Bureaucratic loophole holds up catheter ablations for AF

Thousands of people with atrial fibrillation (AF) are missing out on potentially life saving catheter ablation because of a bureaucratic loophole that prevents health funds from reimbursing privately insured patients.

The $9000 catheter can only be paid for by health funds if it is on the government controlled Prostheses List. But the catheter doesn’t make the cut because it is not implanted or left behind after the procedure.

Because health funds aren’t obligated to pay for the device, privately insured patients join long waiting lists for the procedure in public hospitals.

Cardiologist Dr David O’Donnell, director of electrophysiology at the Austin Hospital in Melbourne, said doctors were increasingly frustrated about the situation.

“Because we can actually put these catheters in, do the procedure and then remove them – because the technology is advancing faster than the government schedules – the catheter is unable to be on the Prostheses List. There is actually nowhere in the health system that allows us to fund disposables at an appropriate cost. As technology changes, hopefully we’re doing more procedures where we are not leaving as much behind so this list needs to change.”

He said the current system forces hospitals to operate at a loss when the procedure is carried out.

“When you operate at a loss that’s not consistent with ongoing access to therapy,” Dr O’Donnell told the limbic.

“We’ve managed to get away with it in many instances because we haven’t been doing as much AF ablation but the procedure is getting better and as we start doing more, patients are going to suffer more if we don’t have access to the catheters.”

The 18-24 month waiting list also means that for many patients, the costly procedure may not work as well as it should.

“There is no doubt that the success of the ablation is better the earlier in the disease process it is performed. The really frustrating component for me is that we know we can do a good job if we get patients early but often, by the time we get to them after 18 months on a waiting list, the AF is more advanced than it was and that makes the procedure harder and the success rates lower.”

Dr O’Donnell said success rates dropped from about 90% with early access to the procedure to 50% with advanced AF.

A new White Paper auspiced by consumer group Hearts 4 Heart provides several recommendations to improve the accessibility of catheter ablation over the next five years.

The report calls for the Federal Government to include catheter ablation in Section C of the Prostheses List and establish Diagnosis Related Group (DRG) coding for the procedure to help increase availability in public hospitals

It has also called for a new MBS item number for GPs to screen for AF, mandatory ECG in age-specific health assessments in general practice, electronic blood pressure machines in pharmacies, and increased medicine checks to improve adherence to anticoagulants.

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