
There are a number of different data gathering methods across the
country. The Perinatal Society of Australia and New Zealand (PSANZ) in
consultation with various States and Territories established the Perinatal
Mortality Classifications with the intention of uniform application. The
following provides an overview of the development of the PSANZ classifications:
In Australia and New Zealand, the different states have
developed or used different classifications, either within hospitals or for
statewide data. In 1996, interested groups, mainly committees responsible for
the review and classification of perinatal deaths in their respective states
and the National Perinatal Statistics Unit, met for the first time in Brisbane,
Queensland, to discuss a classification for national use. Little progress was
made until the Perinatal Society of Australia and New Zealand (PSANZ) annual
conference in 2000 in Brisbane where the Queensland and South Australian
representatives were asked to develop mutually acceptable national
classifications from the ones they used for their states...Their collaboration
resulted in the development, with colleagues in other Australian states and New
Zealand, of the Australian and New Zealand Antecedent Classification of
Perinatal Morality (ANZACPM) based on obstetric antecedent factors, and the
Australian and New Zealand Neonatal Death Classification (ANZNDC), based on
neonatal causes. With the establishment of a Perinatal Mortality Classification
Special Interest Group (SIG) within PSANZ...it was agreed in 2003 that the
classifications would be renamed PSANZ-PDC (Perinatal Death Classification) and
PSANZ-NDC (Neonatal Death Classification).[51]
2.46
In its most recent Australia's mothers and babies report, the Australian
Institute of Health and Welfare National Perinatal Statistics Unit (NPSU) noted
the following in relation to the application of the PSANZ-PDC and PSANZ-NDC
classifications across States and Territories:
Applying these classifications reveals considerable variability
by jurisdiction in the leading cause of perinatal death. This is because this
category includes late terminations undertaken for psychosocial indications,
the majority of which are undertaken in Victoria. There may also be some differences
in the ranking related to jurisdictional differences in applying the
classifications and small numbers in some categories.[52]
2.47
Each year, the NPSU collects information from the States and Territories
to establish the Perinatal National Minimum Data Set (NMDS). In 2008, the NPSU
published a compliance evaluation of data provided by the states and
territories for each year from 2001 to 2005. The NPSU noted in the evaluation
that the NMDS is 'contingent upon a national agreement to collect uniform data and
to supply it as part of the national collection'. The NPSU continued:
This means that data elements should be collected or at least
reported using standard definitions and domain values and reported for all
births within scope. However, there tends to be some variation in the way in
which data is reported among the states and territories.[53]
2.48
The NPSU also commented on data collection for terminations of
pregnancy:
There are inconsistencies among the states and territories in
how terminations of pregnancy are identified in their data collections and some
jurisdictions cannot separately identify those performed for psychosocial
reasons from births.[54]
2.49
Similarly, a November 2008 report on neutral tube defects in Australia
by the NPSU noted problems of perinatal data collections:
Stillbirths in all states and territories include terminations
of pregnancy carried out at 20 weeks gestation or thereafter or resulting in
the delivery of a fetus weighing 400g or more. Some states are able to
distinguish these late terminations of pregnancy from still births, but some
states cannot differentiate them.[55]
Conclusion
2.50
The evidence before the committee points to a lack of data on
terminations performed in Australia. The committee believes that there is an
urgent need to improve the collection and recording of perinatal and neonatal
data generally. The improvement of perinatal and neonatal data collection will
have ramifications for health care policy and practice across Australia as it
will provide improved data to inform government and the medical profession.
2.51
In order for this to be achieved, uniform data from all jurisdictions is
required as well as the use of one classification system across the country. This
would not only improve data for the purposes of analysis and comparison, but
also enable consistency in relation to definitions.
Recommendation 1
2.52
The committee recommends that Australian Health Ministers' Conference
ensure the prompt application of the Perinatal Society of Australia and New
Zealand Perinatal Mortality Classifications across all States and Territories.
2.53
The committee recognises that improvement in data quality and
consistency is essential for a complete national collection. The committee
notes that the NMDS is reliant upon national agreement to provide uniform data as
part of a national collection. It therefore encourages the Australian Health
Ministers' Conference to work with the National Perinatal Data Development
Committee and other key stakeholders to ensure that, across all States and Territories,
comprehensive uniform data is provided to the NMDS.
Recommendation 2
2.54
The committee recommends that Australian Health Ministers' Conference
secure an agreement with all jurisdictions to work towards providing complete and
uniform data to the Perinatal National Minimum Data Set.
