News

GPs call out ‘ridiculous’ changes to cardiac imaging MBS items


Anastasia Tsirtsakis


21/07/2020 4:40:34 PM

GPs will no longer be able to access item numbers for electrocardiograms that include reporting.

ECG
As of 1 August, patient rebates for ECG services provided by GPs will no longer include reporting, with available rebates restricted to item number 11707 (currently 11702) for tracing only.

‘This is a poor-quality decision, and I think it’s an error.’
 
That is RACGP Victoria Chair Dr Cameron Loy speaking to newsGP about the new changes to Medicare Benefits Schedule (MBS) item numbers for electrocardiograms (ECGs), which will limit the capacity of GPs.
 
As of 1 August, patient rebates for ECG services provided by GPs will no longer include reporting, with available rebates restricted to item number 11707 (currently 11702) for tracing only, reimbursed at $19.
 
GPs will be able to request – but not access – the following items that will need to be accompanied by a referral for a specialist or consultant physician:

  • 11704 (currently 11700, 12-lead electrocardiography, tracing and report)
  • 11705 (currently 11701, 12-lead electrocardiography, report only where the tracing has been forwarded to a specialist or consultant physician, not in association with a consultation on the same occasion)
  • 11714 (12-lead electrocardiography, performing a trace and interpretation)
The changes are based on recommendations made by the 12-Lead Electrocardiogram Working Group of the Cardiac Services Clinical Committee of the MBS Review Taskforce.
 
The committee did not regard GPs recording of ECG trace results in a patient file as satisfying the report writing element of MBS item 11700, and suggested item 11702 would more clearly reflect GPs’ performance and interpretation of the ECG, as well as ‘ensure appropriate cardiac imaging services are provided to patients’.
 
The RACGP has strongly opposed the changes since they were first proposed in 2017, holding the position that documenting the ECG outcome in a patient record represented a report, thus satisfying the requirement of item 11700.
 
In its submission to the MBS review, the college argued that GPs should be allowed to continue to claim item 11700, and that rebates be increased to reflect the true cost of an ECG.
 
Associate Professor Charlotte Hespe told newsGP the changes reflect a ‘total lack of understanding’ regarding the role of GPs.
 
‘We are skilled at both being able to conduct an ECG and interpret an ECG and then act appropriately,’ she said.
 
‘To say that we just do a trace is basically designating us to a role of technician rather than actually understanding that we have been trained and skilled in this.
 
‘You do this as a medical student, you do this as a junior doctor, and those are skills that we do every day, and we need to do every day.’
 
Dr Loy agrees, and says the changes send a ‘very poor message to general practice’.
 
‘This is an essential part of the curriculum, this is part of our skill set, 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.
 
‘Or we can do it, we just don’t have an item number that our patients can get a rebate for, which is disappointing.
 
‘I would have hoped that the knowledge base and skill set of general practice was defined by the medical college in that specialty, and not by some nonsense changed item numbers by the Government.’
 
While Dr Loy acknowledges the argument that there may have been some over-utilisation of the 11700 item number, he says the approach being taken is not warranted.
 
‘There have been 2.8 million 11700s activated in the last 11 months, so that’s from July to May. Now that’s not just GPs because that will be cardiologists and geriatricians, all and sundry,’ he said. ‘A lot of ECGs have been done.
 
‘But the response to that is not to just eliminate the item. There are other ways of doing that, that they could have worked through. This is not the way to manage that problem.’

GPs have raised concerns about the prioritisation of care provided by other specialist medical practitioners, which they believe could lead to delayed diagnoses with significant health and financial consequences for patients, particularly those living in rural and remote areas.  
 
‘They’re saying we have to access a specialised cardiologist to interpret an ECG. That’s ridiculous,’ Associate Professor Hespe said. ‘We all know that the sooner we interpret and act on an AMI [acute myocardial infarction] the better.
 
‘So if we’re talking about a rural setting, a remote setting, or even an urban setting, quite honestly, where a patient’s presenting in my room, I do an ECG, I can see they’re having an AMI, that’s me interpreting it. So you’re saying that those skills that I have … I shouldn’t be acting on that?
 
‘I’m sitting here going as a pragmatist, that’s obviously ridiculous.
 
‘It means it’s going to be increased risk to patients, there’s going to be increased costs to the system, and that’s not okay.’

Cameron-Loy-Article.jpg
Dr Cameron Loy believes the changes send a ‘very poor message to general practice’. 

