Dr Hugh Dixson Departments of Nuclear Medicine & Ultrasound and Gastroenterology Bankstown Hospital Sydney, Australia
Fee for service unregulated fees, mostly unlimited services Public hospitals Public patients (70 95%) no charge Most major hospitals are public Public hospitals used by middle class Private hospitals Fee for service Hospital insurance
Single payer Federal Government Funded from tax revenue Fixed rebate for each service In office or (private) hospital Self assessed with audit All residents eligible Grants to States to run public hospitals
Universally supported Restrains medical costs but not services Subsidised medical training $60K for 6 year undergraduate course Zero real interest, non-recourse loan
Family physician (<20 min) $36 Internist (<45 min) $130 Obstetric ultrasound $100 CT abdo/pelvis + contrast $410 Bone scan with SPECT $600 PET Scan $950 MIBI stress/rest $1000
New items added in ad-hoc fashion Items for service not indication Some attempts to encourage technological improvement Echo only paid for colour Doppler machine Additional $100 for SPECT
Source: Medicare Australia
New technology no attempt at assessment New items to reflect new services Based on GE 9800 (1985) 10 scans/day Cost + (capital, running, professional) Extra $100 for contrast
Source: Medicare Australia
Rapid growth in imaging New Technology (MRI, PET) How to control cost?
12,000,000 10,000,000 8,000,000 6,000,000 NM Echo CT US 4,000,000 2,000,000 Source: Medicare Australia 0 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
2,000,000,000 1,800,000,000 1,600,000,000 1,400,000,000 1,200,000,000 1,000,000,000 800,000,000 NM Echo CT US 600,000,000 400,000,000 200,000,000 0 Source: Medicare Australia 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
600% 500% 400% 300% US CT Echo NM 200% 100% 0% Source: Medicare Australia 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
600% 500% 400% 300% US CT Echo NM 200% 100% 0% Source: Medicare Australia 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
1990 no MRI, no PET rebates Overuse of existing technology (CT)
No Medicare Rebate A few machines installed private fees MS Society raised money for MRIs Government relented (mid 1990s)
Rebate for licenced machines ordered or installed at commencement date extra licences based on need Steep increase in orders for MRI machines month before announcement
Limit referrers Limit indications Limit number of scans rebated (not ordered) Obstetrics BMD MRI Risk transferred to imaging practice
Limited indications (sort of) sciatica derangement of shoulder, knee Limited referrers (specialists only) Limited number of scans/year Recently relaxed for <17 year olds replace CTs and bone scans
Source: Medicare Australia
Source: Medicare Australia
Next technology to be considered New process
Medical Services Advisory Committee Established 1998 Advise Federal Government on new and existing items Independent, Scientific, Evidencebased Safety, Efficacy, Cost-effectiveness Transparent, Consistent
Assesses all new procedures Recommends Which technologies to be funded Which indications At what price Advises Minister of Health Political decision
Applicant Specific indication and procedure Expert Advisory Panel Protocol Advisory Subcommittee Assessment Group Evaluation Subcommittee Full MSAC
Source: MSAC
Professional consultants Search literature for appropriate data to assess agreed protocol Sensitivity, specificity of tests Risk/benefit of alternatives Safety Cost
1 August 1999 MSAC to review PET 17 November 1999: there is insufficient evidence at this time from which to draw definitive conclusions about the clinical effectiveness and costeffectiveness of (FDG) PET MSAC recommended interim funding with data collection
2002 Federal govt funded 8 PET cameras Tendered for lowest capital cost Broad range of PET funded (22 items) Neuro (epilepsy, dementia) Cardiac Oncology
