The Federal Government is deferring the controversial private health insurance reclassification of intravitreal injections for another 12 months and will undertake further consultation, in welcome news for thousands of patients who faced the prospect of out-of-pocket costs within months.
“It provides an opportunity to address the wider issue of the lack of access to affordable sight-saving treatment in Australia,” Macular Disease Foundation Australia (MDFA) CEO Dr Kathy Chapman said.
According to the organisation, the government’s proposed reclassification would have resulted in more than 12,200 people no longer being able to use their health insurance to cover the cost of intravitreal anti-VEGF injections, if originally performed in private hospitals and day surgeries.
“Instead, this large group of people would have needed to start paying out-of-pocket costs in order to continue being treated in private ophthalmology clinics,” Dr Chapman said.
The measure was to take effect 1 July 2025, but has now been delayed until 1 July 2026.
The move stems from the Medicare Benefits Schedule (MBS) Ophthalmology Taskforce Review. Finalised in 2020, it recommended reclassification of item 42738 from a Type B to a Type C procedure to reflect it’s a procedure that doesn’t normally require hospital treatment and can be safety performed out-of-hospital.
Shifting the procedure away from the hospital setting – and into ophthalmology clinics – would mean it couldn’t be claimed through a patient’s health fund.
The Australian Society of Ophthalmologists (ASO) received correspondence from the assistant secretary of the MBS Policy and Specialist Programs Branch within the Department of Health, stating the deferral would allow for further consultation “to better understand the impact on patients and to consider options for supporting access to affordable intravitreal eye injection services”.
The letter also goes on to suggest further opportunities to contribute to the consultation process will arise in the coming months, while all other changes to ophthalmology services will be implemented on 1 July 2025, as scheduled.
“The ASO welcomes the opportunity for further consultation on the impacts of the changes for patients,” president Dr Peter Sumich said.
“I have spoken to Minister Butler personally about the difficulties posed by the Type C funding change. It is a no-win situation, demanding very careful thought and planning.
“Patient care must be the prime consideration in whatever outcome eventuates.”
Distressed patients
MDFA said it had received more than 100 phone calls from distressed community members concerned about how they would continue to afford their sight saving treatment if this planned change was to go ahead.
“The voice of the macular disease community has been heard by government,” Dr Chapman said.
“While MDFA welcomes the government’s decision to pause this reclassification, it is absolutely vital that the government addresses the wider affordability issues that continue to be faced by the majority of people requiring sight saving injections.
“Importantly, the government needs to consider that treatment for neovascular age-related macular degeneration (AMD) is usually frequent (typically every four to six weeks) and lifelong. It’s not a one-off like some other medical treatments, and public eye injection services are either not available or oversubscribed, so for most people the out-of-pocket costs are expensive and ongoing.”
With more than 108,000 people with a treatable macular disease (in 2023), treatment persistence has been identified as a significant issue, with approximately 50% of people discontinuing treatment within five years of starting eye injections. The main reason for this is cost burden.
“Eye injections are primarily delivered in private ophthalmology clinics in Australia, with only around 20% of them offering bulk billing, meaning that more than 72,000 people having eye injections have no choice but to pay expensive out-of-pocket costs to receive their treatment to keep their sight, on top of other costs relating to living with macular disease, such as eye specialist appointments, vision aids and associated travel expenses,” Dr Chapman said.
Earlier in March, MDFA called on the next Federal Government to allow bulk billing of eye injections for pensioners through a $11.1 million-a-year program incentivising ophthalmologists.
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