Dr Loy believes the changes take away a whole raft of opportunities for GPs to help their patients in the ‘cheapest, most efficient part of the healthcare system’.
 
‘Will GPs just read them anyway and not be able to generate an invoice? I think that’s a shame,’ he said.
 
‘Are they going to generate a private bill? So increasing out-of-pocket costs on a community that’s already taken an absolute pounding in the last few months with the pandemic?’
 
‘Or are they just going to say, “Oh well, if the Government says we can’t do it, we’re just going stop doing it?”
 
‘A whole lot of nonsense is going to occur and a whole lot of people are going to get transferred to emergency departments to read ECGs, which is insanity. So that’s incredibly disappointing, and I think fairly nearsighted and stupid.
 
‘Once again, there’s been a gouging of money out of primary care, and we already know that some number of billions of dollars has already come out of primary care over recent years. So this is just another one of those.’
 
Dr Hespe says the decision is bringing Australia one step closer to having an expensive, siloed health care system.
 
‘It’s really important that GPs know the RACGP never supported this,’ she said.
 
‘I don’t think that anybody who really knows and understands medical systems and medical care really thinks that it’s just an argument over funding.
 
‘It’s not okay, because who’s going to suffer? The patients are going to suffer.
 
‘We need to just really start pulling back and take a vision of what this country actually needs in terms of healthcare systems and the way it’s funded.’
 
A number of resources outlining the changes are available on the Department of Health website.
 
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Dr Arshad Hussain Merchant   22/07/2020 6:54:19 AM

I feel GPS are not valued in our society but used as scapegoats, unless RACGP show leadership and come with a dollar number valuing the input of their members, this system of abuse will continue....


Dr Stuart John Nash   22/07/2020 7:16:37 AM

Not good enough from our college. This is not advocacy this is saying “we think it’s sad too”. A weak statement from a weak college. GPs will continue to be chipped away at for as long we roll over and take it.


Dr Carolyn Mary Siddel   22/07/2020 7:34:45 AM

Whilst I agree this is a ridiculous attempt at cost cutting has there been a breakdown into GP billing vs hospital outpatient billing?


Dr Hamid Moshtagh   22/07/2020 8:08:57 AM

Ridiculous changes targeting primary care
On top of unnecessary policing of GP performances during the last few years of current government and chief medical team!hope the RACGP will push it back harder than has Been so far!


Dr Paul Andrew Shelly Griffiths   22/07/2020 8:18:29 AM

WTF. I absolutely write full reports on my ECG’s, I administer tenectaplase, DC cardioversions, all kinds of things based on my reports. They clearly haven’t sampled properly.


Ali   22/07/2020 8:53:35 AM

If we can not request it then it means we have to send every suspicious case to ED . I am interested to know how much more money they have to spend for each ED attendance !


Dr Peter Andrew Pfaender   22/07/2020 9:03:34 AM

Next we’ll hear Pharmacies doing ECG tracings. The college needs to stand and truly represent its members .


Dr SA   22/07/2020 10:16:05 AM

I suggest, every single patient whose signs/symptoms warrant an ECG, should have an ECG done at our clinics, then we send all of those patients, along with ECG trace, to EDs, because we are not competent enough to interpret ECGs as being normal or abnormal. Lets see how public hospitals cope seeing extra 3 million disgruntled patients waiting for hours in EDs. And make sure we call ambulance for every single patient whose signs/symptoms suggest any possibility of a cardiac event happening, disregarding the ECG which may seen normal - remember, we are not competent enough to say ECG is normal.


Dr SA   22/07/2020 10:25:47 AM

I suggest, every single patient whose signs/symptoms warrant an ECG, should have an ECG done at our clinics, then we send all of those patients, along with ECG trace, to EDs, because we are not competent enough to interpret ECGs as being normal or abnormal. Lets see how public hospitals cope seeing extra 3 million disgruntled patients waiting for hours in EDs. And make sure we call ambulance for every single patient whose signs/symptoms suggest any possibility of a cardiac event happening, disregarding the ECG which may seen normal - remember, we are not competent enough to say ECG is normal.


Dr Najia Adnan   22/07/2020 10:53:52 AM

I believe ECG is such a useful tool for GP to decide if pt needs hospital transfer or not. If a patient comes in with cardiac sounding chest pain the first things comes in our mind is STEMI or NSTEMI. Does pt needs to send in by Ambo or he/she can drive home. GPs are more than competent to read ECG, we gets chest pain pt every day and we perform ECG on one who warrant them if we don't do it we son's see it and if we don't see it we become de skills in it. Having a physician background and completed multiple terms in cardiology and now applying all this knowledge in GP practice is a life saving thing. Physician, cardiologist appriciate if a GP performed ECG and discuss findings with them to avoid un nessary admission to hospital. Question is even if govt vanish an MBS item no for ECG, dont's we dont still have to do ECG in appropriate cases as a GP answer is YES ( we have duty of care as well ) .


