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Overhauling the ophthalmology Medicare schedule – is it worth it?

The MBS Taskforce has published its final report into ophthalmology items containing recommendations that have come under intense scrutiny from the sector. But it wasn’t all bad news. Insight examines what the future ophthalmology care model may look like under Medicare.

With the MBS Taskforce’s final report into ophthalmology items now before the Federal Government, much of the spotlight has focused on dramatic changes to the way intravitreal injections could be billed and administered in future.

But, among the 19 recommendations to modernise ophthalmological Medicare services, there are many other interesting pieces of information, data and proposals that ophthalmologists across all sub-specialities ought to know.

For example, a raft of new Medicare items appear to be on the horizon to align glaucoma management with modern best practice. A new OCT item that can be claimed up to six times a year for macular degeneration has also been floated. And to tackle eyecare shortages in rural and remote communities, ophthalmologists could soon be offered incentives.

Unlike intravitreal injections, the taskforce resisted the temptation to change the cataract surgery item – whose fee has been reduced three times since Medicare was introduced in 1984. But questions were raised as to why its rebate/fee is higher on a time basis than other equivalent schedule items.

It’s no surprise eye injections and cataract surgery have been under the microscope. Together, they account for 42% of total ophthalmology services and 67% of benefits paid.

In total, in FY2016/17, ophthalmology’s items accounted for approximately 1.45 million Medicare services in Australia at a cost of $346 million. And during the past five years, service volumes for these items have grown at 5.5% per year, and benefits have increased by 6% annually. This growth is largely explained by an increase in the number of services per capita.

Modernising the entire MBS – which has more than 5,700 items – is a major undertaking, so the taskforce decided that specialised clinical

committees should conduct the detailed review. The 15 members of the Ophthalmology Clinical Committee, chaired by Queensland ophthalmologist Dr Bradley Horsburgh, reviewed 189 items and recommended some level of revision to 31.

With the taskforce ultimately deciding the recommendations put before Federal Health Minister Mr Greg Hunt, it broadly supported the ophthalmology committee’s recommendations. But the taskforce and committee didn’t agree on everything.

Eye injections

Since the release of the draft report in 2019, recommendations 18 and 19 have received the most attention for the way in which they would reshape intravitreal injection services.

Recommendation 18 proposes reducing the intravitreal injection MBS fee from $310.15 to $96.55 (-69%), so that it aligns with “the more complex” peri/retrobulbar injections, item 18240. Recommendation 19 then raises the prospect of optometrists and nurse practitioners performing intravitreal injections.

There is no Medicare data that distinguishes between right and left eyes that have received injections.

RANZCO and the Australian Society of Ophthalmologists (ASO) voiced concerns over these recommendations at the draft phase, but the MBS Taskforce forged ahead with the plan in its final report.

Those opposed to dropping the patient rebate/fee believe the measure will double or triple out-of-pocket costs for private patients, or drive them from a well-run private system, into an already struggling public system. RANZCO has previously said the proposed new fee is below the actual cost of providing the service, which would make it difficult for practitioners who provide bulkbilled injections to continue offering the service.

In reaching this final recommendation, the taskforce noted that in comparing the “relatively simpler” intravitreal injection procedure to peri/retrobulbar and other injections, the present rebates do not reflect the relative complexities of the procedures.

The taskforce even kept this recommendation in the final report despite the Ophthalmology Clinical Committee chair Dr Horsburgh stating the committee wasn’t prepared to endorse it.

Interestingly, the taskforce did consult with the ophthalmology committee as to whether the intravitreal injection fee could be justified, to which the committee responded: “[We] consider the current eye injection schedule fee to be justified. The schedule fee underpins service delivery, particularly for patients initially treated in the overburdened public system then transferred to private ophthalmologists, and those treated in ‘privatised’ clinics associated with public hospitals.”

The MBS Review is said to be clinician-led, with no targets for savings attached. But ASO vice president Dr Peter Sumich believed the recommendations were the work of technical experts who were clearly investigating ways to make MBS cost savings, rather than deliver clinical services.

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; 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 noted.

Optometrists and eye injections

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

The ASO has stated previously this would amount to “task substitution” and was simply a cost cutting mechanism that could threaten patient safety. If approved, the organisation says it could struggle to stand up in court – much like the glaucoma scope-of-practice case in 2013.

In its rationale, the taskforce said 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 taskforce report stated.

“[The report] 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 taskforce, international evidence from published, peer- reviewed clinical studies demonstrates that – with the correct training and protocols in place – nurse practitioner-administered intravitreal injections are 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. In the US, the state of Georgia passed legislation to enable optometrists to perform eye injections once they had completed a specialised 30-hour injectables training program, supervised by an approved ophthalmologist.

“The MBS 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.”

New OCT items attached to eye injections 

In other eye injection-related issues, the committee noted that almost all intravitreal injection events include an OCT service and consultation, but the majority of these couldn’t be billed because the MBS only has an initial OCT item.

As a result, the taskforce recommended the creation of a new OCT item number that can be claimed up to six times per year, per patient, for macular degeneration.

There was also a recommendation for creating two separate items for eye injections that define which eye was injected (left or right). Searchable per-eye Medicare data is non-existent, which is crucial to determine and monitor treatment frequency and identify low-value care.

