Glaucoma, Local, News, Therapies

Sector embraces government approval of standalone MIGS

From this month, surgeons can perform standalone minimally invasive glaucoma surgery (MIGS) under Medicare, seeing Australia become the first major developed economy to universally approve the procedure in both public and private settings.

In the 2019-20 Mid-Year Economic and Fiscal Outlook, the Federal Government announced it would support a Medical Services Advisory Committee (MSAC) recommendation to list a new item for the insertion of micro-bypass glaucoma surgery (MBGS) devices – also known as MIGS. The item commenced on 1 May and is available to patients with open angle glaucoma for whom conservative treatment has failed or is contraindicated.

Ashish Agar.

It follows years of advocacy led by the Australian Society of Ophthalmologists (ASO) after a 2017 change in item number regulations threatened funding for all MIGS procedures.

The issue was partially addressed in October 2018 when the government approved a new item number, but limited its availability to those simultaneously undergoing cataract surgery. Ophthalmologists believed the measure did not go far enough because glaucoma patients not needing cataract surgery, or who had already had the operation, weren’t eligible.

“There are a few good stories to come out of this latest approval,” ASO vice-president and glaucoma surgeon Dr Ashish Agar, from the Prince of Wales Hospital in Sydney, told Insight.

“Firstly, Australia is leading the world now to allow this level of access to MIGS, as the first universal healthcare system in the world that will now allow this new technology as a standalone procedure.

“Secondly, it shows the system can work. We spend a lot of time criticising the Australian healthcare system, but this outcome demonstrates that if you approach an issue in a positive light as a team, and work hard through the process and technical work, we can achieve an excellent result for our patients.”

The ASO’s successful application to MSAC comprised a team including health economists Thema Consulting, industry (particularly Glaukos but also crucial data provided by Ivantis), with supporting statements from the Australia and New Zealand Glaucoma Society (ANZGS), RANZCO and Glaucoma Australia.

Agar said MSAC set the bar high in terms of evidence of the safety, effectiveness and cost of MIGS compared with other existing treatments such as trabeculectomy.

“And, as a result of that, we secured the approval but it has been designed to increase the level of science coming out the other end,” Agar said.

“This is not an all-comers process; patients will be screened for their eligibility and will have to meet specific criteria within the mechanism set up by RANZCO and ANZGS to ensure this process is followed.

“It also differs from a normal item number listing; this is a sophisticated approval where we are going to continue collecting data and outcomes and that will actually improve the evidence base going forward.”

At the time of writing, Agar said the ASO had not received documentation on the MBS fee for the procedure.

When it approved the item number last year, MSAC compared MIGS alongside trabeculectomy and concluded that although MIGS was slightly less effective, it was safer and may allow some patients to delay or avoid trabeculectomy.

Other analysis shows MIGS generally costs less than trabeculectomy, and is projected to save the MBS approximately $500,000 per annum by the fourth year of listing. This saving is driven by fewer initial and revision trabeculectomy services, however the true financial impact will depend on the efficacy of MIGS in reducing trabeculectomies, which is uncertain.

“MSAC will review the use of [MIGS] after two years to see what effect it has on the number of trabeculectomies being done and make sure it is still cost-effective,” the committee stated.

MSAC also supported establishing a registry to record outcomes.