Summaryof Key Matters for Consideration by the Applicant

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Final Decision Analytic Protocol to guide the assessment of addiction medicine professional attendance and case conferencing items

June 2012

Table of Contents

MSACandPASC

Purposeofthisdocument

Summaryof key matters for consideration by the applicant

Purpose of application

Background

Currentarrangementsforpublicreimbursement

Intervention

Description

Prerequisites

Co-administeredandassociatedinterventions

Listings proposed for MSAC consideration

ProposedMBSlisting

Clinicalplaceforproposedintervention

Other relevant considerations

Clinical claim

Economic analysis

MSACandPASC

TheMedical ServicesAdvisoryCommittee(MSAC)is anindependentexpertcommitteeappointedby theMinisterforHealth and Ageing(the Minister)tostrengthenthe roleof evidenceinhealthfinancing decisionsinAustralia.MSACadvisestheMinisteron theevidencerelatingtothesafety,effectiveness, andcost-effectivenessof newandexistingmedical technologiesandproceduresandunderwhat circumstances public funding should besupported.

TheProtocol AdvisorySub-Committee(PASC)is astandingsub-committee ofMSAC.Itsprimary objectiveisthedeterminationofprotocolstoguideclinicalandeconomicassessmentsof medical interventionsproposed forpublic funding.

Purposeofthisdocument

Thisdocumentisintendedtoprovideadecisionanalyticprotocolthatwill beusedtoguidethe assessment of an intervention for a particular population of patients.

Protocolsguidingtheassessmentof thehealthinterventionaretypicallydevelopedusingthewidely accepted“PICO”approach.ThePICOapproachinvolves acleararticulationofthefollowingaspectsof the question for public funding the assessment is intended to answer:

Patients –specificationofthecharacteristicsofthepatientsinwhomtheinterventionis to be considered for use

Intervention– specificationof the proposed intervention and how it is delivered

Comparator – specification of the therapy most likely to be replaced by the proposed intervention

Outcomes –specificationofthehealthoutcomesandthehealthcareresourceslikelytobe affected by the introductionof the proposed intervention

However,asdiscussedonp.5below,inthecase ofaddictionmedicineprofessionalattendance, complexplanningandmanagement,andcaseconferencingitems, PASCresolvedthattheadoption of thestandardPICOapproachwasnotappropriateasanassessmentfocussedonsuchanapproach may be so narrow that it would not be informativetoMSAC.

Summaryofkeymattersforconsiderationbythe applicant

ThePASCrequeststhattheapplicantnotethefollowingissuesandaddresstheseissuesinits assessment:

Anassessmentreportissoughtthatpresentstheoverallbodyofevidencethatcouldinforma judgement as to the overall comparative effectiveness, safety and cost-effectiveness of a model of careinvolvingaddiction medicinespecialistscomparedwithalternativemodelsofcare(e.g., managementofpatients bypsychologistsorpsychiatrists; ormanagementbymulti-disciplinary teams).Inadditiontoconsideringmodelsofcarethatdifferbyproviderofmedicalservice, modelsofcarethatinvolvedifferenttypesofservices should also be compared e.g., a model of careinvolvingone-on-oneprofessional attendances(includinglongerconsultationsforcomplex treatment andmanagement) shouldbecompared withamodelofcare thatinvolves both professional attendances andmulti-disciplinarycase-conferencing activitiesandwithamodelof care involvingonly multi-disciplinary teams(e.g., as delivered by psychiatrists).

Onthebasisofthelikelyclaimsofpotentialclinicalequivalenceorsuperiorityforthemodelof care involving addiction medicine specialists compared with alternative models of care, PASC consideredthattheassessmentreportwouldpresent either acost-minimisation or cost- effectiveness analysis, respectively.

Broaderconsiderationsbesidestheimpactonapatient’squality-adjustedsurvivalshouldbe presentedinanapplicationrequesting theavailabilityofadditionaladdictionmedicineMBSitems. Forexample,workforceissuesthatmaybeaddressed(and thedownstream impactonpatient outcomes)byavailabilityofsuchitemscouldbe addressed.Similarly,iftheclaimismadethat provisionof servicesbyaddictionmedicinespecialistswillresult inreducedcostsofcrimeand reducedcostsfor thecriminaljustice system,thentherewillneed tobeaconsideration of these impacts.Impactson familyand society moregenerallycould alsobeincludedinan economic analysis.

