Sussan Ley, the second sworn health minister of the Abbott Government, stood before an audience of doctors, health industry professionals and medical researchers on Wednesday and began with a remark on the clash between her pink blazer and the red chairs. By the end of her speech, discord between the government and health sector had melted.
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Ley's plan for Medicare was consultative where her predecessor's was combative, and broad-reaching where his was targeted.
Peter Dutton had put general practice on the defensive by appearing to target them with the GP co-payment, freeze in indexation and cuts to the Medicare rebate. Ley made them part of the solution by assigning a primary care advisory group to investigate new funding models.
Dutton had been overtly looking to slash costs while Ley has said there is no specific savings target.
His policy was announced in the budget and came as a surprise to the sector. Hers was arrived at after seeking wide advice, and was announced among doctors at an event staged by The George Institute for Global Health.
And while his was accused of being ideological, hers appears practical and far-reaching, including a review of each of the more than 5000 items on the Medicare Benefit Schedule, a mammoth task to be completed by the year's end that has found unanimous approval in the sector.
Treasury has calculated expenditure on the MBS at $19.3 billion in 2012-13 and that is expected to grow to $22.6 billion by 2017-18.
But many of the items on the schedule are either unnecessary or harmful and continue to attract a rebate despite the prevailing research.
A Productivity Commission study of the sector released on Thursday found that only 3 per cent of items on the schedule had been formally assessed by the Medical Services Advisory Committee and half had not been subjected to an economic evaluation.
But the outcry from specialities when the government tried to remove items from the schedule tempered the political will to do so.
"Choosing Wisely" is a clinician-led campaign for evidence-based medicine that has been co-ordinated by the independent National Prescribing Service and will launch in Australia next week, when medical specialty groups will provide examples of tests and treatments that are unnecessary or harmful.
It is unclear whether the MBS review taskforce will take advantage of its findings, which are targeted at best practice medicine rather than saving money, but the timing is serendipitous.
"Choosing Wisely" will target tests such as X-rays for lower back pain, which are known to be unnecessary in most cases.
"Most people who walk in and say, 'I need an X-ray for my back,' ... it's very hard to talk them out of that," says Richard King, Monash Health's medical director and chairman of the advisory board to "Choosing Wisely".
"We're about saying it's not good medicine to do that and patients shouldn't have unnecessary X-rays for their own benefit, because of radiation exposure," he says.
There are potentially hundreds of such examples.
The University of Sydney's Adam Elshaug identified 156 potentially unsafe, ineffective or harmful items in a Medical Journal of Australia article published in 2012.
Among them was Vitamin D testing, which had blown out from 90,000 tests billed to Medicare in 2003 to 4.5 million a decade later, despite very little prevalence of severe vitamin D deficiency in Australia. Spending on this test alone had soared from $3 million to $145 million.
The federal government tightened the eligibility for the Vitamin D rebate in November, which is expected to save more than $600 million over five years.
A change to the item numbers for Vitamin B12 and folate testing at the same time is expected to save $268 million over five years.
"Some things on the MBS are simply out of date and are not being used at all," Elshaug says.
"What happens is, we thought something was delivering an effective treatment for patients but new evidence comes along."
He says the review of the MBS will be a win-win for the government, with its potential to save money at the same time as improving healthcare.
In fact, the review could reach much further. Friends of Science in Medicine is using the opportunity to lobby against Medicare paying for alternative therapies that have no basis in science and have the potential to harm.
It is particularly concerned about the overuse of X-rays by chiropractors, acupuncture treatments and chiropractic treatment for babies and children. Medicare spent more than $1 million on acupuncture treatment for children aged under 14 that has been found to be ineffective.
"We're not advocating a ban on acupuncture or non-evidence based therapies, but people should pay the full dollar," says Friends of Science in Medicine vice president Alastair MacLennan.
"Integrated medicine doctors are a worry because they're using integrated medicine to increase their income and pander to the worried well, who like placebos. Some of these treatments delay the diagnosis of things that could be treated."
But it is early days, still. Nobody is under the illusion that, despite the initial favourable response to the review, there won't be further skirmishes ahead for Sussan Ley.
