Interventional cardiology

Patient safety fears over TAVI remuneration model


A stoush over the best treatment model for a publicly-funded TAVI program appears to be largely resolved, with the item now listed on the MBS and dozens of doctors and hospitals accredited to deliver the procedure.

But cardiothoracic surgeons say questions remain over reimbursement for the procedure to ensure surgeons are involved for patient safety reasons.

Last year, Australian and New Zealand Society of Cardiothoracic Surgeons (ANZSCTS) members threatened to boycott the government’s proposed Medicare-funded transcatheter aortic valve implantation (TAVI) program unless the funding model was changed.

The surgeons wanted a split Medicare item number which paid an interventional cardiologist and a cardiothoracic surgeon to perform the procedure together, arguing that a surgeon needed to be scrubbed and in the room to ensure best patient outcomes.

But the government knocked back the idea, sticking to its original model where a principal operator – either a surgeon or interventional cardiologist – claimed the $1350 subsidy and a second operator could claim a lower fee for assisting.

Meanwhile, the ANZSCTS and the Cardiac Society of Australia and New Zealand (CSANZ) have put aside their differences over the best Medicare model, to co-design a regulatory framework for TAVI.

Joint guidelines for TAVI were developed by the two societies stipulating the procedure must be performed by two experienced consultants –who can be either interventional cardiologists or cardiothoracic surgeons. They formed a committee and developing accreditation guidelines for practitioners and hospitals, a national registry and eligibility criteria for patients.

Under the current Medicare reimbursement model for TAVI, only one operator can claim the primary operator item.

A spokesperson for the Department of Health told the limbic “we fully expect two operators to be involved in TAVI as per the joint guidelines”, which they said was in line with other Medicare-funded procedures

Since November 2017, about 50 doctors and 37 hospitals have become accredited to deliver the TAVI procedure previously only available at a handful of public and private hospitals, and this figure predicted to grow.

But while the two societies may be no longer at loggerheads over the right MBS model, surgeons remain unhappy with the Department of Health’s decision to fund only one principal operator when guidelines state two must be present, according to Professor Paul Bannon, immediate past president of ANZSCTS.

“They are expecting us to work it out. And I still have great problems with that,” he told the limbic.

There are also question marks over how hospitals will meet the guidelines’ specification that TAVI programs are surgically supported, meaning a surgeon is either at the table or “immediately available and able perform their craft” he said.

“But they need to understand that for a surgeon in a private setting to be immediately available they need to have access to a theatre and they need to be funded.”

Professor Bannon said the MBS item’s design leaves the door open for the assistant role to be filled by someone who is not an experienced surgeon or cardiologist.

“To us that’s a great concern. But we hope people will follow the guidelines we have written and will understand that second operator needs to be an experienced one and TAVI accredited.”

Professor Bannon said he was happy the cardiothoracic surgeons and the CSANZ had worked together to deal with the shortcomings of MBS and MSAC reimbursement decisions, even if the outcome was unsatisfactory.

“I don’t think it’s ideal, I think there will be situations where surgeons are pressured into saying they are providing support when they are not physically able to and I worry that there will be a death,  … I think they may not always understand the complexity of surgical support.”

Professor Darren Walters, director of cardiology at the Prince Charles Hospital in Queensland, predicted the lion’s share of TAVI would be performed by interventional cardiologists working in teams, who take turns to claim the primary operator fee.

However he said lingering concerns by surgeons over funding were legitimate.

“One of the issues is there is no reimbursement for surgeons who are providing that cover. They are getting nothing for standing around and providing support. I think they have a legitimate concern – who is going to cover those costs? Is it the private hospital? Is it the patient? Are you going to say (to the patient) to have a surgeon on stand-by it’s going to cost extra?”

“This is going to have to be resolved over time.”

Professor Walters said that overall, the MBS listing of TAVI would have many positive benefits.

The collaboration process had forged a more mature relationship between the cardiology and surgeons societies, he said.

“It wasn’t an option for those two parts of the profession to continue to be at loggerheads. It needed to be cooler heads prevail and a collaborative approach,” he said.

And of course, a big win for those high-risk patients unable to have surgery for severe aortic stenosis.

“It’s going to be a quantum shift, it’s an absolute game changer for patients and over the next few years we’re going to see more people treated in this way,” he said.

“For older patients it’s an absolute boon.”

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