Inadditiontoacomparisonofmodelsofcareinvolvingaddictionmedicinespecialistswith alternativemodelsofcarethatare availabletopatientswithaddictions,PASC recommendedthat any assessment presentedto MSACshould addressawider setof claims including:

oWhatevidenceisavailabletodemonstratethatthereisunmetneedforaddictionmedicine specialistsin theprivate sector,in thepublic sectorandoverall(e.g.,howlong does apatient have to wait to see an addiction medicine specialist; what proportion of patients with addictionproblemsinwhomtheservicesofan addictionspecialist areindicated donotaccess such services;hasa shortageof supply beenidentifiedbyother partiessuch as state health departments, etc)?

oWhat evidence is availablein relation tothe consequences of unmet need?

oTowhatextentisthefailuretoaccessaddictionmedicineservicesduetoshortageof addictionmedicinespecialists(i.e.,duetoworkforceshortage)?Towhatextentisthefailure toaccessaddictionmedicineservicesduetoother factors(e.g.,requirementsforareferral, fees)?

oWhat evidence exists to support the claim that increasing reimbursement for services deliveredbyaddictionmedicinespecialistsinthe private sectorresultsin anincreaseinsupply of addictionmedicine specialists?

oWillanincreaseinsupplyofaddictionmedicinespecialistsresultinimprovedaccessto addiction medicine services (i.e., expansion in number of patients accessing addiction medicine services)? Whatevidenceisavailable withrespecttotheeffects ofdifferent approachestofundingfor thevarious modelsof carethat arepossible? Towhatextentwill increasedfundingintheprivatesectorcauseatransferofservicesfromthepublictothe private sector?To whatextent willincreased funding intheprivatesector resultinan overall increase in expenditure ontheseservices?

Purpose of application

Anapplicationrequesting thelisting of fourtime-tieredprofessionalattendance (consultation)and six time-tieredcase conferencingitemsonthe MedicareBenefitsSchedule(MBS)tobeprovidedby addictionmedicinespecialistswasprogressedby theDepartmentofHealthandAgeing(DoHA)in consultationwiththeAustralasianChapterofAddictionMedicine (AChAM).TheAChAMhadinitially requestedaccessto agreater number ofMBS itemsthan DoHA actuallyproposedto PASC(e.g.items forcomplexplanningand management,andforthe purposeofinterviewing familymembers/carers werealsorequested).DoHAconsidered thatthetime-tieredandcaseconferencingitemsasproposed could potentially be used for such purposes. PASC determined that the application should be broadenedtoincludeitemsforcomplextreatment andmanagementplanning,butdidnotdetermine thatfamily/carerinterviewitemsbeincluded. Theapplicantisseeking afundingmodelthatreflects contemporaryaddiction medicine practice.

PASCnotedthattheapproachofatraditionalMSACHTAassessmentwouldseektoderiveestimates ofthecomparativeeffectiveness,safetyandcost-effectivenessofMBSoftheproposedscenario (wherefourtime-tieredprofessionalattendanceitems,twocomplextreatmentandmanagement items,and sixtime-tiered case-conferencingitems wouldbeavailableandclaimed)versus thecurrent scenario (wherespecific MBSprofessionalattendanceandcase-conferencingitems areclaimed)using the standardMSAC PICO plus economicevaluation approach.

PASCconsideredthat suchanapproachwasnot appropriatein thiscasefortworeasons:(i)the approach wastoonarrow topermit assessmentof variousclaimsmadebytheAChAM; and(ii)the approach was likely to be unhelpful in informingMSAC about the value of services provided by addictionmedicinespecialistsbecause data andevidencetoinformsucha specificapproachwere unlikelytobeavailable.Forexample,therewereunlikelytobedatatoanswerthequestionasto whatthehealthoutcomes associated withafunding mechanisminvolving4time-tiered serviceswould becomparedwithafundingmechanismthathadonlyaninitial assessmentitemandareviewitem. AlthoughPASCconsidered that MSACwouldbeunlikelytobe able toansweraquestionastowhether itwouldbepreferabletohavefourtime-tiered professionalattendance(consultation)items,two complextreatmentandmanagementitems,andsixtime-tieredcaseconferencingitemsontheMBS foraddictionmedicinespecialistscomparedwith thecurrentlyavailableanduseditems,PASC consideredthatevidencemaybeavailablethatwouldpermitMSACtoprovideadvicetotheMinister astothecomparativeeffectiveness,safetyandcost-effectivenessof services asdeliveredbyaddiction medicinespecialistsversusalternative modelsofcareforpatientswith addictions (e.g.,deliveryof servicesbypsychologistsorbypsychiatrists)i.e.,evidencewaslikelytobeavailabletopermitMSAC todetermine aresponsetothequestionastowhetherdedicationofresourcestothisspecialtywas worthwhile in a generalsense. PASC agreed thatthefinal DAP should reflect this approach.

