A few "sensible" changes to the Medical Benefits Schedule (MBS) listings for four cardiac services could save taxpayers over $230 million a year and shave over $30 million annually from the Medicare budget, according to a For debate published in the Medical Journal of Australia.

Professor Richard Harper and Dr Arthur Nasis, from Monash Heart, Monash Health and Associate Professor Vijaya Sundararajan, from the University of Melbourne, wrote that the MBS listings for cardiac services had changed little "despite major advances in the evidence base for the practice of cardiology".

Changes to the listings for invasive coronary angiography (ICA), computed tomography coronary angiography (CTCA), stress testing and percutaneous coronary intervention (PCI) "would improve the clinical practice of cardiology and save substantial amounts of taxpayer money", they wrote.

"CTCA, a new, safer and much less expensive technology, should replace ICA for the diagnosis of coronary artery disease (CAD), but based on Medicare item reports for 2010-2014, this is happening only slowly", the authors wrote.

"Measurement of the fractional flow reserve (FFR) clearly improves the practice of PCI and saves both money and lives; however, the uptake in Australia has been slow.

"A nuclear stress test has a high radiation burden and is 3.4 times more expensive than a stress echocardiogram, yet under the current MBS system it can be ordered by any medical practitioner who may or may not be aware of the cost or the radiation risk."

The authors suggested the following changes to the MBS listings:

  • "the item numbers for ICA should only be payable if the procedure is performed by an accredited interventional cardiologist in a hospital with accredited PCI facilities";
  • "all interventional cardiologists currently accredited to perform PCI be allowed to charge the item numbers for ICA";
  • "the item number for CTCA be payable only if performed in patients without known CAD. For patients whose initial CTCA results are normal, a second CTCA investigation should only be rebatable if it is performed at least 5 years after the first";
  • "the item number for a nuclear stress test be only payable if ordered by a physician and only if a stress echocardiogram is considered unsuitable for technical reasons";
  • "separate MBS item numbers for PCI for troponin-positive acute coronary syndrome and for PCI for stable CAD, thus allowing easier evaluation of the Medicare statistics of an individual practitioner. The item number for PCI for stable CAD should only be payable if one of three conditions is satisfied: (i) a stenosis > 90% in a coronary vessel > 2 mm diameter; (ii) a single lesion in a vessel supplying an area of myocardium identified as ischaemic on stress testing; or (iii) a coronary lesion associated with an FFR below 0.8."

The authors calculated the ratio of ICA to revascularisation and the cost to the taxpayer of unnecessary ICA using Medicare statistics and data from the Australian Commission on Safety and Quality in Health Care. "Taxpayers could have saved $233.5 million and private health insurance companies $139.8 million in 2013-2014", they reported.

"If our suggested changes to PCI were to occur, the annual savings to the Australian health budget would be in the order of $4 million. Changes for CTCA would be cost neutral in the short term but would save costs in the long term.

"In 2013-14, 77 564 nuclear stress tests were charged to Medicare (cost per test, $756). It is likely that at least 75% of these patients could have had a less expensive stress echocardiogram (cost per test, $222) as an alternative. Doing so would have saved over $30 million to the Medicare budget.

"We believe these relatively simple changes to the MBS would result in improved evidence-based cardiology practice and substantial savings to the health budget in an ever-increasingly constrained fiscal climate", the authors concluded.