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MBS Taskforce keeps controversial eye injection proposals in final report

Despite vehement opposition from ophthalmologists, the MBS Taskforce has forged ahead with plans to cut the rebate for intravitreal injections and consider allowing nurses and optometrists to perform the procedure in its final report to the Federal Government.

More than a year after a draft document was released for public consultation, the taskforce this week unveiled its Final Report on the review of Ophthalmology Medicare Benefits Schedule items that contains 19 recommendations for the government to now consider.

Previously, RANZCO and the Australian Society of Ophthalmologists (ASO) have publicly opposed two controversial recommendations, which have remained in the final report.

The first would reduce the intravitreal injection MBS fee from $310.15 to $96.55 (a 69% reduction), so that it aligned with “the more complex” peri/retrobulbar injections, item 18240. The second recommendation raises the prospect of optometrists and nurse practitioners performing intravitreal injections.

Those opposed to dropping the patient eye injection rebate/fee believe the measure will drive patients from a well-run private system, into an already struggling public system. RANZCO has previously said the proposed fee would be below the actual cost of providing the service, meaning bulk billers wouldn’t be able to continue providing their usual service. Patients would ultimately be charged out-of-pocket costs or forced to seek public care.

Lower rebates could lead to greater out-of-pocket costs for patients, particularly if practitioners are unable to provide bulk billed services.

In reaching this final recommendation, the taskforce stated rebates for intravitreal injections and peri/retrobulbar and other injections don’t reflect the relative complexities of the procedures. This would not preclude the intravitreal injection items to be co-claimed with a consultation.

The taskforce kept this recommendation in its report, despite the Ophthalmology Clinical Committee chair Dr Bradley Horsburgh saying the committee wasn’t prepared to endorse it.

“As the governing body for the review, the taskforce is responsible for all recommendations and agreed this recommendation should proceed to public consultation. This recommendation therefore stands alongside other draft recommendations within the report, noting that it has originated from the taskforce,” the taskforce stated.

ASO vice president Dr Peter Sumich said the recommendations were the work of technical experts who were clearly investigating ways to make MBS cost savings rather than deliver clinical services.

Peter Sumich.

He said cutting the intravitreal injection rebate didn’t translate into the real world. It failed to recognise the cost to the private sector in delivering the sight-saving treatments from Brisbane to Bunbury; particularly with an under-resourced public sector that was non-existent in many areas.

“The important thing to note is that this is a report to the government, not by or from the government. Australia has the best clinical outcomes in the world because the current system works,” Sumich said.

Optometrists and eye injections

The committee also set out its rationale for recommending that appropriately trained optometrists, nurse practitioners and GPs be considered for administering intravitreal injections.

Previously, the ASO has stated this would amount to “task substitution” that, if approved, may struggle to stand up in court.

Firstly, the taskforce argued the recommendation was in response to evidence of clinical need, maldistribution of clinicians and constraints on overall supply.

“The Department of Health Workforce Report (2018) found there were 990 accredited ophthalmology specialists with current medical registration in 2016. The large majority were clinicians and, of those, 83% were located in [major cities],” the report stated.

“[It] also noted that the demand for ophthalmology services is estimated to grow at 2.8% per year to 2030, and that projections reveal an undersupply of ophthalmology specialists throughout this projection period. International eye health workforce rates indicate Australia has 36 surgical ophthalmologists per million people, ranking it in the bottom three for OECD countries with available data. Optometry rates are reasonably high, at 184 per million.”

According to the report, international evidence from published, peer-reviewed clinical studies demonstrated that – with the correct training and protocols in place – nurse practitioner-administered intravitreal injections were “as safe as ophthalmologist-delivered services”.

It said nurse administration of intravitreal injections was most established in the UK National Health Service, where the care delivery model has been recognised and codified by the Royal College of Ophthalmologists.

“The Taskforce notes in particular that intravitreal injections have been performed by specially trained nurses at the Auckland District Health Board since 2012. These clinics have been expanded over time to become standalone injection clinics run by Nurse Practitioners (NPs). The NPs assess patients, make decisions on the need for intravitreal injections and arrange for follow up. These clinics run autonomously with collaboration of Senior Medical Officers rather than ophthalmologists,” the taskforce report said.

“Further, nurse-delivered intravitreal injection services have been studied (and results published in the medical literature) in Denmark and New Zealand, and reported in Spain, Australia, Scandinavia, Singapore, and elsewhere.”

If the government adopts this recommendation, the taskforce said it would require input from RANZCO, the Royal Australian College of General Practitioners, the Australian College of Nurse Practitioners and the Australian College of Optometry. This would include updated guidelines specifying that trained nurse practitioners, optometrists and general practitioners may deliver this procedure, as well as by supporting appropriate training programs.

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