Background

Currentarrangementsforpublicreimbursement

There arecurrentlynospecificaddictionmedicineprofessionalattendanceitems,complex treatment and management items,or case conferencing itemson theMBS.

Addictionmedicinewasrecognisedasaspeciality in2009bytheAustralianMedical Council. Subsequently,inthe2010FederalBudget,addiction medicinespecialistsweregrantedaccesstothe GroupA3specialistitemsontheMBS.Asof26 October2011,only eightaddiction medicine practitionershadregisteredwithMedicareAustraliatouseA3specialistattendanceitems.The proposalfor anapplicationstatedthataddictionspecialistshave tendednottoregisterwith Medicare as‘specialists’becauseto dosowouldlimittheirpatients’rebatestoA3specialistitems;instead,they prefertohavetheirpatients seek Medicarereimbursementfortheir servicesintheircapacitiesasGPs, psychiatrists,consultantphysicians,othermedical practitioners,etc,assetoutbelow.TheAChAM advisedthattheA3itemsprovideinadequatereimbursementforclinicallyeffectiveaddiction medicine practice.

Itisreportedthattherearecurrentlyapproximately160addictionmedicinespecialistsinAustralia. TheratioofspecialistsworkinginthepublicversusprivatesettingvariesfromStatetoState.PASC wasadvisedthattheRecognitionofMedicalSpecialitiesAdvisoryCommittee(RoMSAC)reportedthat

75% of surveyed FAChAM were employed in the public sector. The AChAM provided data suggesting thatapproximately25% ofFAChAMprovide atleastsome MBSreimbursed services.However, access toMBSitemsisnotconsistentacrossthemembershipoftheAChAMbecause membershavevarying qualifications. Some have qualifications in addition to addiction medicine e.g. some are also vocationallyregisteredGPs,someareconsultantphysicians, and someareconsultantpsychiatrists. ConsultantphysiciansandpsychiatristsareabletoclaimforservicesunderawiderrangeofMBS items.Otherswhohaveaddictionmedicineas their onlyspecialty arelimitedintheiroptionstoaccess reimbursement of services under the MBS.

Reimbursement for services is currently claimedunder the following groups ofMBS services:

GROUP A1– GENERALPRACTITIONERPROFESSIONAL ATTENDANCES

FiguresprovidedbytheAChAMindicatethat29 (~18%)ofaddictionmedicinespecialistshold Fellowshipof theRoyalAustralianCollegeofGeneral Practitioners oroftheAustralianCollege ofRuralandRemoteMedicine,andafurther18(11%)arevocationallyregisteredGPsand are ableaccess to this group of items.

GROUP A2– OTHER MEDICALPRACTITIONERPROFESSIONAL ATTENDANCES

FiguresprovidedbytheAChAMindicatethat35(~22%)ofaddictionmedicinepractitioners are non-vocationally registered GPs, specialist trainees or other medical practitioners and are ableaccesstothisgroup ofitems.Afurther17(~11%)addictionmedicinespecialistshold FellowshipoftheAustralasianFacultyof Public Health Medicineand couldhaveaccesstothis group of items.

GROUP A3– SPECIALIST PROFESSIONALATTENDANCES

have registered with Medicare Australiatouse GroupA3 specialistattendance items.

GROUP A4– CONSULTANT PHYSICIAN PROFESSIONALATTENDANCES

FiguresprovidedbytheAChAMindicatesthat19(~12%)ofaddictionmedicinespecialists holdFellowshipoftheRoyalAustralasianCollege ofPhysicians(RACP)andareabletoaccess to this groupof items.

GROUP A8– CONSULTANT PSYCHIATRISTPROFESSIONALATTENDANCES

TheChapter hasindicated that44(~27%)ofaddictionmedicine specialistsholdFellowshipof theRoyalAustralianandNewZealand CollegeofPsychiatrists (RANZCP)andwouldhave access to thisgroup of items.

