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MBS proposals draw sharp rebuke from ophthalmic sector

Controversial recommendations to dramatically drop the rebate for intravitreal injections and allow optometrists and nurses to perform the procedure are part of a long-awaited ophthalmic Medicare Benefits Schedule (MBS) review.

The measures, released by the MBS Taskforce for consultation yesterday, could see out-of-pocket costs skyrocket for thousands of macular disease patients. The taskforce has also drawn sharp criticism for ignoring the advice of a 15-member Ophthalmology Clinical Committee, which was formed to provide expert guidance on the subject.

The Medicare Benefits Schedule Review Taskforce Ophthalmology Report has recommended some level of revision to 31 of the 189 MBS its examined. The process has been led by the ophthalmology committee’s chair Dr Bradley Horsburgh, with the overarching government-appointed MBS Taskforce claiming to “broadly support” the proposals.

Two recommendations pertaining to billing and administering of intravitreal injections have been met with immediate disapproval from the Australian Society of Ophthalmologists (ASO).

ASO president Dr Peter Sumich said the review recommended the fee for intravitreal injection its 42738, 42739, 42740 be reduced by 70%, bringing it to the same value as that of peribulbar or retrobulbar injections (it 18240).

In effect, this would take the intravitreal injection MBS fee from $305.55 to $95.10 with a new 85% patient benefit/rebate of $80.83. The benefit under the existing scheme is $259.75, a difference of $178.92.

“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 could potentially put private macular degeneration therapy out of reach for tens of thousands of patients.

“The proposed rebate would be well below cost for a service provider and one would expect to see a doubling or tripling of a patient’s out of pocket expenses. Clearly this will be beyond many patients’ ability and they will need to be managed by the public system which is already struggling.”

He added: “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.”

‘Task substitution’ criticised

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

Comparing the intravitreal injection procedure to peribulbar/retrobulbar injections, the taskforce noted the latter was 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.

However, the taskforce did note, “tracking and monitoring would be necessary to identify the impact on patients in terms of access and out of pocket costs”.

The consultation paper also recommended exploring the notion of appropriately trained nurse practitioners and optometrists performing intravitreal injections under updated guidelines. It states 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.

Overall, Sumich said the recommendations related to intravitreal injections would have “a devastating impact on service provision” in Australia.

“I have no doubt that consumer representative organisations such as the Macular Disease Foundation Australia and Diabetes Australia will be making it quite clear how unacceptable these changes are,” he said.

“ASO will of course also play its role in defending the rights of our patients.”

Sumich said he had been in contact with Federal Health Minister Mr Greg Hunt yesterday, who emphasised debate would now be welcomed as part of the next stage of consultation, concluding on Friday 20 December.

“I did point out that we have already made reasoned argument through my presentation to the Ophthalmology Clinical Committee which has been ignored by Taskforce Chair Prof Bruce Robinson,” Sumich said.

“Mr Kerry Gallagher, our ASO CEO, met in person with Minister Hunt [Thursday morning] in Brisbane to register our concern for continuance of affordable service delivery in outer suburbs, regions and rote areas.”

Sumich also pointed out that, if the injection fee is reduced, then It 105 could be co-claimed with intravitreal injections as before. There were no other recommendations for rebate cuts for ophthalmic its.

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