The regulatory impact of the disallowance of item 16525
2.55
Whilst the committee was not required under its terms of reference to
make recommendations on the motion of disallowance of item 16525 in Part 3 of
Schedule 1 to the Health Insurance (General Medical Services Table) Regulations
2007, consideration of the terms of reference encompassed the effects of a
disallowance which include that of the regulatory context.
2.56
The committee received evidence from the Department of Health and Ageing
that a disallowance of the item would result in the cessation of payments for
procedures currently within the terms of item 16525.[56]
The introduction of a new and/or modified item would follow the standard
regulatory process. The usual timeframe for standard new regulations is six
months and the department commented:
The recommended time frame to draft new regulations by the
Office of Legislative Drafting and Publishing is eight to 12 weeks. That is the
recommended time frame to draft new regulations. Following that time frame,
those regulations have to be presented to executive council, and the
recommended time frame for that is around four to six weeks. It would also
obviously have to fit into the executive council meeting time frames, and they
meet, as you would know, on a fortnightly basis. So it would really depend on
all of those mechanisms.
As well, we would have to liaise with Medicare Australia as to
how soon they could implement a new item on their system. The time frame for
that also depends on what restrictions are on that item. The more restrictions
on the item, the more potential work for Medicare Australia to implement.[57]
2.57
However, the department did agree that there had been instances where
regulation had been made more quickly.[58]
The department went on to state that a six-month timeframe as opposed to a
shorter timeframe would enable consultation with the medical profession:
The six-month time frame that was quoted initially allows for
what is usual, which is a period of consultation with the medical profession,
usually managed through the AMA and the relevant craft groups. The Medicare
Benefits Schedule is essentially a list of services that the medical profession
advises government are clinically relevant services, and the item descriptors
are generally developed in consultation between the department and the medical
profession so that it reflects the service that is rendered by medical
practitioners.[59]
2.58
The committee sought advice from the department on ways to improve
understanding of the uses of item 16525. The department did not support the
further splitting of the item and noted that this would require a change to the
regulations. As to administrative means, the department stated:
But there are various mechanisms that
could be available, such as working with each state's and territory's births
and deaths registry, or, potentially, splitting the item—though, once again, if
you were to split all items there would be far too many items. Another
mechanism could be that when the procedure is performed that particular report
has to be provided to Medicare Australia. So there are various administrative mechanisms, but they
would require a regulatory change and it depends on what mechanism is the
preferred one as to what the regulatory change would be and how much of a
regulatory change that would be.[60]
2.59
Other options considered include modifying the current item descriptor
to either specify a procedure or prohibit a procedure which, according to the
department, could be achieved either through a rule of interpretation to the
particular item or an amendment to the particular item.[61]
2.60
The Health Insurance (General Medical Services Table) Regulations 2008
were tabled in the Senate on 10 November 2008. The last day for giving notice
of a motion to disallow item 16525 in Part 3 of Schedule 1 to these regulations,
if the currently advised sitting days are followed, would be 23 February 2009.
Retrospective implementation
2.61
If item 16525 were disallowed, there would be a period of some months
during which time no regulations would be applicable for services under the
item and therefore no Medicare benefits could be paid. When questioned about
retrospective implementation of the regulation to cover the gap period, the
department noted:
Retrospective implementation of regulation is allowed under the
Acts Interpretation Act as long as it does not impinge on private bodies. That
means that the only liability is on the Commonwealth. Given that this procedure
is predominantly done in hospital, there are private health insurers who are
required, where the procedure is performed within that setting, to outlay the
private health benefits to their constituents. We would have to be very careful
that we do not impinge a retrospective liability on those private health
insurers.[62]
Potential impact of disallowance on private health insurance
2.62
The impact of a disallowance of item 16525 on private health insurance
was raised by the Department of Health and Ageing. The department stated:
If item 16525 were disallowed private health insurers would not
be obligated to pay benefits to their members for this service. Health insurers
can pay benefits for a wide range of health care services that are not covered
under Medicare but this would be a decision for the individual fund.[63]
2.63
The Australian Health Insurance Association (AHIA) responded that:
Private Health Funds are not obliged to pay benefits for this
service if it is not listed on the Medicare Benefits Schedule.[64]
2.64
The AHIA went on to comment on the level of benefits paid:
According to the Australian Government’s Medicare Benefits
Schedule (November 2007), the fee for Item 16525 is $267.00 and the Medicare
benefit paid is 75% = $200.25. Private Health Funds are required to pay the
difference between the Scheduled Fee and the Medicare Benefit (25%). In
addition, Funds negotiate directly with medical practitioners to determine the
percentage of the gap which is payable. This will vary between Funds.[65]
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