FEATURE: FUNDING FOR EXERCISE-BASED THERAPIES HOW CAN AUSTRALIA’S MEDICARE SYSTEM BE REFORMED SO THAT EXERCISE-BASED THERAPIES Let’s see what the MBS has to offer her in terms of rebates for exercise-based ARE PROPERLY therapies compared to other options to allow her to get exercising and reduce her FUNDED? mortality from breast cancer (Table 1). Table 1 shows that the most generous by mainstream medical specialists. decrease her mortality by 30%; in lay rebate offered (for a 40-minute service) We have to break the perception of terms, “save her life” or “cure her cancer”. is for a discredited procedure for her “real/hard/proper” medicine being drugs But let’s make her a typical real-life condition – a knee arthroscopy and and surgery and that therefore exercise patient and give her a right knee medial chondroplasty. This has been subjected prescription is “soft/easy/basic.” But even meniscal tear with early osteoarthritis to multiple randomised control trials though I think physios and SEM physicians and bilateral tennis elbow pain, so that (RCTs) and has never been able to should be part of a lobbying block, I don’t when her oncologist or GP ask her to significantly beat a comparator treatment see a future of major cross-referral “do some exercise,” she says, “I can’t or placebo surgery. Yet it is by far, the between these two groups that cuts exercise my legs because my right knee most generously funded item by Medicare out the GP. In fact, and I’ll eventually hurts and I can’t do anything with my (remembering that the surgeon also has work my argument towards this, arms because my elbows hurt.” We’ll also the benefit that the hospital funding is GPs may actually be the key health put her on a Health Care Card and having paid separately so rent does not need to practitioner to drive the change of her breast cancer treated in the Public be paid out of the MBS rebate as it does exercise-based practitioners being Hospital System because she struggles for the consultation items). Although the taken seriously by the health system. to afford out of pocket expenses. I won’t number of knee arthroscopies have touch on her chemotherapy, radiotherapy dropped in recent years as patients How badly has the MBS been hacked by and breast surgery management, because become more aware of evidence, item the non-exercise based practitioners I don’t know much about how these are 49561 was still claimed 32,429 times who have traditionally had greater pull funded (although I presume good quality in Australia in the most recent financial with the health bureaucrats? Let’s treatment is available in the Public year July 2017 – July 2018. Menisectomy consider a hypothetical patient: ‘Patient Hospitals). I’m keen to discuss how plus chrondroplasty, as a discredited X’ who is a 55-year-old sedentary female a practitioner might get this patient operation, should have lost most of with breast cancer. There is very good to be able to do more exercise, which its funding, but it has been indexed over evidence that successfully implementing we need to remember, is a very important the years even as the RCTs mount up an exercise program in this patient will factor in whether she survives her cancer. showing that it is an ineffective operation. Table 1 – Rebates available for various practitioners to treat Patient X Practitioner MBS Item Best MBS rebate Service Evidence- Best MBS rebate Best 40 Best 20 number for a 40-minute based? for a 20-minute min rebate min rebate – 2018 service in 2018 non-initial service 2008 in 2008 General 743 $151.25 Coordinating multidisciplinary Yes $72.80 $131.35 $63.75 practitioner case conference Chronic care consult based Physiotherapist 10960 $52.95 on exercise & load Yes $52.95 $48.95 $48.95 management Exercise Chronic care consult based physiologist 10953 $52.95 on exercise & load Yes $52.95 $48.95 $48.95 management Anti-vaccine 10964 $52.95 Chronic care consult based No $52.95 $48.95 $48.95 Chiropractor on ??? Orthopaedic 49561 $505.50 Arthroscopic menisectomy/ No $37.15 $467.10 $33.75 surgeon chondroplasty Chronic care consultation Rheumatologist 132 $227.70 including cortisone Yes?/No* $114.00 $207.25 $103.75 injections* All other Physicians 132 $227.70 Chronic care consultation ? $114.00 $207.25 $103.75 (not SEM) Sport & Exercise 104 $73.85 Consultation based on Yes $37.15 $93.80 $63.75 Medicine Physician exercise & load management * According to the 2017 Therapeutic Guidelines: Rheumatology, a rheumatologist should treat both knee osteoarthritis and tennis elbow with multiple cortisone injections. Randomised controlled trials against placebo injections has found that cortisone injections are harmful for both of these conditions when compared to placebo injections. 36 VOLUME 36 • ISSUE 2 2018