Reducing negative incentives in the
Medical Benefits Schedule:
Submission on the detailed review of funding for
diagnostic imaging services
Presented to the Department of Health and Ageing
April 2010
Authorised by:
Pat Maher
President
Australian Physiotherapy Association
Level 1, 1175 Toorak Rd
Camberwell VIC 3124
Phone: (03) 9092 0888
Fax:
(03) 9092 0899
www.physiotherapy.asn.au
Executive Summary
Physiotherapists may request R type x-rays that relate to the spine, hip and pelvis and in such cases
patients will receive a full Medicare rebate to the same amount as a GP requested rebate.
R type x-ray items for peripheral joints are not available to the patients of physiotherapists, nor are R
type diagnostic ultrasound items. While NR type x-ray and ultrasound items are available on request
from a physiotherapist, rebates for patients are lower than the R type item. This can result in
physiotherapists referring their patient’s back to the treating GP in order for the GP to request the
appropriate imaging. This results in a circular referral. The sequence of events described as a
circular referral is:




A patient attends the physiotherapist in the first instance due to a musculoskeletal injury, for
example rotator cuff tear (a type of shoulder injury)
Due to acute pain and swelling, an ultrasound is clinically indicated for differential diagnosis
and to exclude certain pathologies
After being presented with the option to either pay the significant additional costs of the
diagnostic ultrasound or obtain a referral from their GP and thereby attract an R type
Medicare rebate the patient chooses to attend the GP for a referral
In addition to referring the patient for an ultrasound, the GP refers the patient to a specialist,
who diagnoses a rotator cuff tear, and refers the patient to back to the original
physiotherapist for ongoing management
The funding mechanisms in place for physiotherapist ordering of peripheral x-rays and diagnostic
ultrasound encourage a wasteful and expensive process. Circular referral unnecessarily delays the
onset of treatment - which could have started prior to the specialist referral. The current funding
arrangements compromise patient care and can mean a more prolonged recovery period than
necessary.
Fee relativities should be changed to reduce or eliminate the incidence of circular referral patterns.
The cost of providing an x-ray or diagnostic ultrasound is not different depending on who refers a
patient to the service, and the Medicare fee differential provides an incentive for physiotherapists to
refer clients to their general practitioner based on financial rather than clinical need.
Equitable Medicare rebates for the patients of physiotherapists (for peripheral as well as spinal x-ray
and diagnostic ultrasound) will deliver the following benefits:

Patients will be able to access the imaging they need in a more timely manner, facilitating
better health outcomes due to more efficient and earlier diagnosis

Treatment plans will be able to be implemented earlier. This will be particularly beneficial
with injuries or conditions which require immediate treatment to prevent further
complications such as rotator cuff tear or tendinitis

Incidents of unnecessary GP and specialist consultations placing additional workload on
medical professionals will be reduced

Medicare rebates for circular referrals will be reduced

Diagnosis will be expedited for many patients, and outcomes will be improved.

