News

Controversial ECG changes to be reviewed after six months following severe GP backlash


Doug Hendrie


12/08/2020 5:21:22 PM

Health authorities have rejected widespread calls to postpone changes to Medicare item numbers for ECGs – but opened the door to a review.

Ripped ECG
The move to effectively strip GPs of the ability to bill Medicare for the interpretation of ECGs has been taken as a professional slight.

The changes, which effectively strip GPs of the ability to bill Medicare for the interpretation of electrocardiograms (ECGs), have been slammed by GPs as a threat to the viability of community-based ECG interpretation.
 
GP-led interpretation of ECGs is seen as a way to relieve pressure on hospital emergency departments and long waiting lists for cardiologists.
 
The move has been taken as a professional slight and an indirect cut by many GPs.
 
The changes send a ‘very poor message to general practice’, RACGP Victoria Chair Dr Cameron Loy told newsGP when the changes were introduced.
 
‘This is an essential part of the curriculum, this is part of our skillset, this is something that we utilise, and it looks like the Government has said that we’re no longer able to do that,’ he said.
 
The changes come as a GP academic in the field has questioned why an explicit expert recommendation for an ECG interpretation Medicare Benefits Scheme (MBS) item applicable to GPs was seemingly ignored.
 
Among the 1 August changes are the removal of item number 11700 – which covered 12-lead electrocardiography, tracing and a report – and the introduction of new item numbers such as 11707, which covers GPs but permits tracing only.
 
The controversy over the changes drew Federal Shadow Health Minister Chris Bowen to make an unusual intervention in the process, joining with the RACGP, the Australian Medical Association (AMA) and the Rural Doctors Association in opposing the changes.
 
The RACGP also wrote to Department of Health (DoH) Secretary Professor Brendan Murphy to call for an immediate postponement to the changes due to the college’s ‘significant concerns’.
 
The letter states that the RACGP’s feedback on was disappointingly ‘not considered’. It also points out that reducing support for access to community-based GP-led ECG is unwarranted, as well as poorly timed given the second wave of COVID-19 and concerns over undiagnosed heart disease.  
 
The letter claims the Cardiac Services Clinical Committee (CSCC), which made the recommendations, and the MBS Review Taskforce adopted ‘flawed’ assumptions over geographical variations in use of ECG care, leading to the ‘incorrect assumption’ they represent low value care.
 
‘There is widespread concern among GPs about the impending changes, with general consensus this is another funding cut for primary healthcare, which may not actually reflect the recommendations of the Committee as recently reported in the medical media,’ the letter states.
 
‘Reducing the rebate will reduce patient access to this care in the community, unless GPs and practices increase patient out-of-pocket costs.
 
‘Some practices may no longer offer ECG services, which will require patients to present to other medical specialists and emergency departments.’  
 
Professor Murphy rejected the RACGP’s postponement calls in a letter seen by newsGP, but said he acknowledged the concerns. He also said Federal Health Minister Greg Hunt has ‘agreed to monitor the impact of the ECG changes with a review to be conducted within six months from the date of implementation’.
 
‘It was the view of the CSCC that some GPs may have inadvertently been claiming referred services for ECG trace and report [item 11700],’ Professor Murphy said in his letter. ‘It was the view of the CSCC it would be preferable to clarify the items and give GPs certainty regarding items they can claim.’
 
The RACGP consistently defended the right and ability of GPs to interpret ECGs in submissions to the committee investigating the matter in 2017 and 2018.

Brendan-Murphy-departure-Article.jpg
DoH Secretary Professor Brendan Murphy rejected RACGP call to postpone the changes, but did acknowledge the college’s concerns. (Image: AAP)

Chair of the RACGP Expert Committee – Funding and Health System Reform Dr Michael Wright told newsGP he is ‘very disappointed’ the DoH has pressed ahead with the changes.
 
‘The department has not taken into account the strong opposition we have provided. But we are pleased to see that Professor Murphy as the new Secretary has agreed to a review of this in six months’ time,’ he said.
 
‘We will keep resisting changes to the health system that make high-quality general practice less viable.
 
‘With the MBS review in its final stages, we would urge the DoH to make sure any further changes out of that review are communicated clearly and make sure they don’t further reduce the capacity for practices to provide care at this very difficult time.’
 
Dr Wright said the timing is particularly disappointing, given the changes have been rolled out in the middle of the coronavirus pandemic.
 
‘GPs are skilled in performing and interpreting ECGs. It is dangerous if changes to the MBS discourage GPs from performing high-quality care,’ he said. ‘We want to be providing care in the community where patients need it, not sending people unnecessarily to other providers just so they can get a rebate.’
 
Questions have circled around the decision-making process since the changes were made public, with Minister Hunt defending the move as coming from the MBS Taskforce.
 
‘It’s the highest clinical advice and it was based on safety,’ Minister Hunt told the ABC (as reported in The Guardian).
 
A DoH spokeswoman offered a similar explanation, also citing ‘patient safety’ as a rationale to the ABC.
 