Dr TL   22/07/2020 11:21:13 AM

Soft by the RACGP. You knew this since 2017 and only speaking up now?
Quite frankly it’s inaction like this that is also destroying GP. Blame the government all you want but without true effort in advocating for your specialty, you take part of the responsibility. I don’t need to touch on how the pharmacy guild is eroding GP practice.
I say this as a junior doctor who was interested in GP practice but by the day I keep reading concerning stories making me less likely to choose this specialty. I don’t have the confidence in RACGP to stop the dismantling of GP’s.
I would expect more juniors doctors to remain in the system as a result than choose GP as stories like this continue to get out.


Dr Pradeep Harshan Jayasuriya   22/07/2020 11:30:38 AM

This decision is outrageous, who is on this committee?. This is a defining moment for the RACGP.


Dr Nell De Graaf   22/07/2020 11:38:52 AM

Time for some names and qualifications of the people on the Cardiac Services Commitee that advised this bullshit.
Dont hide stand up and be called out


Dr Peter James Strickland   22/07/2020 11:55:47 AM

Who has made this decision, and who were the advisers? Many GPs are well trained and experienced in reading ECGs, and esp. those who work in hospitals in the bush. ECGs were an important component of my training, and later experience over 50 odd years of practice in rural and metro practices, and a lot of GPs have attended Cardiac Weekends, and I have chaired these conferences. Many consultant physicians only know as much about ECGs as good GPs, and this Medicare decision is nothing short of impractical and ridiculous --- what happens in an emergency situation when reading the ECG by a GP is essential without a defibrillator apparatus, and to start treatment? Over to you RACGP to reverse this nonsensical decision.


Dr Slavko Doslo   22/07/2020 1:03:38 PM

for me is not about money and reduction in payment , this is insult for my care of patient ,
" yes you can do it, yes you can see it , yes you can diagnose and yes you can act on it and save life " but I do not care about it and I am not going to award you for your knowledge and effort to become better doctor , saving lives, I really do not care MBS say"
Dear Greg Hunt read this


Dr Slavko Doslo   22/07/2020 1:05:45 PM

for me is not about money and reduction in payment , this is insult for my care of patient ,
" yes you can do it, yes you can see it , yes you can diagnose and yes you can act on it and save life " but I do not care about it and I am not going to award you for your knowledge and effort to become better doctor , saving lives, I really do not care MBS say"
Dear Greg Hunt read this


Dr Umberto Boffa   22/07/2020 1:24:28 PM

No-one believes GPs can't read ECGs or that doing so does not save money for the system or doesn't save lives.
Yet again, this is about the government knowing GPs will continue to do something for nothing, as they always do.
Well, will we Harry?
Bert Boffa


Dr Aditya Reddy Vitta   22/07/2020 3:09:03 PM

Tale of a GP
Ok ,So I decided to become GP . Went through the minimum requirement for 2 years doing core runs in hospital then SJT(first mcq then SJT then interview) then off to rural training for years(stay away from family, constant travel no consideration given for family requirements) then finally pass 1. AKT 2. KFP and 3.OSCE then finally Fellowship with a tag of RACGP. so after a total of 6 to 7 years you only realise that you title means nothing. I mean the Govt allows Pharmacist , Nurses to do half your jobs and then financially medicare freeze for years, then they increase rebates by cents then you medicare cuts like ECG which is probably the first of many cuts.Do we really need this fellowship? Is it really worth leaving family kids and training in remote corners only to find Pharmacist, Nurses , Podiatrists, Lab technicians are doing way better than us with lesser training time, loans , location restrictions and professional services reviews. I really repent the years I have


Dr Cameron Troy Williams   22/07/2020 3:46:19 PM

Unbelievable. Ridiculous
Perhaps all GP's that treat politicians and public service employees should refuse to bill them to medicare and only bill privately and let them sort out there own medicare item numbers until there is change.

There seems to be the belief in government that our non-GP specialist colleagues are so much more deserving than us. Ridiculous rebates for procedural skills, eye injections etc etc etc - yet they are clawing money off GP with a few minor restrictions on the number of echo's per year - really these committees have no idea.
I am disgusted.


