1. Executive summary

The Medicare Benefits Schedule (MBS) Review Taskforce (the Taskforce) is undertaking a program of work that considers how more than 5,700 items on the MBS can be aligned with contemporary clinical evidence and practice in order to improve health outcomes for patients. The Taskforce also seeks to identify any services that may be unnecessary, outdated or potentially unsafe.

The Taskforce is committed to providing recommendations to the Minister for Health that will allow the MBS to deliver on the following key goals:

  • Δ Affordable and universal access.
  • Δ Best‐practice health services.
  • Δ Value for the individual patient.
  • Δ Value for the health system.

The Taskforce has endorsed a methodology whereby the necessary clinical review of MBS items is undertaken by Clinical Committees and Working Groups. The Taskforce has asked the Clinical Committees to undertake the following tasks:

  1. Consider whether any MBS items are obsolete and should be removed from the MBS.
  2. Consider identified priority reviews of selected MBS services.
  3. Develop a program of work to consider the balance of MBS services within its remit and items assigned to the Committee.
  4. Advise the Taskforce on relevant general MBS issues identified by the Committee in the course of its deliberations.

The recommendations from the Clinical Committees will be released for stakeholder consultation. The Clinical Committees will consider feedback from stakeholders and then provide recommendations to the Taskforce in a Review Report. The Taskforce will consider the Review Report from Clinical Committees and stakeholder feedback before making recommendations to the Minister for Health, for consideration by the Government.

The Cardiac Services Clinical Committee (the Committee) was established in April 2016 to make recommendations to the Taskforce regarding MBS items in its area of responsibility, based on rapid evidence review and clinical expertise. The Taskforce asked the Committee to review cardiac‐related items. The Committee convened five Working Groups with specific areas of focus and expertise, incorporating an additional 24 clinicians and two additional consumer representatives.

The Committee was assigned 188 MBS items to review, including procedures, investigations and other services related to cardiology. All recommendations relating to these items are included in this report for consultation. The Committee also provided input on items that will be referred to their primary reviewing Clinical Committee to assist with their recommendations for consultation.

An inclusive set of stakeholders is now engaged in consultation on the recommendations outlined in this report. Following this period of consultation, the recommendations will be finalised and presented to the Taskforce. The Taskforce will consider the report and stakeholder feedback before making recommendations to the Minister for Health for consideration by the Government.

1.1 Key recommendations

The Committee has highlighted its most important recommendations below. Of the 188 items reviewed, 65 were found to require no change and 117 have undergone some level of revision. Six services were considered obsolete, and the relevant items have been recommended for removal from the schedule. The complete recommendations and accompanying rationales for all items can be found in Sections 4 to 9. These recommendations are provisional and may be revised based on feedback received during consultation. Appendix C contains a complete list of items considered by the Committee.

1.1.1 Broad themes

During the Committee’s review, a number of general issues emerged that were relevant to multiple items under consideration. In part, this is because many of the reviewed items are clinically related and interdependent, and many recommendations are constructed as a package of changes to reflect this, and to ensure that MBS items are cohesive and complementary. These issues do not have a dedicated section in the report (instead, they are specifically discussed under the applicable items), but they are highlighted here.