Curiously, the final report of the CSCC clearly recommends the creation of a new MBS item, 11703, which would permit ‘all practitioners’ to claim for the interpretation of ECG results. 
 
This recommendation was not followed, and 11703 was not created. 

In an opinion piece in medical media, Professor Richard Harper – who chaired the committee – defended the process and said he had no control over the rebate amount.
 
‘In developing an item number for GPs, the committee was aware that many GPs had little interest in interpreting ECGs and had not developed the skillset to do so,’ Professor Harper wrote.
 
In a later article, Professor Harper stated there are ‘no restrictions on GPs performing and interpreting ECGs … the new item [number] 11707 specifically allows this’.
 
University of Western Australia senior lecturer in general practice Dr Brett Montgomery told newsGP that assertion is only ‘half true’, given the new item number does not cover interpretation.

‘The taskforce report specifically argued for separate item numbers to cover tracing alone … but also an item number to cover tracing plus interpretation,’ he said. ‘This recommendation seems to have been either overlooked or ignored by the department, which is disappointing.
 
‘I am further disappointed that Professor Harper – the Chair of the committee that authored the report – seems either unaware of this or to be talking around it.’
 
Dr Montgomery, the author of a recent article in The Conversation on the issue, said many justifications offered by Minister Hunt and the DoH do not seem to be in line with what the report recommended. 
 
‘The Minister and [departmental] spokespeople said they were following the advice of the expert taskforce committee and added it was about safety,’ he wrote. ‘That carries the clear imputation that GP interpretation of ECGs is unsafe.’
 
Dr Montgomery wrote directly to Minister Hunt on 31 July, asking why he was not following the advice of the MBS Taskforce to introduce the ECG interpretation item relevant to all practitioners.
 
‘The implicit message here is that GPs aren’t up to this, or that it might be unsafe for GPs to have responsibility for this,’ Dr Montgomery said. ‘That’s what GPs have found insulting and degrading in this whole episode.
 
‘The question should be, “Why is there no funding for ECG interpretation by GPs?”. Fundamentally, Medicare should be paying for that – and now they’re not doing it.’
 
The DoH did not respond to questions prior to deadline.

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The RACGP is now calling for feedback from members on the impact of the changes for patients requiring ECGs to provide to the DoH for the six-month review. Feedback can be sent to healthreform@racgp.org.au



electrocardiogram item numbers MBS



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Dr Bruce Victor Hocking   13/08/2020 6:45:08 AM

I work in a remote Aboriginal community without immediate access to cardiology services or support. I have to interpret ECGs and have developed skills to do this. The decision to not pay for my service will mean I will continue to provide it but paints the government as cheap and ignorant of the importance of GP services ato our health system.


Dr Michael Lucas Bailey   13/08/2020 6:49:16 AM

I think that since I’ve been basically told I’m not competent then I’ll just send anyone that needs an urgent ECG to the emergency department and anyone who doesn’t for a holter monitor.

It won’t work of course. It will be like trying to get chronic pain patients reviewed by a pain specialist with the new PBS rules. The pain specialists in the public hospitals are rejecting the referrals and saying GPs should refer to their colleagues. Can’t do that with ECGs though.

Really what is the future of general practice? More advanced skills are being deitemised. Basic things are being given to untrained pharmacists instead - diagnosing and treating UTIs in pharmacy, immunisations in pharmacy and now COVID testing in pharmacy.


Dr Carolyn Mary Siddel   13/08/2020 11:16:21 AM

The government knows we will keep doing it regardless and we are the free community intern. The question is not whether or not we should keep doing it but whether or not we are covered medicolegally if we act on our interpretation and commence management? On the 6 month review, is that not the same as your parents saying 'not now'?


Dr Anthony Charles Van Der Spek   13/08/2020 1:02:03 PM

It seems after 50 years of general practice I am now not competent to interpret ECGs. This is a huge slight on our profession.
This will result in:
Perhaps less ECG’s being performed
GP’s having to perform the interpretation effectively for free but still taking responsibility for any misinterpretation
Delay in interpretation of ECG’s which could be fatal
Patients having to pay privately for this item in a time of COVID generated recession if the GP bills privately
Increased cost to the government as cardiologist time is not cheap
More dissatisfaction with General Practice as a career
I believe this to be a totally regressive step despite the decision being made by a so called expert committee. I would wager there is not one GP on that committee
Another cut in the destruction of General Practice


Dr David Antone Monash   13/08/2020 5:09:56 PM

This sleight of hand by a Sir Humphrey is an insult to the profession of general practice and removes 30 million dollars per year from general practice. The solution is simple. GP's should continue doing the ECG tracings and acting on their interpretation of the findings and billing 11707 for this process. But if I'm no longer competent to report I will clearly be at risk of medico-legal consequences if the ECG is not reported by someone qualified to do so. I will therefore refer all tracings to a physician to report them officially and store the reports in the file with the tracing. If the majority of GP's feel the same way then this will cost the department an additional 60 million dollars . Maybe they will reconsider the deal they were getting previously.


