Medicare benefits schedule review - August reports from clinical committees

Closed: 08 September 2017

The MBS Review Taskforce (the Taskforce) has released four new reports for public consultation:

• Report from the Intensive Care and Emergency Medicine Clinical Committee
• Report from the Cardiac Services Clinical Committee
• Report from the Endocrinology Clinical Committee
• First report from the Pathology Clinical Committee on endocrine tests

There are a number of recommendations within these reports that may affect general practice services. A summary of these recommendations, along with accompanying notes from each report’s rationale, are provided below.

We welcome member feedback in relation to these recommendations, to help inform the RACGP’s response to the Taskforce.

Please note there are extensive recommendations made under the Cardiac Services report, which are summarised below.

Intensive care and emergency medicine

Recommendation 2 suggests the use of a consistent item framework for all emergency attendances, regardless of what type of medical provider attends to the patient. This recommendation focuses on improving billing transparency for patients and providers, by ensuring the item billed reflects the nature of the service provided.

The Taskforce have suggested that:

• the gold standard for emergency care is vocational recognition as an Emergency Medicine Specialist by the Australasian College of Emergency Medicine – therefore, higher emergency medicine rebates should be retained for those with this recognition.
• other providers (such as GPs) should be encouraged to gain emergency attendance experience, but because they provide a substantively different skillset, with substantively different level of ED attendance service, they should not attract higher rebates.
• there are no substantive differences between emergency medicine services provided by VRGPs and non‐ VRGPs. Many non‐VRGPs have substantial experience in providing services in the ED context.

Pathology – Endocrine tests

Recommendation 1 seeks clearer guidance on when the TSH (thyroid-stimulating hormone) test for item 66716 is appropriate for doctors to request.

• The Pathology Clinical Committee agrees that TSH should not be used as a screening test in asymptomatic patients, as recommended by the RACGP Choosing Wisely guidelines and international guidelines.

Recommendation 4 seeks the removal of item 66545 (Oral glucose challenge test) from the MBS and the consolidation of items 66542 under 66548 and include use in pregnant women and certain specific patient groups. In support of this recommendation, the Committee has said:

• In pregnancy the glucose challenge test has been superseded by the full glucose tolerance test. This has been recommended by the Australian Diabetes in Pregnancy Society.
• While there are still recommendations by the RACGP that women with a history of gestational diabetes have an OGTT 6–12 weeks postpartum, there is a recognition that a shift to HbA1c might improve adherence with testing.

The Endocrinology Clinical Committee advised:

• Changing the item descriptors to explicitly include the maximum number of tests permitted under rule 25, which is four tests in a 12-month period for item 66551 and six tests for pregnant patients under item 66554. For example, the proposed item descriptor for item 66551 is as follows: ‘Quantitation of glycated haemoglobin performed in the management of pre-existing diabetes; maximum four tests in a 12-month period (Item is subject to rule 25).’

Cardiac services

The Cardiac Services Clinical Committee’s (the Committee) report provides recommendations on the following areas:

• Cardiac imaging
• General
• CAD-related
• Electrocardiography (ECG)
• AECG and electrophysiology
• Cardiac surgery

The majority of the Committee’s report focuses on Cardiac surgery, for which there are no recommendations identified as affecting general practice.

Throughout the other areas, there are a number of matters for review as outlined below.

Cardiac imaging recommendations

Recommendation 3 relates to the gatekeeper for cardiac imaging, recommending EST as an appropriate first line investigation in low risk patients.

• For GPs, Consultant Physicians and Cardiologists, standard EST (rather than stress echo or MPS) should be the first-line investigation for symptomatic adult patients with suspected CAD and an Australian Absolute risk score for cardiovascular event of less than 10 per cent over 5 years, and who have an interpretable ECG and are able to exercise. This should be reflected in the revised MBS descriptors.

Recommendation 4 relates to stress echocardiograph, recommending a restructure of stress echo items into seven new items.

• The Committee recommended that a GP education campaign be undertaken regarding the appropriate use of cardiac imaging modalities and other cardiac investigations.

Recommendation 5 relates to myocardial perfusion scans, recommending the schedule fee for the single rest items should be revised such that the combined fee for the separate rest and stress items is equal to the fee for the combined item.

• Conduct a GP education campaign focused on the appropriate use of cardiac imaging modalities and investigations, including EST, stress echo, MPS, ICA and CTCA.
• The Committee recommended that a GP education campaign be undertaken regarding the appropriate use of cardiac imaging modalities and other cardiac investigations.

General recommendations

Recommendation 10 relates to Heart Teams, recommending that two new services should be added to the MBS for Heart Team case conferences. The Committee:

• recommended creating two new items for Heart Team consultations in order to increase the likelihood that patients receive the most appropriate treatment for their condition.
• recommended that a Heart Team should include a minimum of three providers, and that the items should be claimable by a maximum of six providers including the convenor. The conference should include a GP or non-interventional specialist and, where a decision on revascularisation is required, a cardiac surgeon and interventional cardiologist.
• recommended Heart Team case conferences require a letter or copy of the recommendation to be provided to the patient’s GP if they are not present for the conference.
• agreed that face-to-face attendance is desirable. However, telemedicine is important for rural and remote access, and the Committee therefore recommended permitting telemedicine attendance by GPs or offsite providers who bring specific expertise to the conference.

CAD-related recommendations

Recommendation 14 relates to CT coronary angiography (CTCA), recommending the proposed structure of the CTCA item into the 3 items, including an item for GP access to CTCA.

• The Committee agreed that CTCA is a robust test with a very strong negative predictive value in terms of outcomes. However, the CTCA item with limited GP access 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:
  • many CTCAs ordered by a GP would otherwise have been ordered by a cardiologist;
  • the test can only be ordered following Absolute risk assessment; and
  • the test cannot be repeated in patients in whom the result is positive, or within five years of a negative result. Nonetheless, the Committee acknowledged this risk and recommended that the MSAC reviews these changes prior to implementation.
• If the item is not well defined, there is a risk that poorly informed providers will use the test for screening, or for other low-value indications due to pressure from patients.
• A concern was raised about the potential risk of GP overuse of this item leading to significant volume increases, similar to past experiences noted by the Department with GP access to services such as knee MRI. Ensuring GPs and providers strictly comply with the indications for the test is intended to avoid over-usage of the test.
• The Committee agreed that a targeted GP education program should be implemented. Education for GPs, whether provided by professional bodies or the Department, may improve the effectiveness of GPs as gatekeepers and custodians of health system resources.
• It was also suggested that the ability to refer for the new GP-access CTCA item could be made dependent on the completion of an education module.

Non-invasive CAD investigations

Respondents are asked whether they agree with the diagram relating to non-invasive CAD investigations which may be requested by a GP or other provider.

ECG recommendations

Recommendation 16 relates to ECG trace and report, proposing indications, service requirements, frequency intervals, restrictions, and explanatory notes (where relevant) for 11700 (electrocardiography)

• New explanatory notes to include: “A GP referral to a cardiologist or consultant physician for a standard consultation should not be regarded as a referral for an ECG.”
• The Committee determined that item 11700 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.

The Committee agreed that it is important to continue remunerating GPs for this service.

Background

In April 2015, the Department of Health announced the formation of the Medicare Benefits Schedule (MBS) Review Taskforce as part of the Government’s Healthier Medicare initiative. The 2017-18 Federal Budget allocated funding for the MBS Review Taskforce to continue for another three years until 2020.