GROUPA13-PUBLICHEALTHPHYSICIANATTENDANCESTOWHICHNOOTHER

ITEM APPLIES

FiguresprovidedbytheAChAMindicatethat17 (~11%)ofaddictionmedicinespecialistshold Fellowshipof theAustralasianFacultyofPublicHealthMedicineandhaveaccesstothisgroup of items.

GROUP A15– CASE CONFERENCING

Specialistsdonothaveaccesstocase conferencing items,butaddictionmedicinespecialists whoareeithervocationallyregisteredornon-vocationallyregisteredGPs(and whohavenot registered withMedicareAustralia asGroupA3 ‘specialists’)haveaccessto existingGroupA15 careplanningandcaseconferencingitems721-758;consultantphysicianshaveaccessto case conferencing items 820-858; and consultant psychiatrists have access to case conferencingitems 861-880.

GROUP A20– GP MENTAL HEALTH TREATMENT

Addictionmedicinespecialistswhoareeither vocationallyregistered ornon-vocationally registeredGPs(numbersasabove)haveaccesstothisgroupof GPMentalHealthtreatment plan itemsand, depending on their further training, to Focussed Psychological Strategy items.

Theapplicationnotedthatthetraditionalstructure ofspecialist professionalattendances(GroupsA3 andA4oftheMBS)provideamoregenerouslyrebateditemforaninitial attendance andaless generouslyrebateditem forafollow-upattendance.Theapplicationsuggestedthatthistraditional structuredoesnotsuitdiscussion-based,cognitivespecialtiessuchasaddictionmedicine,whichrely ontimespentwithapatienttoassessandresolve morecomplexissues.Theapplicationnotedthat, withtheexceptionofMBSitemsforprofessionalattendancesbyspecialistsinpsychiatry,items relatingtoprofessionalattendancesby specialistsaregenerallynotclaimableunderMedicarefor ongoingcare.Itisclaimedthat,becauseaddictive disorders,likepsychiatricdisorders,aretypically complex,chronic,remittingandrelapsing,addiction treatmentrequiresamodelthatallowsongoing careitemsforattendancesthatwillvaryintermsofbothtimeandcomplexity. Hence,it wasinitially proposedthatanapplicationrequestinglisting offourtime-tieredprofessionalattendance (consultation)items andsixtime-tiered caseconferencingitemsbeprovidedontheMBS(foruseby addiction medicinespecialists)besubmittedto MSAC.Asdiscussedin the section titled‘Purpose of application’ onp.5above,PASCnotedthatattemptstoderiveestimatesofthecomparative effectiveness, safety and cost-effectiveness of MBS ofthe proposed scenario (where four time-tiered professional attendance items, two complex treatment and management items, and six case

professionalattendanceandcase-conferencingitemsareclaimed)usingthestandardMSACPICO (pluseconomicevaluationapproach) wouldlikelybefutile,asthereareunlikelytobeanydata availabletoanswerthe questionastowhatthe outcomes wouldbe(wherebothscenariosare compared).

PASCconsideredthatevidencemaybeavailabletopermitMSACtoprovideadvicetotheMinisteras tothecomparativeeffectiveness,safety andcost-effectivenessof servicesasdeliveredbyaddiction medicinespecialistsversusalternative modelsofcareforpatientswith addictions (e.g.,deliveryof servicesbypsychologists orbypsychiatrists)i.e.,MSACcouldprobablydeterminearesponsetothe question as to whether dedicationof resources to this specialty was worthwhile in a generalsense.

Intervention

Description

In relation to the professional attendance items and complex planning and management items, an addictionmedicinespecialistwouldprovideaclinicallyrelevantcombinationof thefollowing: inpatient orambulatorywithdrawal management(from substancesincludingalcohol, opioids, stimulants, cannabisandbenzodiazepine);assessmentandmanagement ofpeople withchronicpainand problematicprescriptionopioiduse;motivational enhancementandpsychologicalinterventions includingbutnotlimited tocognitive based therapy(CBT)-basedinterventionsfor substanceuse disorders and pathological gambling;assessment and management of psychiatric and medical co- morbidities andcomplications ofsubstanceabuse(e.g.,viral hepatitis,HIVinfection,injectingrelated infections).