By eliminating the ‘de facto’ system where many patients are referred to GPs who then
order the diagnostic imaging requested by physiotherapists, Medicare Australia will be able
to more accurately track the instances of physiotherapists ordering diagnostic x-ray and
ultrasound
Current referral practices are costly on a number of levels. If physiotherapists had the right to refer
for equitably rebatable diagnostic ultrasound, there would be savings in time and expense for
patients, physiotherapists and GPs alike, as well as cost savings to the health system.
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Physiotherapists are first contact practitioners and their patients should not be required to attend a
GP in order to receive a full rebate. Physiotherapists, who are independent, accountable health
professionals should have the same access to the diagnostic imaging required by their practice as
GPs.
As a matter of practicality, patients, physiotherapists and GPs should not be required to
accommodate legislation that places funding barriers on clinically required diagnostic radiology
services. As a matter of efficiency, the system should be altered to save the Australian taxpayer
from excessive duplication and red tape.
Recommendation:
That specific MBS item numbers for physiotherapists ordering peripheral x-rays and diagnostic
ultrasound be established. These items should attract the same rebate as diagnostic imaging
ordered by medical practitioners.
Australian Physiotherapy Association
The Australian Physiotherapy Association (APA) is the peak body representing the interests of
Australian physiotherapists and their patients. The APA is a national organisation with state and
territory branches and specialty subgroups. The APA corporate structure is one of a company limited by
guarantee. The organisation has approximately 12,000 members, some 70 staff and over 300 members
in volunteer positions on committees and working parties. The APA is governed by a Board of Directors
elected by representatives of all stakeholder groups within the Association.
The APA vision is that all Australians will have access to quality physiotherapy, when and where
required, to optimise health and wellbeing. The APA has a Platform and Vision for Physiotherapy 2020
and its current submissions are publicly available via the APA website www.physiotherapy.asn.au.
www.physiotherapy.asn.au
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Submission on the detailed review of funding for
diagnostic imaging services
Background
Physiotherapists are primary health care practitioners with an expansive scope of practice. The
physiotherapy workforce is Australia’s largest contributor to healthcare after nurses and doctors with
close to 21,000 registered physiotherapists around the country. The knowledge and skill set of
physiotherapists and the changing care needs of the population mean that their contribution must
increase to fulfil community needs. Physiotherapists are experts at preventive health and
rehabilitation and have a vital role to play in reducing hospitalisation rates and facilitating early
hospital discharge.
Physiotherapy is a holistic approach to the prevention, diagnosis, and therapeutic management of
disorders of movement or optimisation of function, to enhance the health and welfare of the
community from an individual or population perspective. The practice of physiotherapy
encompasses a diversity of clinical specialties to meet the unique needs of different client groups.
Physiotherapists work in fields such as continence and women’s health; neurology; occupational
health; gerontology; paediatrics; and sports: as well as areas such as in orthopaedic screening
clinics and emergency departments. Physiotherapy services are used in a wide variety of areas such
as hospitals, health organisations, private practices, schools and community, sports and workplace
settings.
The practice of physiotherapy is founded upon a clinical reasoning process and may incorporate the
following activities: the performance of physiotherapy assessments and the treatment of any injury,
disease, or other condition of health, or the prevention or rehabilitation of injury, disease, or other
condition of health, by the use of physical interventions, and/or electrophysical agents, and/or
exercise prescription within a framework of empowerment of the individual/carer or the community
through education.
Physiotherapists use a variety of imaging tests to assist them in diagnosis. Training in interpretation
of diagnostic imaging tests is integrated throughout all entry level physiotherapy curriculums. Each
unit of the syllabus includes the interpretation of imaging tests relevant to the systems under study.
Diagnostic imaging interpretation is also included as part of clinical education. Physiotherapists
graduate with the competence to interpret a variety of diagnostic imaging tests relevant to the
management of their patients.
Current scope of access to MBS x-ray items
Physiotherapists may request the following R type x-rays that relate to the spine, hip and pelvis:
Table 1
57712
Hip joint
57715
Pelvic girdle
58100
Spine – cervical
58103
Spine – thoracic
58106
Spine – lumbo-sacral
58109
Spine – sacro-coccygeal
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58112
Spine – two regions
58120
Spine – Four regions (one service per year)
58121
Spine – Three regions (one service per year)
However physiotherapists are not able to request other R type peripheral x-rays which are routinely
indicated for in clinical practice. These peripheral x-rays are described in table 2.
Table 2
57506
57512
57518
57524
Hand, wrist, forearm, elbow or humerus
Hand and wrist or hand, wrist and forearm or forearm
and elbow or elbow and humerus
Foot, ankle, leg, knee or femur
Foot and ankle, or ankle and leg, or leg and knee, or
knee and femur
57700
Shoulder or scapula
57706
Clavicle
While NR type x-ray items are available on request from a physiotherapist, rebates for patients are
lower than the R type referral. This can result in physiotherapists referring their patient’s back to the
treating GP in order for the GP to request the appropriate x-ray. This results in a circular referral as
described later on in this document.
Current scope of access to MBS diagnostic ultrasound items
Physiotherapists’ patients are not able to access R type MBS items for any type of diagnostic
ultrasound. Differences in rebates for the NR type items are a significant to patients and are shown
table 3:
Table 3
R-type item
number:
NR-type item
number:
Ultrasound
R-type
Benefit 75%
NR-type
Benefit 75%
Variation
55032
55033
Neck
$81.85
$28.40
-$53.45
55044
55045
Pelvis male
$83.50
$28.40
-$55.10
55731
55733
Pelvis female
$73.50
$26.25
-$47.25
55804
55806
Forearm or elbow
$81.85
$28.40
-$53.45
55812
55812
Chest or abdominal wall
$81.85
$28.40
-$53.45
55824
55826
Buttock or thigh
$81.85
$28.40
-$53.45
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55832
55834
Lower leg
$81.85
$28.40
-$53.45
55840
55842
Mid foot or fore foot
$81.85
$28.40
-$53.45
55800
55802
Hand or wrist
$81.85
$28.40
-$53.45
55808
55810
Shoulder or upper arm
$81.85
$28.40
-$53.45
55816
55818
Hip or groin
$81.85
$28.40
-$53.45
55828
55830
Knee
$81.85
$28.40
-$53.45
55836
55838
Ankle or hind foot
$81.85
$28.40
-$53.45
Circular referral
The fee differentials within these imaging modalities often result in a circular referral. The sequence
of events is as follows:




