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Research Request – Bulimia and Anorexia Nervosa: Medicare Benefits Schedule

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Research Request – Bulimia and Anorexia Nervosa:

Medicare Benefits Schedule

AAT Matter: Research the details of a new suite of Medicare Benefits Schedule (MBS) items which were introduced on 01/11/19 to support a model of best practice evidence based care for patients with anorexia nervosa and other eligible patients with eating disorders.

Brief

Date: 24/01/2020

Requester: Shannon [redacted — s47] (Assistant Director - TAB)

Researcher: Craig [redacted — s47] (Tactical Research Advisor – TAB/AAT)

Contents

  • Summary ……………………………………………………………………………………………………………………………….. 2
  • Eating Disorder specific MBS items ………………………………………………………………………………………….. 2
  • Eating Disorder Management Plans (EDP) …………………………………………………………………………………. 2
  • Eligibility ……………………………………………………………………………………………………………………………….. 3
    • Diagnostic Criteria for Eligibility ……………………………………………………………………………………………. 3
  • Approved Evidence Based Treatments ……………………………………………………………………………………… 4
  • Best Practice: Stepped Model of Care ………………………………………………………………………………………. 4
    • The Stepped Model …………………………………………………………………………………………………………….. 5
    • Integrated Team Approach ………………………………………………………………………………………………….. 6
      • Practitioner Training …………………………………………………………………………………………………………… 7
  • Subsidy Fees ………………………………………………………………………………………………………………………….. 7
  • Reference List ………………………………………………………………………………………………………………………… 8

Please note:

The research and literature reviews collated by our TAB Research Team are not to be shared external to the Branch. These are for internal TAB use only and are intended to assist our advisors with their reasonable and necessary decision making.

Delegates have access to a wide variety of comprehensive guidance material. If Delegates require further information on access or planning matters they are to call the TAPS line for advice.

The Research Team are unable to ensure that the information listed below provides an accurate & up-to-date snapshot of these matters.

Research Request – Bulimia and Anorexia Nervosa: Medicare Benefits Schedule Page 1 of 8

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Summary

• On 1 November 2019, 64 new Medicare Benefits Schedule (MBS) item numbers were introduced to support a model of evidence-based care for eligible patients living with an eating disorder.

• The items incorporate a “stepped model” for best practice care.

• Practitioners delivering services under an Eating Disorder Program must have the scope to deliver evidence based treatments which are outlined in the schedule.

Eating Disorder specific MBS items

On 1 November 2019, 64 new Medicare Benefits Schedule (MBS) item numbers were introduced to support a model of evidence-based care for eligible patients living with an eating disorder.

The item numbers are specific for patients with anorexia nervosa, or with severe presentations of bulimia nervosa, binge eating disorder or other specified feed and eating disorders (OSFED) who meet the eligibility criteria.

Eligible patients will be able to receive a Medicare Rebate for:

• The development of an Eating Disorder Plan (EDP) by a medical practitioner (including a General Practitioner, Psychiatrist or Paediatrician);

• General Practitioner reviews of their progress against the treatment plan after every 10 sessions of psychological treatment;

• Specialist review by a Psychiatrist or Paediatrician after 20 sessions of psychological treatment;

• Up to 40 sessions of evidence-based eating disorder psychological treatment (in a 12 month period) with a suitably trained Clinical Psychologist, Registered Psychologist, Accredited Mental Health Social Worker or Accredited Mental Health Occupational Therapist, or with a General Practitioner who meets the General Practice Mental Health Standards Collaboration requirements and is entered on the Register as being eligible to render a Focused Psychological Strategy service; and

• Up to 20 dietetic services with an Accredited Practising Dietitian (in a 12 month period).

Eating Disorder Management Plans (EDP)

An EDP is needed for those eligible to access the eating disorder specific MBS items. This plan is developed by a:

• GP or medical practitioner (items 90250-90257), OR

• Consultant psychiatrist (items 90260-90262) OR

• Consultant paediatrician (items 90261-90263).