Dr David Zhi Qiang Yu   23/07/2020 10:32:48 PM

GPs should be allowed to continue to claim item 11700, and that rebates be increased to reflect the true cost of an ECG.


Dr Paul Kevin Nylander   25/07/2020 9:46:48 AM

I’ve been a GP for 33 years. I’ve sadly watched the de-skilling and associated poor remuneration for GP’s, Accreditation requires more capex for less profits. Corporates do not have our interests at heart and in fact I’ve had them lie to me. It is little wonder that students do not want to do what I used to feel was a great Specialty. Reading ECGs is fundamental to decision making. It increases our risk but takes pressure of public hospitals. If the end game here is capitation of GP’s, decide on appropriate remuneration after costs. Build, staff and equip General Practices. Then our value will be realised. Too late for me with low standard uni output and even fellows not wishing to practice proper medicine leaves me amazed and disgusted. I give up. Few take interest or responsibility for anything. I cannot see this ending well without strong and experienced leadership from the college alone and not every splinter group and the AMA. Good Luck everyone.


Dr TR   25/07/2020 11:16:56 AM

So this means that ambos can use ECGs to interpret and take action, give cardiac meds etc but GPs cannot. Ridiculous.The RACGP is prevailing over the slow death of general practice to be taken over by nurses, physics, chiros and chemists who have access to numerous practical upskilling and accreditation programs if they want to pay while GPs only have more online CPD and three yearly CPR training. And even that is not even a medical program but some sort of generic CPR session conducted by "trainers" not doctors. The RACGP has always lacked a strong advocacy base and has been too busy pandering to the bureaucrats. It is bad news for patients who are slowly losing coordinated primary care to be replaced by this piecemeal ad hoc role substitution system which will cost far more in the long run.


Dr Bram Singh   26/07/2020 12:15:32 AM

RACGP and AMA both presented to their GPS with chest pains......... Let's pray for them.🙏


Dr Julia Ann Conway   29/07/2020 11:36:03 AM

The previous rebate was $32, now reduced to $19- for the nurse to record an ECG ($13 removed for a GP to interpret ECG and act on findings). It was always insulting! In a 10 minute appointment there is little incentive to disrupt waiting times by doing one anyway especially if the nurse is already busy. Furthermore why bother adding an extra 10 minutes writing a referral letter to the ED giving our findings? Probably best just to pack them off to ED with their probable reflux pain! Some of them will not bother going of course because of the long ED waiting time.
I see this as protectionism by doctors who realized they would never be rich training as GPs and chose cardiology instead. With waiting times of over a year for Public Cardiology appointments, patients will have to find the money to see these specialists privately or risk dying in the meantime. Moving to a primarily based specialist system will see costs escalate and treatment unaffordable to many- just look at the USA now.


Dr Julia Ann Conway   29/07/2020 11:40:32 AM

P.S I can get a troponin level back quicker than the hospital ED waiting time. We can also effectively follow up and provide continuity of care. Why do cardiologists ask patients to see their GP if they have any more issues in between their very infrequent appointments?


Dr John Paul Kennedy   30/07/2020 12:23:56 AM

With all the fire and brimstone of the G.P. response to this rebate cut, you would think a few more of us would be brave enough to just bill our patients privately for their ECGs.
This is the only escape from the bulk-billing trap.
Sure, many G.P.s cannot privately bill anyone but many of us just choose not to because we feel it is awkward to be assertive or to make this transition.
We can be our own worst enemy.
If we get the BB rate down from 86% to below 75% we will make the government think twice before they erode rebates further.
The RACGP is not a union, so it's role is limited to one of advocacy and maintaining standards of training and ongoing medical education.
If G.P.s really want to have a representative organisation, perhaps it is time for us to re-visit the A.M.A. and re-invigorate its G.P. chapter.


Dr Mark Robert Miller   30/07/2020 2:33:07 AM

It has been interesting to see a bit of distancing in the medical media around this decision. Fundamentally not all decisions are correct and there are often unintended consequences. The obvious risk to patients from delayed diagnosis and the risk of deskilling is obvious. If it’s felt the item number is being overused or gamed - then perhaps applying a protocol or algorithm would be appropriate, for ordering,justification, however if an algorithm is written with maximal safety In mind as to ordering and report then I suspect we would find the use of the item number not going to go down. How many times have we seen patients with AF / “atypical chest pain” / rhythm disturbances not picked up until their GP performs AND interprets the need for intervention, referral,triage.