GPs should still be interpreting ECGs: Cardiac committee chair

Doug Hendrie

17/08/2020 4:27:17 PM

Confusion over the MBS change continues, as Professor Richard Harper tells newsGP the wording of the controversial new item number ‘could have been better framed’ – and should be formally changed.

GP looking at an ECG
Many GPs saw the changed item number as an attack on their competency, as well as a cut that could force patients to increase out-of-pocket costs.

‘The intention of the committee was that MBS [Medicare Benefits Schedule] item 11707 be for a GP self-referred ECG and interpretation – without the necessity to provide a formal report in the way a pathology service does.’
That is Professor Richard Harper, Chair of the Cardiac Services Clinical Committee (CSCC), talking to newsGP about the controversial MBS changes that have effectively stripped GPs of the ability to bill Medicare for the interpretation of ECGs.  
‘Clearly there is no point in doing an ECG if it is not going to be interpreted,’ he said.
‘In retrospect the wording of the descriptor “ECG tracing only” could have been better framed. The word “only” referred to the fact that a formal report was not required, but was not meant to imply that interpretation was not allowed. 
‘A better wording for 11707 would have been “ECG tracing and interpretation” and I am hopeful that the Health Department will make this change.’
The 1 August changes to ECG MBS items have angered many GPs, who saw the move as an attack on their competency as well as a cut that could increase out-of-pocket costs for patients.  
The CSCC final report calls for two separate ECG items for GPs – one for a trace only; and one for a trace plus interpretation. However, only one, the trace, was approved.
If the changes suggested by Professor Harper are made, it will go some way to mollifying outrage at a move perceived as stripping GPs of the right to interpret ECGs.
But the broader issue of the cuts to the ECG rebate will remain.
Until 1 August, GPs used item 11700 for an ECG trace and report, which attracted a rebate of $27.45. The new item 11707, covering an ECG trace only, attracts just $16.15.
The reduced rebate may be linked to the CSCC report’s findings that ECG technology had reduced in cost and complexity.  
Professor Harper said the committee ‘had no role in the determination of the fee’, which was done in consultations with the Department of Health (DoH), the Australian Medical Association, the RACGP and the Cardiac Society of Australia and New Zealand.
The RACGP is on record in repeated submissions as saying that the rebate for the now-replaced ECG item – 11700 – was inadequate as it was, given the cost of the service and consumables.

The move to reduce the rebate further is not in line with the RACGP’s calls.

In a recent letter to DoH Secretary Brendan Murphy, the RACGP noted that ‘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,’ the RACGP states in the letter.
As of 2017, more than 2.7 million ECG services were claimed on Medicare annually, with 98% claimed through the old trace-and-report MBS item.
The CSCC’s final report states concern about the fact these services were growing at 7% a year, well above population growth.
‘The committee agreed that growth at this rate is not driven by shifting disease patterns and felt that the substantial and growing investment in a relatively straightforward activity could be better directed to other necessary services,’ the report states.
‘The committee agreed that many ECGs are of low value, particularly those performed without a referral … 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.’  
The report also noted that when ECG items were introduced, the technology was expensive and relatively complex and time-consuming to operate.
By contrast, the report states, modern ECG machines are ‘more affordable, and technological improvements [such as sticky electrodes, which have replaced suction cups] have reduced the amount of time and effort required to take an ECG trace’.
GP and University of Western Australia researcher Dr Brett Montgomery has welcomed the push to clarify the wording of the new MBS item.
‘I absolutely agree with Professor Harper that, “there is no point in doing an ECG if it is not going to be interpreted”,’ he told newsGP. ‘I’m pleased that Professor Harper shares my concern about the poor wording of the [item].
‘I was wondering how I was supposed to interpret, but not fully interpret, my ECGs, while still interpreting them fully enough to be medicolegally defensible.
‘On the current wording, it seems I need to produce a sort of “Schrödinger’s ECG interpretation” that is simultaneously fully and not fully interpreted. I look forward to a change to the item descriptor as he proposes.’
Dr Montgomery said that while ECG machines may be cheaper, they cost the same whether purchased by a cardiologist or a GP. 
‘The question remains as to why there is inequity in what Medicare proposes to pay for tracing and interpretation by different medical practitioners – more for any other specialist than a GP. This inequity seems unfair to me,’ he said.
A DoH spokesperson told newsGP that MBS item 11707 ‘enables an interpretation of the trace to inform a clinical decision to be made’.
The spokesperson said Federal Health Minister Greg Hunt had asked the DoH to ‘monitor the impact of the ECG changes’ ahead of a review to begin on 1 February 2021.
‘The details are yet to be finalised; however, it is anticipated that this timeframe will allow initial data on the items to be analysed by the department,’ the spokesperson said.
‘The review process will involve consideration of any clinical or implementation concerns about the changes, and consideration of concerns raised by stakeholders.’
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Dr BT   18/08/2020 9:44:51 AM

Mmmm, just a thought.... maybe if a bit of actual thought went into this ridiculous decision in the first place there wouldn't be backtrack after backtrack after backtrack

Dr David James Maconochie   18/08/2020 5:18:23 PM

1) We do ECGs in the absence of symptoms. Of course we do, it is called preventative medicine. As the cardiology committee members ought to know, the majority of myocardial infarctions are silent.
2) The number of ECGs is rising by 7% per year. Well perhaps that is because Medicare, the Health Dept and the RACGP are encouraged proactive management of chronic diseases, which includes regular checks of renal, liver and cardiac function in line with good medical practice.
3) We are using ECGs to screen patients. Yes, for atrial fibrillation, prevalence more than 25% in the elderly. Compare the cost of a stroke prevented v the cost of a GP ECG billed at 11700, and you have to wonder what planet the committee live on, because it is not down here on earth.

Dr Cynthia Filipcic   18/08/2020 7:42:37 PM

In my opinion, the issue is not the rebate but the fact that this taskforce has decided that GPs are not qualified to interpret ECGs. Despite the fact that we are registered as specialists with AHPRA apparently an FRACGP or FACCRM is not a specialist qualification. This is an insult to our profession, our clinical skills and our capability.

Dr Christopher St John Kear   18/08/2020 9:30:24 PM

It's a campaign to cut costs, and ultimately we'll be pushed into a corner and asked to take capitation-based payments with some additional incentive payments for achieving demonstrable targets agreed with Medicare accountants. That's what happened in the UK. It was called the "Golden Hello", and then money was carefully removed from GP's over following years. We really do need to fight this, and nip these nasty ideas in the bud. It's a drive towards cheap and nasty medicine run by big corporates, and the abolition of GP's ability to practice independently.