Addictionspecialistscarry outcomplex biopsychosocialassessments,however aninitialconsultation maybe opportunistic and directedtoimmediateproblems, and afulldetailedassessmentmaybe deferreduntilameasureofstabilityisachieved.As bothinitialandfollow-upconsultationscanbe eithershorterorlonger,dependingonapatient’sneeds,time-tiereditemshavebeenproposedas theywouldallowaddiction medicinespecialiststo billtherelevantitembased ontimespentwitha patient.

Itisclaimed that,with thehighprevalenceofpsychiatricandmedicalco-morbiditiesandfrequently compromised personaland socialfunctioning,multidisciplinarycareofapatientisfrequently needed, withco-ordination of anumberofmedical,psychological, social welfareandlegal services.Addiction specialiststhereforerequested accesstoitemsforcomplex careplanning,caseconferencing, interviewingfamily/carers,aswellasaccesstoalliedmentalhealthservices,particularlythrough directreferralrights to clinicalpsychologists(asdopsychiatristsandpaediatricians).Asstatedearlier, PASCdeterminedthatthe time-tiereditems,complexplanningandmanagementitems, andcase conferencingitemsbeconsidered.Inrelationtothecomplexplanningandmanagementitems,and thecaseconferencingitems,itisproposedtheseitemswould only applytoapatientwho suffersfrom at least onemedical condition that has been (or is likely to be) present forat least 6 months, or that is terminal,andhas complexneeds requiring care froma multidisciplinary team.

The proposed requirement, in relation tocase conferencing items, that the itemcould only beclaimed for a patientwho suffers from at least one medicalcondition that has been (or islikely to be)present for at least 6 months,or that is terminal,and has complex needs requiring care from a multidisciplinary team, is not included inthe proposeditem descriptors. In the case of (consultant physician) case conferencing items, a footnote directs physicians to explanatorynotes that specify thesecriteria. PASC presumed a similarnote would be included foraddiction medicine case conferencingitems.

The case conferencing items would enable a multidisciplinary team to carry out the following:

discuss a patient’s history;

identify a patient’s multidisciplinary careneeds;

identifyoutcomestobeachievedbymembersofthecaseconferenceteamgivingcareand service to thepatient;

identifytasksthatneedtobeundertakentoachievetheseoutcomes,andallocatingthose tasks to members of the case conferenceteam;and

assesswhether previouslyidentified outcomes (if any) have beenachieved.

Prerequisites

REFERRAL

Theproposed itemdescriptors(provided inTable1)indicatethatitisproposed that thepatientmust bereferredfortheinterventionbyamedicalpractitionerotherthanthe addictionmedicine specialist whoistoprovidetheintervention.ThereferralprocesswillbeinaccordancewiththeMBSG6.1

Referralof Patientsto Specialistor Consultant Physician.

Although the requirement for referral from a medical practitioner is included in the descriptors for existingprofessionalattendanceitems,theproposalfortime-tiereditems noted that,forsome marginalisedpatients,theneedtoobtainaGP referralmaycompromise accesstotimelyaddiction specialistadvice.ItisclaimedthatitmayalsobecounterproductivetorequireGPreferralwhen peoplearedirectedtoseeanaddictionmedicinespecialistbythecourts,authoritiessuchasthe Roadsand TrafficAuthorityortreatmentagencies.AsuggestionwasreceivedbyPASCthat considerationshouldbegiventoacceptingwrittenreferralfromsuchagencies.Itwassuggestedthat aprecedentforreferralfromanon-medicalpractitioner toaspecialistdidexist(e.g.,optometristscan referpatientstoophthalmologistdirectly).The PASCdidnotprovideonanycommentonthis suggestion.

TRAINING

ItisproposedthatonlyqualifiedaddictionmedicinespecialistswillbeabletobilltheproposedMBS

items.

Tobeeligibleforregistrationasanaddictionmedicinespecialist,a practitioner musthavecompleted threeyearsoftrainingatthe‘Advanced Training’ levelunderthe ChapterofAddictionMedicine,18 monthsof which must be in accredited drug and alcohol positions. Entry into training is by recognition ofbackgroundandpriorexperienceofapplicants.ThetrainingprogramisoverseenbytheChapter's

EducationCommitteeandsuccessfulgraduatesareawardedFellowshipoftheAustralasianChapterof

Addiction Medicine (FAChAM).

