The head of ophthalmic surgery at a major public hospital says the current Medicare fee for intravitreal injections only creates a slim profit and plans to slash it by two thirds would trigger a flood of patients into a public system that almost certainly couldn’t cope.
Dr Mark Chehade, who commenced in his role as the Head of Unit at the Royal Adelaide Hospital this month, also fears suitable patients for treat-and-extend dosing regimens could be prevented optimal care if non-ophthalmologists are allowed to perform the procedure, potentially leading to unnecessary treatment burdens and costing the Federal Government more in the long term.
The concerns follow a final report into ophthalmology Medicare items that the MBS Taskforce has prepared for the government. Despite opposition from the sector, the taskforce has proposed cutting the intravitreal injection MBS fee from $310 with a rebate of around $250, to a $96 fee with a rebate of around $75 (a 69% reduction). It also raises the prospect of optometrists, nurse practitioners and GPs performing intravitreal injections.
Chehade said the current fee and rebate charged in the private system was “about right” once OCT scans (for which there is no item number), medicine acquisition, support and reception staff, practice running costs and the surgeon’s time were accounted for.
“The injection only represents the tip of what is a very involved process, and the MBS Taskforce is hellbent on slashing the fee and rebate,” he said.
“It’s marginally profitable at best when you consider the entire event. I have discussed this with many retinal specialists and asked whether it can be cut back by any amount, and they look at me and say: ‘Are you for real? It’s barely profitable as is’.”
The MBS Taskforce has proposed a new OCT item to be claimed up to six times a year for macular degeneration, which Chehade acknowledged would have some mitigating effect.
The end of ‘goodwill’ injections
In South Australia, Chehade said the ophthalmic public system was overwhelmed, despite only performing 5-10% of intravitreal injection services. At the Royal Adelaide, the glaucoma clinic has had to make way to create greater capacity for higher priority macular injections.
This has meant patients waiting to be seen for non-urgent conditions like cataracts or suspected glaucoma are sitting on a 1,500-person waiting list for outpatient appointments. About 1,100 of those have been waiting for more than a year – more than 70% compared with a national average of 5%. Shockingly, 350 have been waiting more than three years.
Chehade said this demonstrated the precarious position of the public system that, crucially, is being supported by private ophthalmologists seeing public macular injection patients without charging a gap (bulkbilling). But the economic unviability of the proposed new fee would lead many ophthalmologists to stop this work.
“I don’t charge a gap to around 30% of my injection patients who can’t afford to pay a cent in private – that’s out of goodwill, but that’s exhausting. If you look at just those patients who should – by right – be looked after in the public system but are being looked after privately, there would be another 15-20% flooded into the public system and it would fail,” he said.
“That’s just looking at the goodwill work. Then you’ve got people who were paying out-of-pocket costs who have been tipped over the edge because of the increased gap. They have gone from approximately $250 Medicare plus the $80 gap, to the other way around; there are not many people or pensioners who can afford more than $200 out-of-pocket every four or six weeks, and yes there is a safety net but that doesn’t kick in until they have spent a lot of money already.”
Without the ability to bulkbill or see patients that can’t afford the increased out-of-pocket costs, Chehade said ophthalmologists are worried about ultimately sending patients into public hospitals knowing for certain they won’t get the required care.
Dosing frequency concerns
Chehade is also concerned about the impact of optometrists, GPs and nurse practitioners being involved in intravitreal injection care.
He said models in the UK and other countries have shown nurse-driven injection services led to patients receiving a monthly dosing schedule, meaning patients suitable for treat-and-extend dosing probably weren’t getting optimal care.
“They basically go through this carrousel of frequent doses, because it’s only the specialist who understands the nature of the disease and can make the decision to extend,” he said.
With treat-and-extend, Chehade added, patients could be getting four injections per year, instead of 13. With that comes considerable cost savings. It also avoids inconvenience and risks, such as endophthalmitis.
“You’ve got to be careful when trying to reduce costs by taking the specialist out of it. The logic is wrong because ultimately with the injection fluid, which is around $1,600 a vial, if you are calling on the government to provide it every four weeks – rather than four times a year for patients who are destined to be well controlled – you are not only subjecting them to a lot of treatment, a huge amount of inconvenience and clogging up clinics, but you’re also creating a considerable cost to the health system.
“I think the government are not keen on seeing that happen.”
The final MBS Taskforce report is now with the Federal Government and Minister for Health Mr Greg Hunt.