  • ΔThe Committee modified descriptors across the items under review to reduce low‐value care. For example, many investigatory services—such as stress echocardiograms (stress echos)— have been restricted from use in asymptomatic patients or for screening. Clinically appropriate repeat intervals have also been added to prevent inappropriately frequent services, such as routine annual surveillance that does not align with the guidelines. These changes will free up capacity in the health system and prevent patients from receiving low‐value, inconvenient, potentially harmful and costly services.
  • ΔThe Committee identified a significantly higher than expected rate of co‐claiming of specialist consultations with various services. The MBS rules on co‐claiming consultations are being refined by the Principles and Rules Committee, and it is the recommendation of this Committee that these requirements be made more visible to providers to reduce inappropriate co‐claiming.
  • ΔThe Committee noted the need for strong compliance and audit functions to identify and prevent low‐value use or misuse. Although every effort has been made to align the proposed descriptors with contemporary best practice, it is not possible (nor is it desirable) to create descriptors that account for every complexity of clinical medicine. Beyond this, implementation of these recommendations will be complex and presents challenges to providers, patients and the system. Such challenges are unavoidable when significantly modernising a system that is used by thousands of providers and millions of patients across the country. For this reason, the Committee recommends that MBS compliance, the Colleges, and professional and educational organisations work together to support the effective implementation of these recommendations.
  • ΔThe Committee identified the need to support providers in locating previous investigations, in order to avoid repeating them. For this reason, it recommends adding all the reviewed non-surgical items to the Department of Human Services (DHS) MBS items online checker tool. This will allow providers to ensure that a patient is eligible for a service before performing it, thereby reducing low‐value repeat services. However, the Committee noted that this provides minimal assistance in locating previous results if a patient is ineligible for a service. For this reason, the Committee also strongly supports the development of a system that allows clinicians to locate or access past reports of their patients.
  • ΔWhen considering various recommendations, the Committee considered what impacts they may have on several specific groups, such as paediatric patients, patients from regional and remote areas, and patients from disadvantaged backgrounds. In some instances, recommendations were amended to minimise any potential consequences, and specific exceptions may have been granted in rare circumstances, such as for patients with complex congenital heart disease.
1.1.2Section 4 – Cardiac imaging recommendations

Echocardiography

  • ΔThe Committee recommends restructuring the existing echocardiography items into six new items:
    • Item 5511A: Initial complete echocardiogram (echo).
    • Item 5511B: Serial echo for valvular dysfunction.
    • Item 5511C: Serial echo for heart failure or structural heart disease.
    • Item 5511D: Serial echo for complex or rapidly evolving congenital heart disease.
    • Item 5511E: Frequent repetition serial echo for specified indications, with a lower schedule fee to reflect the focused nature of these services.
    • Item 5511F: Repeat echo not covered by items A–E for exceptional circumstances. This should represent a very low proportion of a referrer’s services and should be closely monitored by compliance.
    The descriptors for these items align with best‐practice guidelines and specify intervals between studies to reduce low‐value repeat services. The descriptors also provide greater specificity on the technical requirements of an echo to reduce low‐quality studies.
  • ΔThis recommendation is intended to reduce low‐value use and high growth in service provision, without restricting appropriate use. Echos (excluding stress echos) account for over 900,000 services and over $180 million in annual benefits, with average growth in service volume of 7 per cent per year over the last five years. The Committee noted that twice the number of services per population were performed in New South Wales, Queensland, Victoria and South Australia, compared with other states. It felt that the high annual growth and geographic variability represent significant practice variation, including over‐ and under-servicing—a view supported by the published literature (1).