Dr David Adam   13/08/2020 6:25:30 PM

Executive summary of the review in six months time:

"Should we restore the higher-priced item number?"
No.


A.Prof Christopher David Hogan   13/08/2020 6:37:37 PM

See what happens when GPs act as a group !!!!


Dr Sean Kumar Das   13/08/2020 7:30:17 PM

Typical and insulting behaviour from out of touch medical professionals such as Brendan Murphy who have spent too long in their ivory towers, looking down on the rest of us providing care on the front line and literally risking our lives in the current Covid crisis to do so. Greg hunt is no better and hasn’t a clue about health care, like most politicians. No surprises either that our views are ignored once again nor that this was thrown at us without consultation and buried deep within Covid. Utterly disgraceful and beneath contempt.


Dr David Zhi Qiang Yu   13/08/2020 10:27:30 PM

How to interpreter ECG is essential for the GP training and daily work we have conducted as a GP. To cancel the item number of 11700 is to insult the General Practice and send the very wrong message to general practice.


Dr Najia Adnan   14/08/2020 11:19:46 PM

I am disappointed to see this, as a GP registrar, cardiology is an area I am highly interested in. I spent good number of years in hospital in cardiology and learnt these ECGs from highly respectable cardiologists. Now I have a fear that mostly practice will stop doing ECG and I will loose my skill, in my 1.5 year of GP training I have done multiple ECGs and it always helped me to decide if this pt need to go to hospital and so far we (me and supervisor) made correct decesions. Basically it is passing a message to new GPs that we are not capable enough to read a basic skill which we been taught during and as soon as we finish Med school. Hopefully the decision will be in favour of GP because GPs are doctors of life so among many other skills this is something we can easily interpret and act accordingly.


Dr David Christopher Rivett, OAM   15/08/2020 12:04:24 PM

This is such a bizarre and dangerous misuse of process that it is surely time to name and shame all those who participated in deriving such a change, and to ensure they never again provide any "expert" advice to government


Dr Gursel Alpay   15/08/2020 8:26:04 PM

GP's will be more and more primary care clerks. IF ANYONE COMES TO US WITH PALPITATIONS AND CHEST PAIN WE WILL SEND THEM TO ACCIDENT AND EMERGENCY DEPARTMENTS.
This is a great insult to GP's.


Dr M Isaac   16/08/2020 3:51:37 PM

Few points to consider'
1- Cardiac Services Clinical Committee (CSCC), which made the recommendations, seem they have no work and they need GPs to refer to cardiologist so they can earn some money.
2- Professor Murphy rejected the RACGP’s postponement calls .. with a review to be conducted within six months from the date of implementation. Why 6 months? to make GPs forget about it or enforce the changes and put the issues into sleep? by the way who appointed this Chief medical officer?
3- RACGP consistently defended the right and ability of GPs to interpret ECGs in submissions to the committee investigating the matter in 2017 and 2018, so the issues has been discussed and considered since 2017, what did the college do? apart from defending and condemning !! who was the president at that time? why didnt they inform college's members immediately since 2017 !!!
4- Why didnt medicare audit the claims from GPs for item 11700 since 2017 and find out true from false claims?!


Dr Masoud Davatgaran Tabriz   16/08/2020 9:00:55 PM

This is an insult to General practice However
Some of our colleagues unfortunately do few GPS with no Good reasons , Then medicare try to reduce the costs of each visits .
Very few numbers of Gps may have done wrong or been obsessive but the the others pay the price Of their Unprofessionalism .
For medicare what is important is to monitor not Patients being charged for different item numbers . They wanna limit the amounts of ECG , xrays , US , CT , pathologies ?
of The studies , no matter Today is for the ECG , lastvyears was about 4 y health assessment then MRI knee< 50 years ,
If it is about health budget then ,
Paying $17 ECG is more cost effective then $300 hospital ED visit .
Theyhave done it after Corona then they say we appreciate front line health workers for what they have done so far.
Onr other side, Is an Emergency medicine or RMO in ED hospital is a cardiologist to Interpret or decide for all ECGS .
GPs have any doubt they will communicate with cardiologists.


Dr Masoud Davatgaran Tabriz   16/08/2020 9:01:57 PM

This is an insult to General practice However
Some of our colleagues unfortunately do few GPS with no Good reasons , Then medicare try to reduce the costs of each visits .
Very few numbers of Gps may have done wrong or been obsessive but the the others pay the price Of their Unprofessionalism .
For medicare what is important is to monitor not Patients being charged for different item numbers . They wanna limit the amounts of ECG , xrays , US , CT , pathologies ?
of The studies , no matter Today is for the ECG , lastvyears was about 4 y health assessment then MRI knee< 50 years ,
If it is about health budget then ,
Paying $17 ECG is more cost effective then $300 hospital ED visit .
Theyhave done it after Corona then they say we appreciate front line health workers for what they have done so far.
On other side, Is an Emergency medicine or RMO in ED hospital is a cardiologist to Interpret or decide for all ECGS .
GPs have any doubt they will communicate with cardiologists.