According to the report, more than 24 injections per year for both eyes can exceed the recommended frequency supported by drug information and randomised clinical trials, but 0.4% of patients (247) received 24 or more injections in FY2016/17.

Additionally, fewer than three injections per year most likely indicates low-value care. In FY2016/17, 31% of patients (21,222) received three or fewer injections. The committee noted there were several valid reasons for low treatment frequency, and that this would be too difficult to monitor.

Concerns were also raised over the number of in-hospital intravitreal eye injections, which should occur in fewer than 3% of patients, but currently occur in 18% – with this number is increasing.

The ophthalmology committee believes this is largely unnecessary and may be due to financial incentives, prompting it to recommend that item 42738 be reclassified as a Type C procedure, which requires clinicians to fill out a form to justify in-hospital use.

“Various studies have compared injections given in an outpatient setting with those performed in an operating theatre and found no significant difference in endophthalmitis rates,” the report stated.

“Performing these injections in a hospital or day surgery adds significant cost to the procedure with no apparent clinical benefit.

The cost of cataracts 

The ophthalmology committee recommended no change to cataract surgery item 42702, stating that both the volume and service growth were in line with expectations.

Although the taskforce indicated it didn’t want to override this, it did ask the committee to explain why the MBS rebate/schedule fee for cataract surgery is higher on a time basis than other schedule items.

Notably, the taskforce pointed out the average time to perform cataract surgery has decreased from approximately 60 minutes 20 years ago, to 30 minutes today; and the rebate per hour of $1,140 is 1.7 times greater, or $481 per hour greater, than the rebate per hour for the next comparable procedure (prostatectomy); and 2.3 times greater, or $639 per hour greater, than the average of comparable procedures.

Cataract surgery is the most performed ophthalmic procedure in Australia.

In response, the committee said it believed the cataract surgery schedule fee is justified, and had already been reduced three times in 1987, 1996 and 2009, and frozen since 2010.

“There has been no material change in the time efficiency of cataract surgery since the late 1990s. The introduction of new technology, such as toric intraocular lenses, has also increased patient expectations. Responding to these expectations requires enhanced preoperative technical measurement and additional staff, equipment and infrastructure,” the committee stated.

Interestingly, the report stated that occasionally educated patients request clear lens exchange surgery to be billed as a cataract surgery. Although this is rare and explicitly excluded in the item descriptor, the committee said it may explain the 0.2% of total services provided to patients below 40 years of age.

As such, it recommended MBS Compliance investigate these cases, noting there are legitimate uses of 42702 under age 40, such as premature cataract due to other ocular or systemic conditions.

High out-of-pocket costs for cataract surgery and a low number of bulk-billed services for the procedure (just 3.5% on average) were also raised in the report.

It also noted that the bulkbilling rate only varies slightly across socio-economic groups, ranging from 2% in the least disadvantaged group to 5.9% in the most disadvantaged group in FY2015/16.

The committee agreed this low bulkbilling rate may be driven by additional costs of cataract surgery that are not covered by the MBS. These costs are usually covered by private health insurance. (For example, the cost of intraocular lenses and theatre fees, which are typically $1,800–$2,200, must be paid by an uninsured patient, irrespective of what fee is charged by the ophthalmologist).

Additionally, the committee recognised that several jurisdictions include visual acuity in cataract surgery referral guidelines, including in Victoria, New Zealand and Sweden. But it believed Snellen visual acuity was a “rationing mechanism” that doesn’t adequately represent visual function and important criteria such as contrast sensitivity and glare.

It considered the UK’s National Institute for Health and Care Excellence guidelines to be more reflective of modern practice which could be adopted more widely in Australia. These guidelines do not include Snellen visual acuity and emphasise the effects of cataract on the patient’s ability to perform day-to-day activities.

Modernising the glaucoma schedule 

Advances in glaucoma care has far outstripped the MBS over the decades and, as a result, many procedures that reflect current best practice don’t have an item number.

In its final report, the taskforce backed the recommendation for several new items covering at least nine procedures, such as repair of cyclodialysis cleft, glaucoma drainage device removal or insertion of intraluminal stent or tying off of lumen, and OCT diagnosis/monitoring of glaucoma, optic disc photographs.

The committee recognised these procedures require ongoing assessment of clinical efficacy and nominated Associate Professor Paul Healey and Professor Stephanie Watson to work with the health department and RANZCO, with the latter agreeing to sponsor Medical Services Advisory Committee (MSAC) applications for these items and provide supporting evidence.

Other recommendations 

Focusing on eye injections and cataracts, it was noted that out-of-pocket costs were high for these procedures, and the public system needed greater capacity and efficiency to allow uninsured patients to seek timely access to cataract surgery within public hospitals.

To address this, it was recommended the government allocate more funding to ophthalmology staff specialists in the public system, with these positions only available to ophthalmologists who participate in the training and supervision of registrars.

The higher prevalence of eye disease in rural Australians compared to their urban counterparts – particularly among the Aboriginal and Torres Strait Islander population – also prompted a new recommendation to entice more ophthalmologists to these areas.

Current outreach funds focus on assisting patients in accessing available health services, rather than incentivising clinicians to provide services, so the taskforce recommended a mechanism to cover the additional costs of rural and remote ophthalmology service provision.

More reading

MBS Taskforce keeps controversial eye injection proposals in final report

MBS eye injections plan could spell disaster for public system, ophthalmologist warns

Endorsed optometry report released for government consideration

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