Gatekeeper to functional imaging

  • ΔThe Committee recommends that for General Practitioners (GPs), Consultant Physicians and Cardiologists, standard exercise stress testing (EST) with a reported Duke Treadmill Score (DTS) (rather than stress echo or myocardial perfusion scan [MPS], collectively referred to as ‘functional imaging’) should be the first‐line investigation for symptomatic patients with suspected coronary artery disease (CAD) who have an Australian Absolute risk score for cardiovascular event over 5 years of less than 10 per cent and an interpretable electrocardiogram (ECG), and are able to exercise.
  • ΔThe Committee agreed on two core principles that are central to this recommendation. Firstly, coronary investigations are best considered from a prognosis‐and‐outcomes perspective, rather than a risk‐of‐anatomical‐disease perspective. This represents a paradigm shift in the literature, moving away from how CAD has previously been considered by many clinicians. Secondly, the population in question are patients with atypical/uncertain symptoms—as defined by the National Institute for Health and Care Excellent (NICE) guidelines (i.e., low or intermediate risk of obstructive CAD)—who are able to exercise and have an interpretable ECG, and who have an Australian Absolute risk score for cardiovascular event over 5 years of less than 10 per cent. The other recommendations described in this report allow GP access to functional imaging or CT coronary angiography (CTCA) for patients who do not fall into this low‐risk category.
  • ΔThe Committee noted that EST is a completely non‐invasive, broadly available and low‐cost technique that performs well in patients with a normal resting ECG whose symptoms suggest a low to intermediate pre‐test probability (PTP) of myocardial ischaemia. The Committee agreed that although stress echo and MPS have superior sensitivity and specificity compared with EST for the anatomical diagnosis of CAD (as determined by invasive coronary angiography [ICA]), outcomes and anatomical diagnosis are not the same thing. The addenda to the European Society of Cardiology (ESC) guidelines state that there is no evidence that the superior “diagnostic” accuracy of stress echo and MPS over EST leads to improved patient outcomes (2), and the only randomised study comparing outcomes between EST and functional studies (in this case, MPS) showed no benefit for MPS over EST (3). Furthermore, two studies have shown that for the typical patient seen in general practice with symptoms suggestive of a low to intermediate probability of obstructive CAD, a negative stress ECG has a strong negative predictive value (in the order of 99 per cent over four years) for adverse cardio‐vascular outcomes such as heart attack or death (4,5). EST is also considerably less expensive than stress echo or MPS.
  • ΔAlthough there are concerns that this change may result in increased health expenditure and inefficiency for some patients (as well as other concerns discussed later in the report), the Committee agreed that, on balance, the recommendation has the potential to considerably improve the value of functional imaging by reducing unnecessary testing in patients with a low probability of CAD and a low risk of adverse outcomes. This recommendation is supported by the available literature (although a limited number of published studies have examined outcomes rather than anatomical disease), as well as the American Heart Association (AHA) and ESC guidelines and the American College of Cardiology/AHA acceptable use criteria (6,7). Although the NICE guidelines recommend against the use of EST as a test for the exclusion of CAD, it was noted that the evidence cited for this relates to anatomical disease (8). CTCA or ICA should be used to exclude anatomical disease, but the Committee agreed that EST with DTS was an appropriate gatekeeper to functional imaging, with the aim of reducing low‐value imaging in patients with an Australian Absolute risk over 5 years of less than 10 per cent and a DTS greater than or equal to five.
  • ΔThe Committee also noted that functional imaging has grown by an average of 8.4 per cent per year over the last five years, and that it now outnumbers the less expensive standard EST by almost three to one. Stress echos are the primary driver of this growth, increasing at a rate of 12 per cent per year. MPS services are growing at less than 1 per cent per year, but they still account for 24 per cent of functional imaging services. GPs are the referrers for 70 per cent of stress echos and 35 per cent of MPS services. Medicare statistics show that stress echos and MPS lead to a revascularisation procedure over the next 18 months in only 2–3 per cent of cases. Furthermore, there is marked variation in the rate of functional imaging per 100,000 population between states (1,9). The Committee agreed that this variation likely includes under‐servicing in some areas and over‐servicing in others and that steps should be taken to reduce this low‐value use.

Functional studies

  • ΔFor many patients who require functional testing for the assessment of ischaemia, MPS and stress echo provide clinically equivalent information. To prevent perverse volume shifts, the recommendations across both groups of items have been largely aligned, and the Committee recommends that these should be considered as a single package of changes.

Stress echocardiography

  • ΔThe Committee recommends updating the stress echo item descriptors to restrict use for lowvalue indications and require providers to be appropriately trained, ensuring that only highquality, high‐value services are provided to patients. This includes splitting the stress echo items into stress echo with limited ‘safety’ baseline echo and stress echo with complete structural echo (with appropriate co‐claiming restrictions applied to the standard echo items).
  • ΔThe recommendations are intended to preserve best practice for patient safety, improve patient experience and reduce low‐value services, freeing up resources such as technicians, equipment and specialists. The Committee noted that stress echos account for over $56 million in benefits annually, and that service volumes have grown at a rate of 12 per cent per year over the last five years. This growth rate is concerning, and the Committee agreed that it goes beyond what could reasonably be attributed to clinical need. Many stress echos are likely to be low value, and MBS data shows that only 2 per cent of patients who have a stress echo subsequently receive a revascularisation procedure over the next 18 months (for MPS, the rate is 3 per cent). Furthermore, 7 per cent of patients receive repeat services in a single year, and 20–45 per cent of patients are receiving annual stress echos—a practice not supported by the evidence in the absence of clinical changes.
  • ΔThe restructuring is also intended to prevent circumvention of co‐claiming restrictions. For example, some patients may be unnecessarily required to attend for services on multiple days: 17 per cent of patients (almost 41,000 per year) received a standard echo within the four weeks prior to their stress echo and a portion of these services are likely to be inappropriate. As a result of these changes, providers will have greater flexibility and clarity regarding the requirements of the stress echo items.
  • ΔThe restructure also enables the creation of complete medical services by combining the EST item with the stress echo items. In light of these changes and the recommended new item structure the Committee recommends the fees for the new items be reviewed with the outcome being at least cost‐neutral to the MBS.