A patient attends the physiotherapist in the first instance due to a musculoskeletal injury, for
example rotator cuff tear (a type of shoulder injury)
Due to acute pain and swelling, an ultrasound is clinically indicated for differential diagnosis
and to exclude certain pathologies
After being presented with the option to either pay the significant additional costs of the
diagnostic ultrasound or obtain a referral from their GP and thereby attract an R type
Medicare rebate the patient chooses to attend the GP for a referral
In addition to referring the patient for an ultrasound, the GP refers the patient to a specialist,
who diagnoses a rotator cuff tear, and refers the patient to back to the original
physiotherapist for ongoing management
This funding mechanism encourages a wasteful and expensive process. Circular referral
unnecessarily delays the onset of treatment - which could have started prior to the specialist referral.
The current funding arrangements compromise patient care and can mean an unnecessarily
prolonged recovery period.
Detailed review of funding for diagnostic imaging services
This section addresses specific points raised in the discussion paper Detailed review of funding for
diagnostic imaging services: discussion paper. It does not address all areas of the paper, only those
areas that are directly relevant to the funding of diagnostic imaging services for the clients of
physiotherapists.
25. What are the common minimum requirements and associated costs to provide high
quality diagnostic imaging services, in terms of workforce, capital infrastructure,
accreditation requirements, consumables, information technology etc and how does
this differ within and between diagnostic imaging modalities:
 What are the elements that contribute to the cost of providing each service?
Circular referral contributes to the costs of providing services. The requirement that a GP order the
ultrasound or x-ray prior to a patient accessing a full Medicare rebate means that many
physiotherapy clients will visit a GP to save themselves unnecessary expense, at significant cost to
the health system, as well as to medical practitioner capacity.
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In order to establish appropriate fee relativities within different diagnostic imaging modalities, it is
important to ensure that all costs are considered. This includes the cost of unnecessary circular
referrals and the health costs of delay in treatment. In the past, the APA surveyed its members to
estimate the cost of circular referrals to the health system. The subsequent report speaks for itself:1
The data collected demonstrates that the designation of limb, shoulder, scapula and clavicle
x-rays as ‘NR’ items costs the Government over three million dollars per annum. This cost
is only partially offset by the savings the Government makes in offering a lower rebate to
patients for ‘NR’ items, around two million dollars. Even taking these savings into account,
the APA has demonstrated that the Government is still losing at least one million dollars per
year.
The survey is nearly 10 years old, was related to the referrals for x-ray only, and did not take costs
associated with circular referrals for diagnostic ultrasound into consideration. It is clear that the costs
will have risen substantially since that time.
The APA does not believe that the financial and health costs of circular referrals have been taken
into consideration in the current R/NR model for the ordering of x-ray’s and diagnostic ultrasound. As
physiotherapists have the clinical and practical training to confidently order imaging for spinal and
peripheral imaging and diagnostic ultrasound, this cost is an unnecessary burden on the health
system.