Eligibility

A person is eligible for an EDP if:

  1. They have a clinical diagnosis of Anorexia Nervosa according to the DSM-5 (assessed by GP)

    OR

  2. They have a clinical diagnosis of bulimia nervosa, binge eating disorder or other specified feeding or eating disorder (OSFED)

    AND

    a. They have a Global EDE-Q (Eating Disorder Examination Questionnaire) score of 3 or higher b. Their condition is characterised by rapid weight loss, or frequent binge eating or inappropriate compensatory behaviour as manifested by 3 or more occurrences per week. c. They have at least 2 of the following factors to be eligible:

    • Clinically underweight with a body weight less than 85% of expected weight where weight loss is directly as a result of the eating disorder.
• Current or high risk of medical complications due to the eating disorder.
• One or more serious medical or psychological conditions (in addition to your eating disorder) significantly impacting on your health status and function, for example, diabetes, Obsessive Compulsive Disorder (OCD), depression, anxiety disorder, Crohn’s Disease.
• Overnight inpatient admission – that is, a hospital or treatment centre - for an eating disorder in the last 12 months.
• Inadequate treatment response to evidence-based eating disorder treatment over the past six months despite active and consistent participation. 1 2

Diagnostic Criteria for Eligibility

Practitioners should have regard to relevant diagnostic criteria set out in:

1 Butterfly Foundation for Eating Disorders, “Medicare changes: New Eating Disorder Plan (EDP) starts 1 November 2019”, [website], 2020, https://www.thebutterflyfoundation.org.au/understand-eating-disorders/medicare-changes-information-eating-disorders-2, (accessed 23 January 2020) 2 Australian Government, Department of Health, “Medicare Benefits Schedule Book Operating from 1 November 2019”, 2019, https://www.eatingdisorders.org.au/wp-content/uploads/2019/10/201911-MBS.pdf

Approved Evidence Based Treatments

The evidence-based treatments approved for use by practitioners delivering psychological treatment under an EDP are:

  • Family Based Treatment (FBT) for Eating Disorders
  • Adolescent Focused Therapy for Eating Disorders
  • Cognitive Behaviour Therapy for Eating Disorders (CBT-E)
  • Cognitive Behaviour Therapy for Anorexia Nervosa (CBT-AN)
  • Cognitive Behaviour Therapy for Bulimia Nervosa and Binge Eating Disorder (CBT-BN or CBT-BED)
  • Specialist Supportive Clinical Management (SSCM) for Eating Disorders
  • Maudsley Model of Anorexia Treatment in Adults (MANTRA)
  • Interpersonal Therapy (IPT) for Bulimia Nervosa and Binge Eating Disorder
  • Dialectical Behaviour Therapy (DBT) for Bulimia Nervosa and Binge Eating Disorder
  • Focal Psychodynamic Therapy for Eating Disorders

Best Practice: Stepped Model of Care

The eating disorder items in the Medicare Benefits Schedule incorporate a ‘stepped model’ for best practice care that comprise:

  • assessment and treatment planning
  • provision of and/or referral for appropriate evidence based eating disorder specific treatment services by allied mental health professionals and provision of services by dietitians
  • review and ongoing management items to ensure that the patient accesses the appropriate level of intervention.

³ Eating Disorders Victoria, “About the DSM-5”, [website], 2020, https://www.eatingdisorders.org.au/eating-disorders/what-is-an-eating-disorder/classifying-eating-disorders/dsm-5, (accessed 23 January 2020)

⁴ C. Fairburn et al., “Eating Disorder Examination”, Ed. 17, 2014, https://www.credo-oxford.com/pdfs/EDE_17.0D.pdf

⁵ National Eating Disorders Collaboration, “NEW Medicare Benefits Schedule (MBS) Items”, [website], 2019, https://www.nedc.com.au/professional-development/new-medicare-benefits-scheme-mbs, (accessed 23 January 2020)

⁶ Australian Government, Department of Health, “Medicare Benefits Schedule Book Operating from 1 November 2019”, p. 183, 2019, https://www.eatingdisorders.org.au/wp-content/uploads/2019/10/201911-MBS.pdf

