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Ensuring all Australians have access to guideline-based health care should be a priority for both the government and the medical profession.
In this article, we focus on inequitable access to guideline-indicated cardiac MRI. We do so because it directly impacts our most vulnerable patients. But that’s not the example that we want you, the reader, to focus on. We want you to think of examples that impact your patients. Our objective here is to start a conversation around the role that health technology assessment (HTA) has played in creating these problems and the role that it could play in solving these problems. What we are proposing is a philosophical shift in how Australia approaches HTA, not just a bureaucratic reform.
Cardiac MRI
In Australia, the role of cardiac MRI in clinical practice is well established. There are numerous centres capable of performing high quality scans, supervised and reported by cardiac MRI-accredited cardiologists and radiologists. The problem is that availability and accessibility are not the same thing. Currently, there are only six indications for cardiac MRI listed in the Medicare Benefits Schedule (MBS). Access to cardiac MRI for non-Medicare eligible but guideline-recommended indications is thus effectively restricted to patients who can afford to pay the full cost of a cardiac MRI study, typically $700–$1000. In the current economic environment, that is a significant barrier.
For cardiologists, the most respected sources of clinical practice guidelines are the European Society of Cardiology (ESC) and the American Heart Association/American College of Cardiology (AHA/ACC). Recent reviews of all active ESC and AHA/ACC guidelines found that most of their guidelines discussed cardiac MRI in the text, and at least half made cardiac MRI-specific recommendations. AHA also produces scientific statements focused exclusively on cardiac imaging, while ESC produces technical guides focused exclusively on cardiac MRI. This reflects the centrality of cardiac imaging to the practice of cardiology and the importance of cardiac MRI as a cardiac imaging modality.
Two recent guidelines warrant special mention. Firstly the 2023 ESC guidelines for the management of cardiomyopathies, which has adopted a new phenotype classification system based on both morphological and functional traits, including myocardial tissue characterisation findings. This makes cardiac MRI an essential step in the assessment of all patients with a suspected cardiomyopathy. Depending on the underlying aetiology, the guidelines also attribute variable prognostic significance to the myocardial tissue characterisation findings, which has direct implications for management. Indeed, the guidelines provide worked examples of how this new, more detailed, better integrated, cardiac MRI-dependent approach creates the potential for personalised treatment plans.
In Australia, however, only patients suspected of having the relatively rare condition of arrhythmogenic right ventricular cardiomyopathy, are currently eligible to undergo a Medicare-funded cardiac MRI. Of even more relevance though is the timeline associated with the listing of this item in the MBS. The Cardiac Society of Australia and New Zealand applied for Medicare funding of cardiac MRI in the setting of suspected non-ischaemic cardiomyopathies in 2014. The relevant HTA agency, the Medical Services Advisory Committee (MSAC), split the application into two assessments, which were not finalised until October 2016 and August 2017, respectively. The latter report supported funding for suspected arrhythmogenic right ventricular cardiomyopathy but the implementation process for the new MBS item was such that it did not become available until May 2018.
The 2022 ESC guidelines on cardio-oncology is the second recent guideline of note. Cardio-oncology is essentially a new subspecialty that has emerged to deal with the cardiac side effects of the rapidly expanding array of new cancer treatments. Targeted therapies and biological therapies, including immunotherapy, are converting cancer into a chronic disease, which is making managing their complications increasingly important. These guidelines have, however, been criticised for the high proportion of Class 1 recommendations based on “Level C” evidence. While this reflects the fact that the clinical problem has emerged in advance of an evidence base for managing it, it nonetheless makes it unlikely that MSAC would support funding for any of the guideline’s recommendations.
The role of HTA
Australia’s HTA agencies, especially MSAC, have been subject to much criticism. This has led the government to consider significant reforms, including the possible merger of our major HTA bodies. However, from our perspective, what is required is a fundamental change in Australia’s philosophical approach to HTA, not just bureaucratic reform.
HTA is a multidisciplinary process that is supposed to “inform decision-making in order to promote an equitable, efficient, and high-quality health system”. Conceptually, HTA bodies lie on a spectrum from reactive to proactive. At the reactive end, governments use them as an administrative barrier to limit the introduction of new technology. At the proactive end, governments use them to both identify technology gaps and to facilitate the introduction of new technology to fill those gaps.
Australia has a reactive HTA system in which our HTA bodies act, philosophically, as gatekeepers. MSAC’s primary role is that of an arbiter of applications for MBS funding, the majority of which come from applicants with a pecuniary interest. Not unreasonably, given that context, MSAC places the onus on the applicant to prove that the technology meets the necessary standards for comparative safety, clinical effectiveness, cost-effectiveness and total cost. MSAC has traditionally combined high standards for evidence with a low tolerance for uncertainty.
But it doesn’t have to be this way. Australia could adopt a proactive HTA system (or, realistically, a pluralistic HTA system with both reactive and proactive elements). In this scenario, our HTA bodies would act, philosophically, as facilitators. The government would determine which technologies to consider for funding and the HTA bodies would then attempt to develop implementation strategies for those technologies that are, in the context of the Australian health care system, equity focused, cost-efficient and fiscally responsible.
The establishment of the MBS Review Advisory Committee (MRAC) as part of the MBS Continuous Review presented such an opportunity. However, based on the four assessments it has finalised in its first three years, MRAC appears to be modelling itself on MSAC. Nonetheless, it could potentially be co-opted for this purpose.
Guidelines as a basis for HTA agenda setting
We believe that all Australians should have access to guideline-based health care, regardless of their financial circumstances, and that this should be a priority for both the government and the medical profession. Accordingly, we propose that professional societies should routinely review all new guidelines for the purposes of identifying differences between guideline-based health care and MBS-based health care. The results of these reviews should then be formally communicated to the government so that they can be used as the basis for determining HTA priorities for the proactive HTA body proposed above. Importantly, this approach can and should be applied equally to both investment in new technology and disinvestment in superseded technology.
Dr Jon Ryan is a cardiothoracic surgeon. Dr Simon Eggleton is an imaging cardiologist. They both have conjoint academic appointments at UNSW and clinical appointments at Prince of Wales Hospital, Prince of Wales Private Hospital and Eastern Heart Clinic.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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