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Latest eye injection proposals draw sharp rebuke from ophthalmology

02/10/2019By Myles Hume
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Controversial plans to dramatically reduce the rebate for intravitreal injections and also allow non-ophthalmologists to perform the procedure have divided Australia’s eyecare sector, with advocacy bodies considering the implications for patients.

The measures form part of the long-awaited Medicare Benefits Schedule Review Taskforce Ophthalmology Report, which has been released for public consultation. It recommended some level of revision to 31 of the 189 MBS items under review.

The report has been led by an Ophthalmology Clinical Committee, chaired by Dr Bradley Horsburgh, with the overarching government-appointed MBS Taskforce claiming to “broadly support” the proposals. However, the taskforce has received criticism after it included divisive recommendations, some of which the committee refused to endorse.

The most controversial proposals pertain to lowering the MBS fee and rebate for intravitreal injections, as well as new measures to allow optometrists and nurse practitioners to perform the procedure.

The Australian Society of Ophthalmologists (ASO) and Optometry Australia (OA) have openly commented on the recommendations, while the Macular Disease Foundation Australia (MDFA) is reviewing its potential impact. RANZCO and Diabetes Australia (DA) declined to comment at the time of publication.

ASO president Dr Peter Sumich said his organisation was most concerned about a proposal to reduce the fee for intravitreal injection items 42738, 42739 and 42740 by 70%, bringing it to the same value as that of peribulbar or retrobulbar injections (item 18240).

This would take the intravitreal injection MBS fee from $305.55 to $95.10. The 85% patient benefit/rebate would drop from $259.75 to $80.85, a difference of $178.90.

Dr Peter Sumich, ASO
Dr Peter Sumich, ASO
"It's the sort of recommmendation that could only come from a committee of tenured academics"
Dr Peter Sumich, President at ASO

“The Ophthalmology Clinical Committee made no recommendation to change the patient rebate for intravitreal injections and the matter was taken out of their hands by the MBS Taskforce chaired by Professor Bruce Robinson,” Sumich told Insight.

“It’s the sort of recommendation that could only come from a committee of tenured academics with no real world experience of service delivery in the private sector.”

Sumich said the recommendation would effectively cut the intravitreal therapy rebate for patients by two thirds. This would be well below cost for a service provider, and could potentially put private macular degeneration therapy out of reach for tens of thousands of patients.

“The scale of the problem is immense. There are 105,000 bulk billed retinal procedures per year, which would immediately be at threat. Elderly patients prefer visiting their local ophthalmologist and would be reluctant and sometimes unable to travel further,” he said.

“I have no doubt that consumer representative organisations such as the MDFA and DA will be making it quite clear how unacceptable these changes are.

Comparing complexity

In justifying its rationale for the recommendation, the taskforce stated it wanted to align the rebate with the relative complexity of the procedure.

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In comparison to intravitreal injections, the taskforce noted that despite presently having a lower fee, peribulbar/retrobulbar injections were more technically demanding and required a more complex injection technique through multiple planes without direct observation of the infiltrated space, as well as comparable levels of potential complications, preparation and aftercare.

The consultation paper also recommended exploring the notion of trained nurses and optometrists performing intravitreal injections under updated guidelines.

Darrell Baker
Darrell Baker
“OA has recently indicated to RANZCO and the ASO our interest in working collaboratively to enhance patient access to intravitreal injections in a manner that upholds patient safety”
Mr Darrell Baker, Optometry Australia

It states that this is in response to evidence of clinical need, maldistribution of clinicians and constraints on overall supply, and claims international evidence supports this approach.

Sumich said the ASO, as well as the Australian Medical Association, was opposed to the prospect of what he referred to as “task substitution”.

He pointed to recent comments in which he claimed such measures would lower clinical standards.

In contrast, OA CEO Ms Lyn Brodie said the organisation welcomed this recommendation. “It makes sense to capitalise on the capacity of our highly-skilled optometry workforce to meet community need by broadening their role in this way.

“We are very open to working with ophthalmology in consideration of how the two professions can collaborate most effectively to meet the needs of our communities.”

Brodie said OA would now carefully consider the taskforce’s recommendations as it begins to formulate a submission. “Our focus is particularly on those recommendations that pertain to optometry and how we enhance community access to the eyecare they need.

“More broadly, we will be emphasising the need to ensure that item fees for services from all eye health care professionals are realistic and enable a sustainable eyecare system.”

The MDFA is not yet in a position to comment publicly on the specifics of the report, however CEO Ms Dee Hopkins told Insight the organisation is currently reviewing the recommendations and “the impact they may have on our community”.

“At this stage, we anticipate our advocacy on this matter will be at a national level, and our position will be made known in due course, after consulting with our community,” she said.

 

More reading:

Controversy: confusion reins over eye injection guidelines
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