The Stepped Model

Below is a summary of the 5 steps within the stepped model: 7

Step Number Step Title and Item Number(s) Summary
Step 1 PLANNING (trigger eating disorders pathway) 90250-90257 and 90260-90263 An eligible patient receives an eating disorder plan (EDP) developed by a medical practitioner in general practice (items 90250-90257), psychiatry (items 90260-90262) or paediatrics (items 90261-90263).
Step 2 COMMENCE INITIAL COURSE OF TREATMENT (psychological & dietetic services) Once an eligible patient has an EDP in place, the 12 month period commences, and the patient is eligible for an initial course of treatment up to 20 dietetic services and 10 eating disorder psychological treatment (EDPT) services. A patient will be eligible for an additional 30 EDPT services in the 12 month period, subject to reviews from medical practitioners to determine appropriate intensity of treatment.
Step 3 CONTINUE ON INITIAL COURSE OF TREATMENT 90264-90269 (managing practitioner review and progress up to 20 EDPT services) It is expected that the managing practitioner will be reviewing the patient on a regular, ongoing and as required basis. However, a patient must have a review of the EDP (90264-90269), to assess the patient’s progress against the EDP or update the EDP, before they can access more than 10 EDPT services. This is known as the ‘first review’. The first review should be provided by the patient’s managing practitioner, where possible.
Step 4 FORMAL SPECIALIST AND PRACTITIONER REVIEW 90266-90269 (continue beyond 20 EDPT services) A patient must have two additional reviews before they can access more than 20 EDPT services. One review (the ‘second review’) must be performed by a medical practitioner in general practice (who is expected to be the managing practitioner), and the other (the ‘third review’) must be performed by a paediatrician (90267 or 90269) or psychiatrist (90266 or 90268). Should both recommend the patient requires more intensive treatment, the patient would be able to access an additional 10 EDPT services in the 12 month period. These reviews are required to determine that the patient

7 Australian Government, Department of Health, “Medicare Benefits Schedule Book Operating from 1 November 2019”, p. 184, 2019, https://www.eatingdisorders.org.au/wp-content/uploads/2019/10/201911-MBS.pdf

Step Title

Step Number Step Title and Item Number(s) Summary
has not responded to treatment at the lower intensity levels.

The patient’s managing practitioner should be provided with a copy of the specialist review. The specialist review by the psychiatrist or paediatrician can occur at any point before 20 EDPT services. The practitioner should refer the patient for specialist review as early in the treatment process as appropriate. If the practitioner is of the opinion that the patient should receive more than 20 EDPT services, the referral should occur at the first practitioner review (after the first course of treatment) if it has not been initiated earlier.

It is expected that the managing practitioner will be reviewing the patient on a regular, ongoing and as required basis. However, a patient must have a review of the EDP (90264-90269), to assess the patient’s progress against the EDP or update the EDP, before they can access the next course of treatment.

Step 5: ACCESS TO MAXIMUM INTENSITY OF TREATMENT 90266-90269 (continue beyond 30 EDPT services)

To access more than 30 EDPT treatment services in the 12 month period, patients are required to have an additional review (the ‘fourth review’) to ensure the highest intensity of treatment is appropriate. Subject to this review, a patient could access the maximum of 40 EDPT treatment services in a 12 month period. The fourth review should be provided by the patient’s managing practitioner, where possible.

Integrated Team Approach

A patient’s family and/or carers should be involved in the treatment planning and discussions where appropriate. The family can be involved in care options throughout the diagnosis and assessment, and are usually the support unit that help to bridge the gap between initial diagnosis and eating disorder specific treatment.

The National Standards for the safe treatment of eating disorders specify a multi-disciplinary treatment approach that provides coordinated psychological, physical, behavioural, nutritional and functional care to address all aspects of eating disorders. People with eating disorders require integrated inter-professional treatment that is able to work within a framework of shared goals, care plans and client and family information. Frequent communication is required between treatment providers to prevent deterioration in physical and mental health (RANZCP Clinical Guidelines: Hay et

Practitioner Training

It is expected that practitioners who are providing services under the Medicare Benefits Schedule items have appropriate training, skills and experience in treatment of patients with eating disorders and meet the national workforce core competencies for the safe and effective identification of and response to eating disorders. 8

Subsidy Fees

The fee subsidies are detailed in the “Medicare Benefits Schedule Book Operating from 1 November 2019

Reference List