Interventional cardiology

Cardiac committee takes scalpel to overblown MBS items


A specialist cardiac clinical committee has red-flagged MBS items that are obsolete, wasteful or dangerous and made sweeping recommendations to tighten up the inappropriate and overuse of other items.

The new proposals include restrictions on GPs ordering expensive services such as functional imaging tests, and a strict limit on surgeons ordering multiple MBS items for single services.

If approved, a revamped MBS would see exercise stress tests (EST) become the gatekeeper for all other cardiac imaging.

In a bid to curb overuse of echos and nuclear tests, ESTs will become the first line test for patients with atypical chest pain who are at low risk of having a heart attack or other serious problem.

According to the Committee, functional imaging has grown by an average of 8.4% each year over the last five years – outnumbering the less expensive standard EST by almost three to one.

Meanwhile stress echo services have grown by 12% each year over the last five years but only 1–3% has led to interventions such as surgery.

Stress echos would be limited to patients who are likely or known to have heart disease with changing symptoms while myocardial perfusion scans would be restricted to situations where a stress echo is not available or not possible.

The recommendation is designed to discourage the tests from being used where there is no evidence of benefit such as in routine check-ups, screening, or patients without symptoms.

The widespread use of ECGs has also come under fire with the committee flagging more than 2.7 million services are claimed every year at a cost of $71 million.

It has recommended that ECGs done on referral from a doctor attract a higher rebate than ECGs done directly by a GP or specialist, however a lower rebate will remain for ECGs performed outside hospitals.

To be eligible for the higher rebate, a formal report and ECG trace would need to be provided to the referring doctor – a system similar to how X-ray and pathology tests are carried out, the Committee added.

The review has also put a spotlight on a number of cardiac surgeries and procedures it said are carried out unnecessarily in many patients.

They called for invasive coronary angiograms to carry a rebate only in a patient who is having a heart attack, before cardiac surgery or when there is evidence of significant heart disease.

Also under the new proposal percutaneous coronary intervention will be paid for each blood vessel treated and only for those arteries where there is evidence of ischaemia – a change from the current system, which pays for each stent inserted.

“This is not a helpful incentive so these changes remove that incentive by making the same fee for whatever number and length of stents are used to treat each vessel. The changes also mean that if a doctor chooses one long stent for their patient instead of two short stents, the MBS rebate doesn’t change.”

The Committee has also moved to restrict doctors claiming multiple items for CABG procedures – a practice it said allows providers to get higher MBS rebates – by restructuring CABG items as complete medical services.

The Committee claims the new structure is ‘clearer and simpler’ with a single item for bypass surgery and provision for some add-on items that make the surgery longer or more difficult.

Among several new additions to the Schedule is the recommendation to include an item number to fund Heart Team case conferences, which would bring together an interventional cardiologist, a cardiac surgeon, a general cardiologist and the patient’s GP if necessary to decide on the best course of treatment for a patient.

The full draft report is available here. Submissions can be made online here until 4 October 2017

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