To enterthe trainingprogram, applicantsmustbe registeredmedicalpractitionersinAustraliaorNew ZealandAND EITHER havecompleted firstparttrainingandexaminationsfor theFRACP ORhold Fellowship ofone of theseCollegesor Faculties:

Anaesthetics(FANZCA)

EmergencyMedicine (FACEM)

General Practice (FRACGPand FRNZCGP)

Internal Medicine (FRACP)

PaediatricsChild Health (FRACP)

Pain Medicine(FFPMANZCA)

Psychiatry (FRANZCP)

Public HealthMedicine (FAFPHM)

RehabilitationMedicine (FAFRM)

Australian College of Ruraland RemoteMedicine (FACRRM)

Co-administeredandassociatedinterventions

Asnotedabove,arequirementwillbethatreferral fromamedicalpractitioner(orotherapproved referringauthority)berequiredpriortotheinitiationofacourseof treatmentundertheseitemsbyan addiction medicine specialist.

Noother specificservices arerequired tobe administeredpriorto,withorfollowingtherequested medicalservices.However,follow-upservicesthatmightneedto berenderedfollowingan addiction medicineservicewouldbediscussedduringtheconsultation.Anaddictionmedicinespecialistmay order various pathology tests or diagnostic imaging services during an initial or subsequent

consultationfor assessment of a patient’s substance status or broader healthstatus.

Listings proposed for MSAC consideration

ProposedMBSlisting

The proposed MBS item descriptors areprovided in Table 1.

Table 1:Proposed MBSitemdescriptorfor proposed addiction medicine services

Althoughthe proposeditemdescriptorsdonotspecifythepatient populationtowhomtheitemsmay bedelivered,PASCconsidereditreasonabletoassumethatanaddictionmedicinespecialistwould onlybe attendingtopatients with addictions. However,itnoted thatpatientsrequiringthe servicesof anaddictionmedicinespecialistareaheterogeneousgroup.PASC agreedthatnospecificationofthe patientpopulationtowhomtheitemsmaybedeliveredneedstobeincludedinthe MBSitem descriptors.

Asdiscussed onp.5,PASC resolvedthat thetraditionalMSAC HTA assessmentapproach,whichwould seektoderiveestimatesofthecomparativeeffectiveness,safety andcost-effectivenessofMBSofthe proposedscenario(wherefourtime-tieredprofessional attendanceand sixtime-tieredcase- conferencing itemswould beavailable andclaimed)versusthecurrentscenario(where currently availablespecificMBSprofessional attendance and case-conferencingitems areclaimed),wasnot appropriatefortworeasons:(i)the approachwastoonarrowtopermitassessmentofvariousclaims madeby theAChAM; and (ii)theapproach waslikelytobeunhelpfulininformingMSAC aboutthe valueofservicesprovidedbyaddictionmedicinespecialistsbecausedataandevidencetoinformsuch aspecificapproachwereunlikelytobeavailable.Forexample,therewereunlikelytobedatato

answerthequestionastowhatthehealthoutcomes associatedwithafundingmechanisminvolving4 time-tieredserviceswouldbecompared withafundingmechanism thathadonlyaninitialassessment itemandareviewitem.AlthoughPASCconsideredthatMSACwouldbeunlikelytobeabletoanswer aquestionastowhetheritwouldbepreferabletohavefour time-tieredprofessionalattendance (consultation)andsixtime-tieredcaseconferencingitemsontheMedicareBenefitsSchedule(MBS) foraddictionmedicinespecialistscomparedwith thecurrentlyavailableanduseditems,PASC consideredthatevidencemaybeavailablethatwouldpermitMSACtoprovideadvicetotheMinister astothecomparativeeffectiveness,safetyandcost-effectivenessof services asdeliveredbyaddiction medicinespecialistsversusalternative modelsofcareforpatientswith addictions (e.g.,deliveryof servicesbypsychologistsorbypsychiatrists)i.e.,evidencewaslikelytobeavailabletopermitMSAC todetermine aresponsetothequestionastowhetherdedicationofresourcestothisspecialtywas worthwhile in a generalsense.

