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Antenatal care item descriptor ‘doesn’t scratch the surface’


Morgan Liotta


17/11/2022 3:17:52 PM

GPs are pushing for an update to the two-word, 30-year-old MBS descriptor to better reflect the level of care that falls under it.

Antenatal care in general practice
MBS item 16500 for antenatal care has not been updated since it was introduced in 1991.

While Medicare is often accused of being overly complex and prescriptive, the two-word descriptor for item number 16500 – ‘Antenatal attendance’ – may be the briefest in the MBS.
 
But given the complex care involved during the antenatal period, some GPs believe the descriptor – and its current Medicare rebate of $42.40 – are inadequate.
 
Dr Michael Rice, a rural GP, senior lecturer at University of Queensland School of Medicine, and Chair of the Rural Doctors Foundation, is concerned.
 
‘The current descriptor “antenatal attendance” might have encapsulated what was expected and available in the early 1990s when I achieved my diploma,’ he told newsGP.
 
‘But it’s the shortest descriptor I can find in the current MBS, and it doesn’t scratch the surface for the current level of complexity in standard practice.’
 
A Department of Health and Aged Care (DoH) spokesperson confirmed to newsGP that MBS item 16500 has not been updated since it was introduced on 1 December 1991.
 
‘The item provides an MBS rebate for the provision of routine antenatal care, and is shared by GPs and specialist obstetricians,’ the spokesperson said.
 
The DoH spokesperson advised that ‘preliminary discussions’ have been had with representatives of the RACGP on the matter of updating the item descriptor.
 
‘We will continue to work with the college to consider their views on the longstanding MBS items for GP antenatal care,’ they said.
 
‘The [Federal] Government is already working on options to support expectant mothers to access appropriate antenatal care and other maternity services.’
 
But Dr Rice says change is needed now as the item descriptor is outdated and falls short of covering the level of care provided during pregnancy.
 
‘Because every pregnant patient’s needs are different, because their histories and expectations are different, we need a flexible set of descriptors,’ he said.
 
‘The fairest approach [to updating item 16500] would be content-based with a nod to the time required.’
 
His suggestions include:

  • straightforward antenatal attendance including where appropriate – brief history, necessary counselling, targeted examination, request or review indicated investigations
  • long antenatal attendance including the above and, where appropriate, complicated counselling and decision support, comprehensive explanation of investigations, planning and referral
  • prolonged antenatal investigation including the above and exhaustive counselling, decision support, extensive investigations, and creation of management plans
  • an additional item for the use of an interpreter and/or liaison with secondary and tertiary providers.
‘Antenatal care is especially complex in early pregnancy,’ Dr Rice said.
 
‘It often begins in a flurry of excitement, with a small amount of time … and a lot of early ground to cover. It may be necessary to confirm the pregnancy, then to establish whether it’s welcome good news or something else entirely, to get a grip on the dates … and perhaps start models of care and baseline investigations.
 
‘We’re now halfway through the pregnancy and the workload hasn’t eased yet … and that’s before we have to deal with any complications.’
 
GP and women’s health expert Dr Magdalena Simonis agrees the level of care often required is not recognised under the item.
 
‘As an item number, 16500 does not take into account the complexity of these longer consultations which antenatal visits often are,’ she told newsGP.
 
‘Pregnancy is a time of joy for many but it’s also a time of intense change … and covering all issues and aspects of [pregnant patients’] wellbeing takes longer.
 
‘We often spend time counselling our patients on how to manage these changes alongside the regular examinations and … standard tests.’
 
Dr Simonis cites the recent example of COVID-19’s impact on antenatal care and the discussions GPs now need to have around the risks to mother and baby from the virus, as another element that has been ‘been added to the list’.
 
‘These and the vaccination discussions called for extended sessions which we do not charge for,’ she said.
 
Earlier this year, the RACGP reiterated calls for higher Medicare rebates and support for longer  antenatal care consultations. With most antenatal consultations extending beyond 20 minutes, patients can still only access a rebate of $42.40, and the college wants GPs to be allowed to bill MBS Level C and D time-based attendance items.
 
Both Dr Simonis and Dr Rice back these calls.
 
‘Rebates should be increased to support patients who choose continuity of care with their family GP so they can access that at comparable cost to state-funded public care,’ Dr Rice said.
 
‘And so that GPs do not risk being penalised for using time-based consultation items – which many are doing because it seems the sensible thing to do.’
 
Dr Simonis points out that providing antenatal care may also involve taking more time with patients with specific care needs which may impact maternal health outcomes, including those experiencing family abuse and violence, people from rural and remote areas, Aboriginal and Torres Strait Islander people, refugees and asylum seekers, and teenagers.
 
‘Tackling inequities in outcomes requires cultural safety, continuity of care, communication, leadership, resources, training, co-designed interventions,’ she said.
 
‘That happens in GP settings as well as antenatal clinics, so 16500 does not provide adequate reimbursement for these.’
 
With antenatal attendance ‘certainly anything but brief’, Dr Rice hopes an appropriate MBS item update will not only better reflect the care GPs provide, but act as an incentive for them to continue offering that care.
 
‘Antenatal care is an enjoyable and rewarding experience,’ he said. ‘Acquire, develop and maintain the skills.’
 
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Dr Deborah May Allen Smith   18/11/2022 9:22:47 AM

I feel this item number may have been neglected due to the push for this care to be carried out preferentially by other practitioners midwives, antenatal clinics etc
There seems to be some kind of denial as to the massive volume of expert antenatal care provided by GPs and especially GPO’s
I agree Michael the complexity of this care is unrecognized and devalued by the current rebate
This is one of those gender biased rebates to with a greater portion likely being carried out by female GPs/GPOS


Dr Ponnuthurai Paransothy   18/11/2022 4:13:34 PM

Law is for people but not the other way round . Time management is impossible during this pandemic and GP shortage era.
GP shortage is going to get worse in future . QUALITY OF CARE IS IMPORTANT THAN THE TIME.TIME BASED PAYMENT DOES NOT WORK.


Dr Peter James Strickland   19/11/2022 11:49:28 AM

Deborah Smith's comments above are quite sexist, and unnecessary. Most of the GP obstetricians I have worked with were male, and also working full-time more often.
MBS items are largely determined by public servants advising Ministers, and other medicos like specialists etc. On all these MBS items rebates , and including general consultations, there is only one thing on government's mind ---saving money! All the GP items are out of date more than 20 years --just look at the rebate for removing any skin lesion that maybe benign or malignant --it still requires the same procedure of lesion clearance and time of surgery often --the rebates for these procedures are pathetic compared to the cost to Medicare if the patient goes to any hospital (public or private). The main job of the RACGP for GPs should be to radically update ALL these MBS rebates for GPs now -- it is the main reason for graduates not wanting to go into GP practice and have a reasonable income to keep them incentivized.


Dr Louisa Ennis   21/11/2022 8:14:36 AM

yep its just ridiculous. Antenatal consults especially early in pregnancy - are some of the most complex consults we have. They are often highly informed people who may present as a couple - who have many decisions to make and quite rightly want to discuss them. Our local public hospitals are not seeing people til 18 weeks gestation or later. So much that happens prior to that. There is a very big risk of people arriving at their first hospital appointment having missed out on appropriate care.
I too get a sense that there is a push by many in the public hospital system to move AN care away from GPs in some areas (particuarly urban) however until public hospitals are doing earlier assessments and offering all the options for early screening it is simply not possible.