Myocardial perfusion scanning

  • ΔThe Committee recommends restructuring MPS items, which includes creating complete medical services and splitting the items for single‐phase (rest or stress) studies to allow for the inclusion of EST in the stress phase. These changes are intended to modernise the MBS.
  • ΔThe Committee recommends that for suspected CAD in cases where stress echo and MPS provide clinically equivalent information, stress echo should be the preferred option to avoid unnecessary radiation exposure, with exemptions allowing MPS as first line for appropriate patient, modality and access reasons.
  • ΔThe Committee recommends adding an explanatory note to all stress echo and MPS items that encourages (for patients in whom either study would provide equivalent information) consideration of the cost and radiation exposure of an investigation, in addition to access factors, when determining the most appropriate investigation.

Cost comparison of stress echo and MPS

  • ΔDespite analysis suggesting a significant cost difference between MPS and stress echo over 12 months favouring stress echo, the Committee felt that a deeper understanding of the disease burden of each cohort was needed before a definitive cost‐comparison could be completed. The Committee recommends that further research be undertaken outside the MBS Review to understand the cost‐effectiveness of various cardiac investigations and procedures in the Australian context, and that consideration be given to the relative role of these procedures in light of this.
1.1.3 Section 5 – General recommendations
  • ΔThe committee recommends implementing an ongoing review process to maintain the alignment of the MBS with contemporary clinical practice, and reviewing significant recommendations post‐implementation to ensure the intended outcomes are achieved.
  • ΔThe Committee recommends developing a structured request form for cardiac investigations, outlining the minimum information that needs to be provided. This will ensure that requestors consider all relevant information before requesting investigations, and that providers have the information needed to verify that the requirements of the descriptors are met, and that the most appropriate modality is being used, before performing a service (in line with MBS requirements).
  • ΔThe Committee recommends creating two new items for Heart Team consultations in order to increase the likelihood that patients receive the most appropriate treatment for their condition, particularly patients with stable multi‐vessel CAD. These conferences will include a non‐interventionalist, an interventional cardiologist and a cardiac surgeon (at a minimum) where cardiac intervention is considered, and will be required prior to revascularisation in certain circumstances.
  • ΔThe Committee recommends that documentation should be required, generally in the report, for how indication requirements were met for all investigations and procedures with specified indications.
1.1.4 Section 6 – CAD‐related recommendations

Angiography

  • ΔThe Committee recommends ‘rebuilding’ these item numbers to capture two dimensions: indication and complexity. The coronary angiography item numbers have been divided into three broad indications:
    • In acute coronary syndromes (ACS) where strong evidence exists, to support the routine use of angiography to determine the likely need for revascularisation.
    • In suspected or known stable CAD, where the evidence for revascularisation is often less certain.
    • Where the patient is undergoing cardiac surgery and a pre‐operative assessment of coronary status is required.
    Within each indication, there is an item for native arteries and an item for grafts to reflect the increased time and complexity involved. Items for fractional flow reserve (FFR) and right and left heart catheterisation have been retained and updated in line with the principles of the Review.
  • ΔThis recommendation is intended to reduce practice variability and align the MBS with contemporary practice. The Committee agreed that despite relatively clear indications for angiography, substantial variation remains in the provision of coronary angiography across Australia, with New South Wales, the Australian Capital Territory (ACT) and Tasmania performing twice as many angiograms per capita as Queensland and South Australia. It also agreed that although existing item numbers were originally developed to encompass the substantial complexity in coronary angiography provision, the item numbers do not describe the indications for this investigation and are therefore open to differing interpretations and over‐use. (ICA has been growing in Australia at 3 per cent per year over the last five years. In the 2014/15 financial year [FY], 178,958 services were performed and $62 million was claimed in benefits.)