Thus,PASCresolvedthatthe“intervention”should bemorebroadlydefinedthanasproposedabove. PASCresolvedthatitwouldbeappropriatefor an assessmentreporttopresentthe overall bodyof evidencethatcouldinformajudgementastothe overallcomparativeeffectiveness,safety andcost- effectivenessof amodel ofcareinvolvingaddiction medicine specialistscomparedwith alternative modelsofcare(e.g.,management of patientsbypsychologists or psychiatrists;ormanagementby multi-disciplinaryteams).Inadditiontoconsidering modelsofcarethatdifferbyproviderofmedical service,models ofcare thatinvolve differenttypesofservicesshouldalsobecomparedinany assessmentreport submittedtoMSACe.g., amodelofcare involvingone-on-oneprofessional attendances couldbecomparedwitha modelofcare thatinvolves bothprofessionalattendancesand multi-disciplinary case-conferencing activities, and with a model of care involving only multi- disciplinary teamsor a model of care involving only group therapysessions.

Duetothevarietyofaddictionsforwhichpatientsmayseektoconsultanaddictionmedicine specialist,andinrecognitionthatthe strengthofevidenceforsometypesofaddictionconditionsmay bebetterthanforothertypesofaddiction,PASC recommended thattheoverallbodyof evidence shouldbepresentedinasystematisedmannersothatevidenceforsimilar addictionsispresented together.For example,evidencerelatingtowithdrawalmanagement(from substancesincluding alcohol,opiates,stimulants,cannabis,benzodiazepines)couldbepresentedseparatelyfrom evidence involvingassessmentandmanagementofpatientswithchronicpainandproblematicopiateuse; whichcould bepresentedseparatelyfromevidencerelatingtopsychologicalinterventionsfor pathological gambling,etc.Itwasimportant,however,that thenumberof classifications remained limitedsothatconclusionscouldbedrawnthatcould be considered applicable to other addiction conditions where the evidence was more limited.

Clinicalplaceforproposedintervention

Patientstreatedbyaddictionmedicine specialistsincludepeople ofall ageswhosufferfromvarious formsofaddiction.Addictionmedicineinvolvestheassessment,diagnosisandtreatmentofavariety ofaddictivebehaviours(e.g. substance[includingopioid,cannabis,alcohol,stimulants, benzodiazepines,nicotine,etc]usedisordersandproblemandpathological gambling).Addiction specialistsarequalifiedtomanagecomplexmedical andpsychosocialcomorbiditiesandconsequences associated with these disorders.

Theproposalforanapplicationindicatedthatthe clinicalplaceforprofessionalattendancebyan addictionmedicinespecialistoccurs at thepointat whichageneralpractitioner(or other approved referring authority) makesa clinical judgement that such an attendance is necessary.

TheAChAMclaimsthatthereisashortageofmedicalservicesfordrugand alcohol problemsinthe community.Asanexample,itcitesunacceptablewaitingperiodsforopioidpharmacotherapiesin manyouter metropolitan andregional areasandnotesthatless than3.5%of allgeneralpractitioners aremethadoneorbuprenorphineprescribers.Itisclaimedthatgeneralpractitionerslacktime,feel toounskilled,orareunwilling,totreat alcoholandotherdrugproblems,particularlythosethatare morecomplexorsevere. Theproposal foranapplication,however,alsoacknowledgedthatsomeGPs areinterestedinthisareaofmedicalpracticeandchoosetokeepup-to-datewithaddictionmedicine

‘best practice’.

Although it is noted that referral from the addiction medicine specialist back to a GP is desirable wherevertheGPiswilling andable to manage ongoingcare,therearecaseswhere,owingtothe severity and/orcomplexity ofproblemsandthepreferenceof the GP,the addictionspecialistwillneed totake substantialresponsibilityfor ongoingcare, orshared care. Thisisparticularlythecasefor patientswith complexneedssuchasacquiredbraininjuriesandco-morbidmentalhealthissueswho aremorelikelytodisplaydifficultbehaviours.Itisanticipatedthat,underareferral-basedmodel whereaddictionmedicine specialiststakereferralsfromGPsofthe morecomplexendof the spectrum ofsubstanceuseproblems,physical andpsychiatricco-morbiditieswillbetherulerather thanthe exception. It is suggested that this resembles thesituationwith patients with psychiatric disorders.

Other relevant considerations

Inconsideringcomments received ontheConsultationDAP,PASCnoted that thefundamentalclaim madebyaddictionmedicinespecialistsisthatthecurrentMBSrebate structureprovidesinsufficient supporttoensureviable privatepracticespecialisinginaddictionmedicine. PASCnoted that the fundamental objective oftheMBSwas nottoprovidearemuneration systemforhealthpractitioners but,instead,theMBSisapublicsubsidysystem intendedtoensurethatAustralianpublichave equitable accessto effective,safe and cost-effectivemedicalservices.However,PASCacknowledged that,ifamodelofcareinvolvingaddictionmedicinespecialists,providedincrementalhealthbenefits atareasonableincrementalcostcomparedtoothermodelsof care,andif therewascurrentlya shortageofaddictionmedicinespecialistssuchthatpatientsrequiringsuchcarewereunableto receiveit,thenexpansion ofthenumberofservicesprovidedbyaddictionmedicinespecialistsinthe private sectorwould be desirable.