Do services claimed against a particular MBS item generally involve similar costs, or
are there circumstances where the costs would vary?
Services provided at the request of physiotherapists involve the same cost of service as those
referred to by medical practitioners. Despite this, patients receive a lower rebate for the same
service ordered by a physiotherapist.
The argument used to justify this lower rebate is an expectation that if patients of physiotherapists
were able to access imaging without consulting a GP, physiotherapists would be indiscriminate in
their use of diagnostic imaging, thus exposing patients to higher exposures of radiation. However
evidence shows that the opposite is true. Physiotherapists have been shown to have a higher ‘strike
rate’ than that of junior doctors – that is they are more likely to order clinically necessary imaging.
One study from an orthopaedic outpatient department which ran a physiotherapy screening program
showed that costs were reduced because physiotherapist ‘were less likely to order radiographs and
to refer patients for orthopaedic surgery than were the junior doctors’.2 Another UK study found that
that physiotherapists ordered no MR scans or x-rays without therapeutic value, compared to 21% of
3
imaging ordered by doctors. A third study found that physiotherapists did not refer excessively for
4
investigations.
In 2009 the Department of Health and Ageing moved to restrict the number of three and four region
spinal x-rays (items 58108 and 58115) to one per year. This was based on ‘anecdotal evidence’ that
these items were being utilised for non-diagnostic purposes. Following a request by the APA for
clarification of this evidence, correspondence from the Department of Health and Ageing revealed
that the concerns were around ‘some allied health professionals, in particular chiropractors.’ This
supports the APA’s position that the introduction of full rebates for the ordering of peripheral x-rays
and diagnostic ultrasound by physiotherapists would not increase unnecessary referrals for
diagnostic imaging.

Are there any aspects of current MBS items or rules that could be improved to better
accommodate the specific nature of these services?
Rules around the ordering of peripheral x-rays and diagnostic ultrasound should be changed to allow
the patients of physiotherapists to claim an equivalent MBS benefit to those ordered by medical
practitioners.
The APA contends that there is no evidence that there is any over-ordering of radiology services by
physiotherapists. There is no evidence that changing the current system will result in over-ordering
of peripheral x-rays and diagnostic ultrasound by physiotherapists. In 1994 the Professional
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Services Review board was established as part of the Health portfolio to investigate suspected
cases of over servicing referred by the Health Insurance Commission. The panel, that was in part
set up to examine physiotherapists suspected of having engaged in inappropriate practice in
providing Medicare services, has never met. This is due to the fact that no physiotherapist has ever
had to be investigated for over ordering of diagnostic imaging services.
Physiotherapists refer patients for radiology on clinical indications. As health professionals,
physiotherapists are cognisant of the danger of overexposure to x-rays and do not create
unnecessary risks for patients.
A system where all physiotherapists’ referrals were rebatable would ensure transparency and
improve the capacity of Medicare Australia to track physiotherapists’ referral patterns. The current
system is not transparent, as not all physiotherapists’ referrals to diagnostic imaging occur directly.
For example, if a physiotherapist sent some of their patients to the radiologist directly and others to
GPs to obtain their referrals, Medicare Australia would not be aware that all of these referrals
originated with one practitioner.

Are there factors that are outside the diagnostic imaging provider’s control that affect
the cost of providing different diagnostic imaging services?
In order to establish appropriate fee relativities within diagnostic imaging modalities, it is important to
ensure that all costs are considered. This includes the cost of unnecessary circular referrals and the
health costs of delay in treatment. These are beyond the control of diagnostic imaging providers, but
well within the scope of this review.
28. Where there are identified differences in service requirements and costs between and
within modalities are current fee relativities reflecting this?

How well do current funding arrangements support patient access to diagnostic
imaging services and contribute to improved health outcomes?
Current fee relativities do not support improved health outcomes for patients with musculoskeletal
injuries or conditions being treated by a physiotherapist. Early intervention for musculoskeletal
conditions is well established as best practice for achieving optimal health outcomes. However the
circular referral process inhibits prompt diagnoses and thus the implementation of appropriate
intervention. What this means is that patients are waiting longer for physiotherapy and when taking
into account gap fees for GP consultations, are likely to be paying more out of pocket expenses.
There are issues around timely access to GP and specialist services that compound the problems
and potential for less than optimal health outcomes due to length of wait prior to treatment. While
this problem may be perceived to be a rural and remote problem, but it is also a problem in outer
metropolitan areas, as well as in residential aged care facilities. Recent media reports say that the
average waiting time for a routine GP appointment in Tasmania is now one month, and that the
problem also affects inner metropolitan areas.