March 2003 April 2005 30,368 PET studies performed Demographic data Pre- & post-pet staging Prospective Clinical Protocols (PCPs) Subset of indications Looked at management change & outcome Assumed to generalise
Source: MSAC
A.M. Scott, D.H. Gunawardana, B. Kelley, J.G. Stuckey, A.J. Byrne, J.E. Ramshaw, M.J. Fulham. Positron Emission Tomography Changes Management and Improves Prognostic Stratification in Patients with Recurrent Colorectal Cancer: Results of a Multi-Center Prospective Study. J Nucl Med 49(9):1451-1457, 2008. A.M. Scott, D.H. Gunawardana, D. Bartholomeusz, J.E. Ramshaw, P. Lin. Positron Emission Tomography Changes Management and Improves Prognostic Stratification in Patients with Head and Neck Cancer: Results of a Multi-Center Prospective Study. J Nucl Med 49(9): 1593-1600, 2008. A.M. Scott, D.H. Gunawardana, J. Wong, I. Kirkwood, R.J. Hicks, I. Ho Shon, J.E. Ramshaw, P. Robins. Positron Emission Tomography Changes Management, Improves Prognostic Stratification and is Superior to Gallium Scintigraphy in Patients with Low-Grade Lymphoma: Results of a Multi- Center Prospective Study. Eur J Nucl Med Mol Imag 36(3): 347-353, 2009. B.E. Chaterton, I. Ho Shon, A. Baldey, N. Lenzo, A. Patrikeos, B. Kelly, D. Wong, J.E. Ramshaw, A.M. Scott. Positron Emission Tomography Changes Management and Improves Prognostic Stratification in Patients with Esophageal Cancer: Results of a Multi-Center Prospective Study. Eur J Nucl Med Mol Imag 36(3): 354-361, 2009. M.J. Fulham, J. Carter, A. Beldey, R.J. Hicks, J.E. Ramshaw, M. Gibson. The impact of PET-CT in suspected recurrent ovarian cancer: A prospective multi-centre study as part of the Australian PET Data Collection Project. Gynecol Oncol 112(3):462-8, 2009.
Solitary Pulmonary Nodule (2004) NSC Lung cancer - staging Colorectal cancer - Resid/Recurrant Melanoma - Residual/Recurrant Brain cancer - Residual/Recurrant Ovarian Cancer - Resid/Recurrant Cervical Cancer (Cardio) Esophageal ca - staging Head & Neck cancer Lymphoma Sarcoma Refractory Epilepsy Source: Medicare Australia
Initial staging Response to 1 st line therapy Restaging following confirmed relapse Response to 2 nd line therapy when stem cell transplant is considered Indolent NHL staging only (I or IIa)
Lymphoma surveillance Gastric cancer Esophageal cancer relapse Colorectal staging Any neurology except epilepsy Any cardiology Any other oncology
Public Summary Document: MSAC s assessments of Positron Emission Tomography, 2012
Long process, individual items Typically 6 18 months PET: 2 5 years (10 years) Management change v Outcome Change in technology, costs during assessment period No appeal or update mechanism
Successful CED application to MSAC Applied August 2002 Interim funding May 2004 April 2007 Australian data on safety, effectiveness, cost-effectiveness Unconditional funding November 2007 Int J Technol Assess Health Care. 2009 Jul;25(3):290-6.
18 months for CED approval Single indication obscure gastrointestinal bleeding Single manufacturer Single doctor referred, performed, interpreted and acted Cost effectiveness easy (no competitor)
Double balloon enteroscopy gastroenterologists Coronary CTA (CTCA) cardiologists
CT for SPECT/CT Coronary CTA (CTCA)
Additional $100 fee for CT in SPECT No requirement to report or view CT Diagnostic CT paid as usual reported by radiologist to usual standard All new gamma cameras now have CT NM physicians gain confidence with CT
Source: Medicare Australia
700,000 600,000 500,000 400,000 300,000 CT ACAL NM Studies 200,000 100,000 Source: Medicare Australia 0 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
300,000,000 250,000,000 200,000,000 150,000,000 ACAL NM 100,000,000 50,000,000 Source: Medicare Australia 0 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
3 craft groups share CTCA Cardiology Radiology Nuclear Medicine Certification like SCCT 64-slice SPECT/CT or PET/CT