Developing a disinvestment methodology to review Australian medical services - ‘ophthalmology’ as a test case. Tracy Merlin and Jackie Street

1. Adelaide Health Technology Assessment (AHTA)
Tuesday, June 26, 2012
KEEPING AN ‘EYE’ ON THE PROBLEM:
Developing a disinvestment methodology to
review Australian medical services -
‘ophthalmology’ as a test case
Tracy Merlin and Jackie Street
Life Impact | The University of Adelaide

2. Background
2009-2010:
• Government funding put aside to develop an evidence
based method of managing the Medicare Benefits
Schedule into the future. » MBS Quality Framework
Broad aims:
• Maximise health outcomes - safe, effective, appropriately
used
• Promote efficient use of limited health care resources -
could we get better outcomes using our health
dollar elsewhere?

3. What is the Medicare Benefits Schedule?
• List of services performed primarily by clinicians
that are subsidised by the Government
https://www.chf.org.au/pdfs/chf/What-is-the-MBS.pdf

4. Demonstration Whole-of-Specialty
Review: ophthalmology
Participants
– Adelaide Health Technology Assessment , University of Adelaide –
consultants (responsible for the methodology, identification,
analysis and synthesis of evidence)
– Clinical Working Group – experts in the field of ophthalmology
– Australian Government Department of Health and Ageing
– Consumer representation
– Policy advisors – Medical Services Advisory Committee
Guiding principles
– Evidence based
– Fit for purpose
– Consult key stakeholders

5. Challenge 1:
What is the service?
• MBS descriptors are non-descriptive
Item 42809 RETINA, photocoagulation of,
not being a service associated with photodynamic therapy with verteporfin
WHAT IS IT? WHY IT IS DONE?
• Direct photocoagulation • Retinal detachment
• Perifovial photocolagulation • Diabetic retinopathy
• Macular grid photocoagulation • Choroidal neovascularisation
• Pan-retinal photocolagualtion associated with pathologic myopia
• Continuous wave vs pulsed in micro, nano, • Macular oedema
pico or femto seconds • Age-related macular degeneration
• Argon, YAG, Krypton, YLF, HeNe, Diode • Macular holes
• 350nm to 750nm wavelength • Retinoblastoma
• Laser power levels from 1.5 to 8 Watts
• Optically pumped semiconductor lasers
based on near-infrared-pumped quantum-
well structures

6. Challenge 2: How to evaluate established
services?
• Thin evidence base
– Reimbursed on basis of expert opinion
– Data collection ↓ after technology adoption
– Services often difficult to evaluate in trials ie
consultations , number of follow-up tests/re-treatments
• Lack of comparator
– How to determine comparative effectiveness and safety
when technology/service being reviewed is the
benchmark (rightly or wrongly)?
• Level of entrenchment
– Consumer expectations / preferences
– Stakeholder beliefs / income
– Practice variation / usage

7. Mixed Methods Approach
Guidelines
Concordance
Consumer
Mini-HTA
Perspective
Health
Analysis of Stakeholder
technology
claims data / service
Negotiation
Slide 6
© T. Merlin 2011

8. MBS data analysis
• Pattern of claims consistent with
disease burden and patient
demographics?
• Regional variation in practice?
• Rural vs urban uptake?
• Pattern of services used together?

9. Guideline concordance
• Appropriate clinical practice guidelines identified for each
item
• AGREE appraisal instrument used to rate quality of
guideline.
– Recommendations in those guidelines with high AGREE
rating were given more credence than lower rated
guidelines
• Judgement made whether MBS item descriptor was similar
to recommendations in guideline or whether it did not
reflect evidence-based “best practice”

10. Mini-HTA - optimisation
• Research questions:
– Are there particular populations or settings where the
technology works better than others?
– Are there particular forms of the technology that are
more effective?
• Pre-defined PICO (Population, Intervention, Comparator,
Outcomes) criteria → study eligibility
• Databases: Cochrane Library, Embase/Medline, EconLit.

11. Mini-HTA - optimisation
• Search limits: English language, humans, publ 2005-2011
• Hierarchical literature selection by study design:
– Limit 1 – SRs 
– Limit 2 – controlled clinical trials, RCTs or
meta-analyses 
– Limit 3 - any articles + progressive
retrospective 5 year time periods
• Critical appraisal + narrative synthesis (NHMRC body of
evidence matrix)

12. Ascertainment of consumer preferences
• Qualitative literature search – Embase.com, Scopus
• Analysis of weblogs – identified through Google advanced
domain search. Commercial blogs excluded
• Literature imported into NVivo – thematic coding and analysis
Styes...One became big and bad enough that I was prompted to
see an eye doctor in Lapeer- not knowing he was going to
remove it right there in his office- I was in for a huge surprise-
They froze it- felt like they pulled my eyelid back and tied it to my
ponytail- took the stye out- and left me with a huge bruise and a
patch to cover it. That wont [sic] happen again- I assure you. I
have since had styes- but use over the counter stye medication
which seems to be doing a good job.
(TJ, United States, November 13, 2003).

13. Stakeholder negotiation

14. Review Process
• Protocol for Stage 1 drafted and released for public
consultation – Dec 2010
• Stage 1: Review of 61 Medicare items undertaken using
mixed methods approach
– Tailored approach; not all items received all analyses
– Oct 2011: released for public consultation
– Review recommendations – only 20 / 61 services escaped
change
– March 2012: recommendations provided to MSAC →
MSAC provided advice to Minister
• Stage 2: Review of remaining 23 Medicare items is underway

15. Review recommendations
Services deleted Descriptors modified/restricted
+ Items split to separate out services of different complexity 2011
Slide 14
© T. Merlin
(subsidy implications) or Items merged

16. Policy outcomes of
demonstration review
• 2011-2012 Budget Comprehensive Management
Framework for the MBS:
– Commitment to rolling reviews of the appropriateness,
clinical quality, safety and fee levels of existing MBS
items
– Aim is to maximise health outcomes for patients and
be cost neutral
– Methodology feasible and accepted.
» template for all subsequent whole-of-specialty
reviews

17. • Co-author – Jackie Street (consumer preferences)
• Researchers applying methodology – David Tamblyn, Linda
Mundy, Edith Reddin, Ben Ellery, Vineet Juneja, Sophie
Hennessy, Sophia Scrimgeour
• Feedback from Eliza Hazlett, Amy Lambert, Kelly Cameron,
Alex Hunyor, Guy D’Mellow, Russell Bach, Mark Daniell
• Funded by – Australian Government Department of Health &
Ageing.
tracy.merlin@adelaide.edu.au

18. Reference
Merlin T, Street J, Holton C, Mundy L, Tamblyn D, Ellery B, Juneja V,
Reddin E, Scrimgeour S, Hennessy S (2011) Review of MBS Items for
specific ophthalmology services under the MBS Quality Framework.
Canberra, ACT: Commonwealth of Australia
http://www.msac.gov.au/internet/msac/publishing.nsf/Content/Ophthal
mology_Review
Slide 17
© T. Merlin 2011