Are there any patient groups who are not well served by current arrangements? What
options might improve this?
Physiotherapists are primary contact practitioners, and require x-rays to rule out fractures and more
sinister pathologies. Their patients should not be left waiting for a doctor’s appointment or incurring
out of pocket expenses because of their choice to see a physiotherapist for their initial assessment.
These patients of physiotherapists who require imaging – particularly those who require diagnostic
ultrasound, are not well serviced by current arrangements. They face delays in waiting for
appointments with GPs, and in some cases, have had to wait for appointments with a specialist, only
to be referred back to their physiotherapist. They may face out of pocket expenses for these
services, and there is also the cost to Medicare of rebates for one or more visits to a medical
practitioner.
29. What issues exist with the current arrangements that are specific to services provided in
rural, regional and outer-metropolitan areas?
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
How do the current arrangements impact on patient access and referrer patterns in
rural, regional and outer-metropolitan areas?
Geographic location has a particular bearing on the availability of both physiotherapists and medical
practitioners. The rural physiotherapist must often take on an expanded role within a community in
order to make up for the lack of other health professionals available within the area. By placing
needless funding impediments to diagnostic imaging such as decreased rebates or need to visit a
GP to order imaging, the barriers that people residing in these areas already face to optimal health
outcomes are significantly increased.
34. The review will need to consider general issues such as:

What alternatives to fee-for-service under Medicare could potentially be appropriate
for some kinds of diagnostic imaging?
The APA supports the continuation of fee for service for diagnostic imaging ordered by a
physiotherapist, and believes that the rebates available to patients for peripheral x-rays and
diagnostic ultrasound should be equivalent to those available to the patients of a GP. The APA may
also support the inclusion of funding for radiological investigations in care packages or bundled
funding, but only in appropriate circumstances.
Conclusion
Fee relativities should be changed to reduce or eliminate the incidence of circular referral patterns.
The cost of providing an x-ray or diagnostic ultrasound is not different depending on who refers a
patient to the service, and the Medicare fee differential provides an incentive for physiotherapists to
refer clients to their general practitioner based on financial rather than clinical need.
Equitable Medicare rebates for the patients of physiotherapists (for peripheral as well as spinal x-ray
and diagnostic ultrasound) will deliver the following benefits:

Patients will be able to access the imaging they need in a more timely manner, facilitating
better health outcomes due to more efficient and earlier diagnosis

Treatment plans will be able to be implemented earlier. This will be particularly beneficial
with injuries or conditions which require immediate treatment to prevent further
complications such as rotator cuff tear or tendinitis

Incidents of unnecessary general practice and specialist consultations placing additional
workload on medical professionals will be reduced

Medicare rebates for circular referrals will be reduced

Diagnosis will be expedited for many patients, and outcomes will be improved.

By eliminating the ‘de facto’ system where many patients are referred to GPs who then
order the diagnostic imaging requested by physiotherapists, Medicare Australia will be able
to more accurately track the instances of physiotherapists ordering diagnostic x-ray and
ultrasound
Current referral practices are costly on a number of levels. If physiotherapists had the right to refer
for equitably rebatable diagnostic ultrasound, there would be savings in time and expense for
patients, physiotherapists and GPs alike, as well as cost savings to the health system.
Physiotherapists are first contact practitioners and their patients should not be required to attend a
GP in order to receive a full rebate. Physiotherapists, who are independent, accountable health
professionals should have the same access to the diagnostic imaging required by their practice as
GPs.
As a matter of practicality, patients, physiotherapists and GPs should not be required to
accommodate legislation that places funding barriers on clinically required diagnostic radiology
www.physiotherapy.asn.au
9 of 10
services. As a matter of efficiency, the system should be altered to save the Australian taxpayer
from excessive duplication and red tape.
Recommendation:
That specific MBS item numbers for physiotherapists ordering peripheral x-rays and diagnostic
ultrasound be established. These items should attract the same rebate as diagnostic imaging
ordered by medical practitioners.
References
1
Australian Physiotherapy Association, (2003). Report on the Diagnostic Imaging Survey. APA,
Melbourne
2
Daker-White G, Carr AJ, Harvey I, Woolhead G, Bannister G, Nelson I, Kammerling M, (1999). A
randomized controlled trial: Shifting boundaries of doctors and physiotherapists in orthopaedic
outpatient departments, J Epidemiol Community Health, 53:643-650
3
Gardiner J, Turner P, (2002). Accuracy of Clinical Diagnosis of Internal Derangement of the Knee
by Extended Scope Physiotherapists and Orthopaedic Doctors: retrospective audit. Physiotherapy
88:3, 153-157
4
Rabey M, Morgans S, Barrett C, (2009). Orthopaedic physiotherapy practitioners: Surgical and
radiological referral rates, Clinical Governance 14:1, 15-19
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