PCI and angioplasty

  • ΔThe Committee recommends dividing the PCI item numbers into three broad indications:
    • ST elevation myocardial infarction (STEMI), within the context of an acute reperfusion strategy (targeting a door‐to‐balloon time of less than 60 minutes), among patients with chest pain presenting within 12 hours.
    • Troponin positive ACS, including STEMIs outside a door‐to‐balloon time of 60 minutes and non STEMI.
    • Stable CAD with evidence of ongoing ischaemia, despite optimal medical management documented on functional testing or FFR. (Note that involvement of the Heart Team in decision‐making is advocated.)
  • ΔThe redrafted items are intended to capture: (i) the clinical complexity of treating patients with acute coronary syndrome (ACS), compared to treating stable coronary artery disease; and the complexity of multi‐territory PCI during the same procedure (compared to the staged procedures).
  • ΔThe recommendation is also intended to reduce practice variability. For example, despite relatively clear indications for PCI—including appropriateness criteria published by numerous international bodies—substantial variation persists across Australia, with New South Wales performing 40 per cent more services per capita than other states, and South Australia and the Northern Territory providing more than 20 per cent fewer services per capita than all other states. Services have been growing at 4 per cent per year, and 28,224 PCI and angioplasty services were provided in FY 2014/15, equating to $9.1 million in benefits.
  • ΔThe proposed PCI items have also been structured to provide complete medical services (including, for example, set‐up shots and ECGs), thereby addressing highly variable co‐claiming patterns. ICA is not included in the service because patients (particularly in rural areas) may have had a diagnostic ICA performed by a different provider. However, it cannot be co‐claimed if a diagnostic service was performed in the last three months, except in the case of a new ACS event.

CT coronary angiography (CTCA)