Inadditiontoacomparisonofmodels ofcareinvolvingaddictionmedicinespecialistswithalternative modelsofcarethatareavailabletopatientswith addictions,PASC recommendedthatanyassessment presented toMSAC shouldaddressa wider setof claims including:

•Whatevidenceisavailabletodemonstratethatthereisunmetneedforaddictionmedicine specialistsintheprivatesector,inthepublicsector andoverall(e.g.,howlongdoesapatient haveto wait to seean addictionmedicinespecialist; whatproportion ofpatients with addiction problemsinwhomtheservicesofanaddictionspecialistareindicateddonotaccesssuch

services;hasashortage ofsupply beenidentifiedbyother parties suchas state health departments, etc)?

•What evidence is availablein relation tothe consequences of unmet need?

•Towhatextentisthefailuretoaccessaddictionmedicineservicesduetoshortageofaddiction medicinespecialists(i.e.,duetoworkforceshortage)?Towhatextentisthefailuretoaccess addiction medicine services due toother factors (e.g., requirements for a referral, fees)?

•Whatevidenceexiststosupporttheclaimthatincreasingreimbursementforservicesdelivered byaddictionmedicinespecialistsintheprivatesector resultsinanincreaseinsupplyofaddiction medicine specialists?

•Willanincreaseinsupplyofaddictionmedicinespecialistsresultinimprovedaccesstoaddiction medicineservices(i.e.,expansioninnumberof patientsaccessingaddictionmedicineservices)? Whatevidenceis availablewithrespecttothe effectsof differentapproaches tofundingforthe variousmodelsof carethatarepossible?Towhat extentwillincreasedfundingintheprivate sectorcause atransferofservicesfromthepublictotheprivatesector?To whatextent will increasedfundingintheprivate sectorresultin anoverallincreasein expenditureon these services?

Clinical claim

PASCanticipatedthatan application consideringthecomparativeeffectiveness,safetyandcost- effectivenessofamodelofcareinvolvingaddictionmedicinespecialistswithalternativemodelsof care would claim that:

•Patientswhoaremanagedbyamodelofcareinvolvingdeliveryofservicesbyanaddiction medicinespecialistexperienceeitherequivalentor superiorquality-adjustedsurvivalcomparedto patients managed by alternative models of care.

•Appropriatefunding(viathelistingoftheproposeditems)forservicesprovidedbyaddiction

medicinespecialistsislikelytocreate afinancial incentiveforaddictionmedicinespecialiststo provideadditionalservicestopatientswithsubstanceusedisordersinthecommunityandthis will have a positive impactto the community overall.

Economic analysis

Onthebasisofthelikelyclaimsofpotentialclinical equivalenceorsuperiorityforthemodelofcare involvingaddictionmedicinespecialistscomparedwithalternativemodelsofcare,PASCconsidered thattheassessmentreportwouldpresenteitheracost-minimisationorcost-effectivenessanalysis, respectively.

Anappropriateeconomic analysiscould alsoincorporatecostsandbenefitsassociatedwithtransfer of services delivered under the public system to the private system and also costs and benefits associatedwithexpansion ofavailability ofaddiction medicineservicesthroughtheMBS. Estimatesof transfer rates should besupported withevidence.

Broaderconsiderationsbesidestheimpactonapatient’squality-adjustedsurvival shouldbepresented inanapplicationrequestingtheavailabilityofadditionaladdictionmedicineMBSitems.Forexample,

asdiscussedinthepreviousparagraph,workforceissues thatmaybeaddressedbyavailabilityofsuch itemscouldbeaddressed.Similarly,if the claimismadethat provisionof servicesbyaddiction medicinespecialistswillresultinreducedcostsofcrimeandreducedcostsforthecriminaljustice system,thentherewillneedtobeaconsiderationoftheseimpacts.Impactsonfamilyandsociety moregenerallycouldalsobe included inaneconomicanalysis.