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Questions over economic viability of MBS proposals

Proposed cuts to the rebate and fee for intravitreal injections will impact bulk billing services and access to treatment, Australia’s ophthalmic sector has warned.

Optometry Australia (OA) has also voiced its support for changes that would allow non-ophthalmologists to perform the procedure, however the Australian Society of Ophthalmologists (ASO) is against the move.

The comments follow the passing of the 20 December deadline for submissions on the draft Medicare Benefits Schedule Review Taskforce Ophthalmology Report.

Released in October, the report recommended revision of 31 of the 189 Medicare Benefits Schedule (MBS) items under review. Ophthalmic submissions have centred on two controversial recommendations.

The first would reduce the intravitreal injection MBS fee from $305.55 to $95.10. In turn, the patient benefit/rebate would drop 69% from $259.75 to $80.85.

The second recommendation raises the prospect of optometrists and nurse practitioners performing intravitreal injections, a proposal that has split the sector.

In its submission, the ASO states it “strongly opposes” both recommendations and warns changes might impact access to macular disease treatment.

“The suggested patient rebate cut for intravitreal injection procedures, for which there has been no clinical or economic proof offered by the taskforce, will ultimately drive patients from the current established and highly effective and efficient private system, into an already struggling public system, indeed a public system that in many areas is non-existent,” the submission stated.

“Patients suffering critical macular conditions will have their eyesight severely impacted if left to wait for treatment or attempting to locate and secure services in areas where currently none exist.”

The ASO also claimed allowing optometrists and nurse practitioners to independently treat macular disease patients amounted to “task substitution”. It was “simply a cost cutting mechanism” that could seriously threaten patient safety.

The submission referred to a 2013/14 legal case in which the ASO opposed a significant scope of practice change to allow some optometrists to diagnose and independently manage glaucoma.

“The ASO driven court action to challenge that optometrists were not qualified to treat glaucoma patients as they did not have the specialist training and skills required was recognised and accepted by both the Australian Health Practitioner Regulation Agency and the Optometry Board of Australia.

“The ASO is confident, given this legal precedent, that a similar court finding would apply to non-ophthalmologists attempting to treat macular diseases independently.”

RANZCO CEO Dr David Andrews said the college also disagreed with both recommendations. He said plans to reduce the MBS fee for intravitreal injections were “economically unviable”.

“Simply put, it’s below the actual cost of providing the service; time, tests needed, consumables and drugs taken into consideration,” he said.

“Even bulk billers won’t be able to afford to provide the service. This means patients will almost certainly be billed an out-of-pocket fee or have to find a public hospital that does injections. These are very few, because state governments don’t fund it appropriately.”

He added RANZCO’s position was that intravitreal therapy should only be performed by trained ophthalmologists.

Optometry welcomes change

In its submission, OA applauded the recommendation to pursue options for intravitreal injections to be performed by non-medical doctors, including optometrists.

OA stated injections have also increased the burden on the health system, with patients often requiring serial treatments.

“The timely access to the right practitioner at the right time is vital for an efficient and effective health system,” part of the submission supplied to Insight said.

“Not all patients require specialist advice and intervention for every episode of care and the skills of all the practitioners in the health system should be used to their fullest.

“Optometry Australia believes that an efficient and effective system would support ophthalmologists to spend the majority of their time undertaking tasks that only they can perform, and that those patients who can be managed safely by an optometrist or a nurse would be managed by these health professionals.”

OA referenced evidence demonstrating non-medical professionals could undertake intravitreal injections safely.

“It has been shown that optometrists are able to correctly classify disease activity with the same accuracy as ophthalmologists. It is also shown that these changes can be implemented with high levels of patient satisfaction and increased throughput of retinal clinics.”

Concern over patients

Macular Disease Foundation Australia (MDFA) CEO Ms Dee Hopkins said while the organisation supported a review into the current care model, it was concerned about the proposed patient rebate cut.

She said Australia boasted some of the world’s best outcomes for neovascular age-related macular degeneration and diabetic macular oedema patients. This could be jeopardised if people are required to pay additional out-of-pocket costs, which currently average $1900 per patient annually.

“Invariably MBS cuts inherently get passed on to patients, we have seen it time and time again,” Hopkins said.

“Between 18–23% of people are getting access to some public but mostly privately bulk billed services, so the costs of those services are going to be severely impacted first. The risk is that specialists offering those services won’t be able to deliver them for $80.85, the proposed cut.”

Hopkins said the MDFA’s submission featured modelling that demonstrated a rebate cut would increase costs to other parts of the system. She had spoken with Commonwealth Health Minister Mr Greg Hunt who advised her that the review was not financially motivated.

“In our economic modelling, we have shown him there won’t only be MBS savings, there will also be significant [Pharmaceutical Benefits Scheme] savings, however when people lose their vision they are eight times more likely to fall, fracture a hip, mental health issues, there’s the cost of carers, less productivity.

“A cut to this item for sight saving treatment will effectively cost shift to other parts of the health system, and result in direct net costs to the taxpayer.”

Hopkins said the MDFA was open to non-ophthalmologists performing intravitreal injections in future, particularly under supervision by an ophthalmologist, but there isn’t enough detail yet.

“We would welcome an opportunity to explore alternative models, but we would be seeking to ensure we retain the good patient outcomes we already enjoy in Australia, as well as safe access and quality care for patients. If that can be done, and while it’s a valid suggestion, it would however take a long time to implement.”