  • ΔThe Committee recommends splitting the item for CTCA into three items:
    • One structured‐access item for GPs to request CTCA, limited to patients with stable atypical symptoms who are not known to have CAD with an Australian Absolute risk score of cardiovascular event of greater than or equal to 10 per cent over five years.
    • Two specialist‐access items—split into CAD and non‐CAD related indications—with the addition of accepted indications (such as where ICA is unable to delineate a bypass graft).
  • ΔThis recommendation is intended to modify CTCA items to reflect the expanding role of this test in the assessment of acute chest pain and stable CAD. CTCA is a relatively recent addition to the MBS, but it has had an average growth rate of 22 per cent per year over three years, with growth of 12 per cent from FY2013/14 to FY 2014/15. In FY 2014/15, $29 million in benefits were paid for 44,976 services. The Committee agreed that the investigation is coming to the fore as evidence builds of its effectiveness, and that its recommendations for CTCA items should take this into account and be forward‐looking (without over‐reaching).
  • ΔThe Committee agreed that CTCA is a robust test with a very strong negative predictive value in terms of outcomes. However, the new limited‐GP‐access CTCA item carries the risk of considerable uptake (as the Department noted had occurred with GP access to knee MRI). This risk is expected to be mitigated (to some extent) for the following reasons: (i) many CTCAs ordered by a GP would otherwise have been ordered by a cardiologist; (ii) the test can only be ordered following Australian Absolute risk assessment; and (iii) the test cannot be performed for patients with known coronary disease (such as those where the result is positive), or within five years of a negative result. Nonetheless, the Committee acknowledges the risk and recommends that the Medical Services Advisory Committee (MSAC) reviews these changes prior to implementation.
  • ΔThe Committee recommends creating a standardised request form, which includes the preconditions for the request and the information used to calculate the Australian Absolute risk score.
1.1.5 Section 7 – Electrocardiography (ECG) recommendations
  • ΔThe Committee recommends retaining items for ECG trace only, formal report only, and both trace and report, with the following key changes to improve the value of the services:
    • Amend the item for trace and report so that it is a referred service where a formal report is provided
    • Restrict the claiming of ECG traces for patients in hospital, where the costs of obtaining a trace are separately funded.
    • Clarify the requirements of a formal report.
    • Require all traces to be reviewed in a clinically appropriate timeframe and by an appropriately trained provider for patient safety.
  • ΔThe Committee agreed that these changes would not reduce patient access to appropriate ECGs and would improve the clinical value provided by 12‐lead ECGs.
  • ΔThe Committee determined that an item for referred ECG trace and formal report should remain on the MBS in recognition of the access it gives GPs—particularly rural GPs—to specialist review of a trace. Although all doctors should be capable of interpreting ECGs, the Committee acknowledged that GPs (and other clinicians) who are concerned about a trace, or are unable to obtain an adequate trace, should be able to seek additional support.
  • ΔThe Committee agreed that many ECGs are of low value, particularly those performed without a referral. (The financially objective gatekeeping function is not present in non‐referred services.) It also agreed that many providers perform routine/baseline ECGs, screening ECGs or repeat ECGs in the absence of symptoms. These are almost entirely claimed as a trace and report, despite many lacking a formal report or an appropriate clinical indication. For this reason, there was consensus that defining a service for referred ECGs would significantly increase the clinical value of the services provided, and that involving two providers would ensure an element of gatekeeping, thereby enhancing the value of the services. (Appropriate gatekeeping weighs the value of specialist input against the inconvenience to the patient. This function, primarily performed by primary care clinicians, is a cornerstone of the Australian healthcare system.)
  • ΔThis gatekeeping element is intended to address concern about the volume and variability of ECG claims. The Committee noted that more than 2.7 million ECG services are claimed under the MBS every year, at a cost of over $71 million, and that over 98 per cent of these services are claimed as a trace and report. There is also considerable variability in ECG services across the states, with New South Wales and Queensland providing twice as many services as Western Australia and the Northern Territory. People in remote and very remote areas also claim 25–50 per cent fewer services than people in more urban areas. The Committee also voiced concern about the 7 per cent per year growth in service volumes, which is well above population growth of 1–2 per cent per year. The Committee agreed that shifting disease patterns do not account for growth at this rate, and it felt that the substantial and growing investment in a relatively straightforward activity could be better directed to other necessary services.
  • ΔThe Committee recommends that formal ECG traces and reports should be stored and made readily available to other clinicians (with patient consent) in order to provide greater value to the patient and the health system.
  • ΔThe Committee provided greater clarity on the requirements for a formal report, and it recommended that all traces should be reviewed in a clinically appropriate timeframe and by an appropriately trained provider in order to ensure patient safety. It noted that there is always a chance that a life‐threatening abnormality may be detected on the ECG.
  • ΔThe Committee considered the role of the MBS for in‐hospital ECG services, which account for 500,000 services and $15 million in benefits. The Committee agreed that the costs of performing an ECG trace—including nurse time and consumable costs—are already included in the accommodation fee for an admission. It also agreed that the care of an admitted patient by a clinician reasonably includes the review of ECG traces associated with that admission. However, the Committee acknowledged that there may be instances in which a provider requires a second opinion from a specialist on a non‐routine inpatient trace, and sending a trace for a formal report would be appropriate in these circumstances.
1.1.6 Section 8 – AECG and electrophysiology recommendations

Ambulatory ECG (AECG)

  • ΔThe Committee recommends revising the items for AECG monitoring to align with contemporary best practice, with the choice of service linked to the frequency of symptoms under investigation. For example, in patients who experience symptoms very infrequently, a 24‐hour service is unlikely to coincide with those symptoms, and longer‐term monitoring is therefore of greater clinical value. The Committee has not recommended specific indications for each item because there are many high‐value indications for these services.
  • ΔThe Committee recommends permitting the insertion and removal of implanted loop records (ILRs) in an outpatient setting, and reviewing the schedule fee for these services in light of the significant reduction in the time and complexity of the procedures. The Committee agreed that technological advancements mean that it is now possible to safely and quickly insert and remove ILRs in an outpatient setting. This would result in procedures with a much lower cost to the health system and insurers. Such a change could only be implemented with an exception granted by the Prostheses List to allow outpatient insertion.

