A controversial intravitreal injection (IVI) policy shift will force some macular disease patients into paying out-of-pocket costs they haven’t previously – prompting some to drop out of care altogether – while causing disruption to already-stretched ophthalmology clinics.
Macular Disease Foundation Australia (MDFA), the Australian Society of Ophthalmologists (ASO) and the nation’s largest private ophthalmology provider Vision Eye Institute (VEI) are concerned with the government decision that prevents macular disease patients from making private health claims for anti-VEGF injections performed in private hospitals and day surgeries.
Instead, these people will now need to have their injections performed in private ophthalmology clinics. The procedure can’t be claimed through private health in this setting, so an out-of-pocket cost will likely be required.
It will be the only option left because, as MDFA CEO Dr Kathy Chapman pointed out, “public hospital eye injection clinics and bulk billing private ophthalmology clinics are either not available, or already at capacity”.
MDFA said the Federal Government confirmed the measure from 1 July 2025. It estimates 12,200 patients will be affected amid a cost-of-living crisis.
But it also presents a challenge for ophthalmologists who are offering IVIs in hospital settings.
VEI CEO Ms Amanda Cranage said it was fortunate that her organisation’s national network could already offer in-clinic IVI services, but shifting the volume of patients from its day hospitals into its clinics “will not be without its challenges from an operational point of view”.
“For example, navigating the concerns of patients who have private health insurance but are no longer given a choice of where their procedure will be performed, as well as safeguarding patients from abandoning their treatment due to cost concerns,” she said.
The contentious measure stems from the Medicare Benefits Schedule (MBS) Ophthalmology Taskforce Review.
Finalised in 2020, it recommended reclassification of item 42738 into a Type C procedure that does not “normally need hospital treatment”.
In-hospital intravitreal injections should occur in fewer than 3% of patients, the taskforce said, but in reality occurs in 18%, and is increasing. The committee felt “this is largely unnecessary and may be due to financial incentives”.
“This recommendation focuses on reducing low-value care,” it said.
Chapman said MDFA was concerned that with many people already feeling the cost-of-living pinch, macular disease patients previously accessing IVIs through private health would now have another expense to add to their budget.
“Macular Disease Foundation Australia is concerned that this will force people to give up their treatment altogether because they will no longer be able to afford it.”
Decision may ‘compound’ issues
Dr Chapman said MDFA had previously said it would only support the reclassification of this MBS item if there had been a significant increase in the number of public outpatient clinics offering bulk-billed eye injections.
The organisation had several recommendations to improve adequate and equitable access, including an ophthalmology practice incentive to bulk bill IVIs for age pensioners with AMD.
“We know that the cost and affordability of treatment are still huge concerns for many people living with macular disease, and there are still limited options to receive bulk-billed treatments,” she said.
Dr Chapman said MDFA had raised these concerns with the office of health minister Mr Mark Butler and would continue to.
“The Australian, state and territory governments must step up to improve access to eye injections,” she said.
“Our message for government is that investing in increased access to eye injection treatment for people with macular disease will not only save the sight of tens of thousands of people but will also save the government billions of dollars in the long term.”
Cranage said VEI recognised these barriers – cost being the most prohibitive – and in 2016 established its first purpose-built, low-cost IVI injection clinic in Boronia, Victoria. But it continued to offer various cost options to patients across all VEI clinics, including the day theatre setting or as an outpatient.
But she was concerned for patients currently receiving injections in theatre with no out-of-pocket cost. This would be alongside their private health insurance premium which she presumed wouldn’t decrease and may be unaffordable for some.
“We can only assume some patients will be forced to forego some injection appointments due to cost and access to affordable in-room injections. This will have a devastating impact on their sight and quality of life,” she said.
“Patient care is at the core of what we do, and knowing this decision will impact thousands of patients’ access to the care they need is why we are committed to offering a range of cost options for injections across all VEI clinics.”
ASO president Dr Peter Sumich said the IVI situation was “a conundrum”. He called it a “Pandora’s box” that was opened years ago when IVI was not a significant budget item, but was now best left to the business marketplace to sort out.
“It’s like a Rubik’s Cube being turned without a clear solution,” he said.
“To spell out the complexity: at present, in private settings, the Federal Government doesn’t have to fund the full IVI procedure but does fund the drug.
“In public hospitals, the state has to fund the drug but not the procedure. The insurers fund the procedure in private day surgeries, but not the drug, and this funding provides a welcome service to their policy-holders. Whilst the insurers resent the cost it does make their policy-holders happy.
“If private surgeries are not able to acquire funding then the cost may fall back on state governments who cannot even manage the small number of patients they service now.”
Alternately, he said it might fall to the Federal Government, which would be hit for the treatment, plus procedure, plus safety net.
“So in summary, it is convoluted, hard to explain simply, and a change in the system will probably hurt everyone, even the private insurers who will be assailed by their policy-holders who currently enjoy no gap funding,” he said.
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