Cardiac resynchronisation device

  • ΔThe Committee recommends redrafting the items for cardiac resynchronisation devices to simplify the MBS, and removing the requirement for sinus rhythm to align with published evidence and improve patient access to these treatments. This is particularly important in light of reports of patients undergoing cardioversion in order to meet the current descriptor—a practice that is both wasteful and exposes patients to unnecessary risk.
1.1.7 Section 9 – Cardiac surgery recommendations
  • ΔThe Committee recommends restructuring the items for cardiac surgery to create (where possible) complete medical services. Specifically, the items for coronary artery bypass surgery, valvular surgery and aortic surgery have been significantly rebuilt as a schedule of ‘base’ items, incorporating previously co‐claimed items into the new base items (where appropriate) in a cost‐neutral way. Elements of a procedure that may contribute significantly to time or complexity (such as all‐arterial graft use in coronary bypass surgery), or which are performed by only selected providers (such as off pump coronary artery bypass surgery), have been retained as ‘bolt‐on’ items, which are intended to be co‐claimed with the appropriate base procedure.
  • ΔThe development of complete medical services is important, as variation in claiming practices can result in patients receiving very different rebates for the same procedure. This approach has been adopted for recent additions to the MBS and is being used by other surgical committees across the MBS Review.
  • ΔThe Committee noted that cardiothoracic surgical procedures are regularly co‐claimed with items from other areas of the MBS, particularly the vascular and plastics sections. Should the recommended changes to the MBS be implemented, the Committee recommends applying a general rule to the cardiac surgery section of the MBS stating that these items are not to be coclaimed in the same procedure with services outside this section of the MBS. This will prevent providers from claiming other items intended for different procedures, in addition to the ‘complete’ cardiac surgical items.
  • ΔThe Committee noted the recommendation from the Principles and Rules Committee to limit providers to co‐claiming a maximum of three items. The above changes will reduce the number of items claimed per service. However, due to the nature of cardiac surgery, multiple discrete sub‐procedures are often performed in the same procedure, such as a valve replacement and bypass surgery. Even with the proposed items, such a procedure may require more than three items to be claimed. Should this limit be applied, the Committee recommends taking appropriate steps to ensure that it does not have unintended impacts on the provision of cardiac surgery.

1.2 Key consumer impacts

  • ΔThe Committee brought together practitioners with experience in and commitment to the care of people with cardiac conditions to examine how well the descriptions of Medicare items match current clinical practice and meet the needs of Australians. Consumer representatives were on the Committee and every Working Group. The consumer impacts summary (Section 3.4) provides more detail on consumer impacts. There is also a list of all the reviewed items, written in plain English, in Appendix A – Summary for consumers.
  • ΔChanges have been recommended for some items that are no longer up to date. Some items are no longer used, and some should not be used because clinical best practice has changed since they were originally described. These items have been recommended for deletion.
  • ΔThe majority of the work conducted by the Committee focused on clinical issues and the provision of clinical services. As a result, the consumer representative relied frequently upon the advice of the clinicians regarding how consumers would be affected.
  • ΔThe consumer representative used the following framework to assess recommendations:
    • Safety: None of the recommendations negatively affect the safety of cardiac services.
    • Quality: Many of the recommended changes are intended to improve quality, primarily by aligning the reimbursement system with evidence‐based practice.
    • Access: The recommendations do not negatively affect appropriate access. However, some patient groups have been receiving services that they do not need, which can result in either negative health impacts or unnecessary cost. Inappropriate access was restricted where possible.
    • Effectiveness: None of the recommendations reduce the effectiveness of cardiac services. The Committee did recommend that the MSAC consider allowing GPs to order CT scans of heart arteries (at present, only specialists can order these scans), but this is expensive and is not yet supported by strong evidence, so this recommendation might not be approved.
    • Cost‐effectiveness: The recommendations will have a positive effect on cost‐effectiveness because they make it easier to determine which patient groups should have access to specific tests and treatments.
    • Accountability: Many of the changes include wording that facilitates future auditing for quality purposes.
    • Data collection: Data collection for research, monitoring and auditing presents a huge opportunity for a revised MBS, and the recommendations should improve the opportunities to use this data for targeted research in the future.

1.3 Next steps for these recommendations

  • ΔThe Committee’s recommendations will be considered by the Taskforce, along with feedback received during public consultation. The Taskforce will decide if these should be endorsed and recommended to the Government. The Government will then decide which recommendations to implement, and the Department of Health and other relevant agencies will work to implement them. This process may take some time.
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