Frequent intravitreal injections are vital to help many older Australians keep their eyesight, but the costs can be prohibitive. Insight assistant editor Rob Mitchell speaks with those who have found ways to deliver bulk-billed services that maintain people’s vision and the practice’s bank balances.
Mr Devinder Chauhan is used to doing things a little differently.
When he arrived in Australia from Britain in 2006, the altruistic ethos of the NHS drove much of the ophthalmologist’s approach to his work.
Used to the collaboration that often comes from necessity and working with stretched resources, he looked beyond his own cohort to how he could help others in the wider ophthalmic catchment.
“I didn’t know any better,” says the Melbourne-based Vision Eye Institute retinal subspecialist. “Unlike other Victorian retina subspecialists at the time, I basically went out to lots of optometrists to do teaching.”
When his work took him beyond Melbourne, to Victoria’s rural, regional and remote centres, he realised there were many patients who lived far beyond the city’s seemingly gated healthcare community.
“They couldn’t get to the clinic, so I hired a bus to get patients from Bairnsdale, Sale, Traralgon to bring them to Wonthaggi; I would treat them, give them eye injections and send them home.”
When he later retreated back behind the walls of that community in urban Melbourne, the bus journeys continued for those patients.
But Dr Chauhan realised that despite his efforts to ease access to these vital injections and other services, many people were still facing significant out-of-pocket expenses to treat their macular degeneration and maintain their vision.
“It became obvious that there’s a whole bunch of patients for whom cost was a significant issue.”
That inspired him to set up a clinic in Boronia, in Melbourne’s east, in which intravitreal injection services are bulk billed, meaning no out-of-pocket cost to the patients.
That includes intravitreal injections for people living with neovascular age-related macular degeneration (nAMD), and other forms of macular disease, most of whom are pensioners on fixed incomes.
The only cost is $7.80 for the drug administered, which is the cost of the prescription at the pharmacy, subsidised via the Pharmaceutical Benefits Scheme. Patients don’t pay for scans or consultations. The injections, including the time and expertise of Dr Chauhan and others in his team, are covered by Medicare.
Those injections, item 42738 in the Medical Benefit Schedule, are currently reimbursed at $342.65 in the schedule.
Under the schedule’s calculations they are paid out at 85% benefit in ophthalmologists’ rooms ($291.30) and 75% benefit in a private hospital/day surgery ($257).
Dr Chauhan and NSW colleague Professor Mark Gillies believe that this arrangement is financially sustainable while preserving patients’ vision. Especially when those patients may need those injections regularly and frequently for the rest of their lives, and the procedure can be done in barely a few minutes.
But most ophthalmologists and other specialists do not accept the rebate.
Because of the limited capacity of the public system to provide these injections – and with more than 90% of ophthalmologists working in private healthcare – patients have little choice other than to see and pay for a private specialist.
Most of those private practices do not bulk bill for the injections, often only doing so in exceptional cases, meaning the cost of the appointment can be three or four times higher than the Medicare fee. In some parts of Australia, that means patients may have to pay $1,000 or more, or more, with part of that refunded by the rebate and any additional rebates after reaching Medicare Safety Net thresholds.
A plan for change
That is something Macular Disease Foundation Australia (MDFA) is hoping to change.
In its 2019 economic modelling report, MDFA found that intravitreal injections were primarily delivered in private ophthalmology clinics in Australia, with only around 20% of them offering bulk billing, leaving more than 72,000 people with no choice but to pay out-of-pocket cost.
It believes the magnitude of that higher cost is felt beyond the practice and the patient.
MDFA says there are an estimated 1.9 million people in Australia with some form of macular disease. In 2023, more than 108,000 people with a treatable macular disease, including nAMD, diabetic macular oedema, and retinal vein occlusion, received eye injection treatment. The total annual economic cost of vision loss in Australia is estimated to be $16.6 billion.
It says that, for almost one in 10 Australians who receive eye injections, the cost of living with their condition, including eye specialist appointments, injections and vision aids, is more than $6,000 every year.
Many of those are on a fixed income. For those paying out of their own pocket, the median total cost equates to 12% ($3,621) of their annual government pension.
As with so many other areas in healthcare, that cost increases for those living beyond the main centres.
For people living in those regional and rural communities, the median total annual cost was over $400 more per person compared with those in major cities.
The highest cost is more than $1,700 more per year for people living remotely, compared with people living in a metropolitan area ($8,911 vs $7,127).
Boronia-based Dr Chauhan understands what that gap in cost and access means for many of his clients.
“I have patients who live in Queensland and Tasmania for whom, if they book the flight early enough, it’s cheaper to fly here, have an injection and go back,” he says.
“It’s cheaper for people to fly interstate than it is to have injections, because in the really expensive states, New South Wales and Queensland, they literally charge them $1,000.”
MDFA says that higher cost leaves many pensioners around Australia with less money in their bank accounts for rent, bills, food and other essential life expenses.
For some it means making a choice between their eyesight and paying household bills.
‘Treatment persistence’ is a significant problem in Australia, with approximately 50% of people stopping the injections within five years of starting them.
MDFA CEO Dr Kathy Chapman says its findings highlight that cost and access are the two main reasons people delay or stop treatment.
“Our research underscores the immense financial pressure that these high costs have on people living with macular disease who rely on their pension payments to get by,” she says.
“Even when the country is not in a cost-of-living crisis, accessing affordable or bulk-billed treatment is an insurmountable problem for too many low-income earners, pensioners, and self-funded retirees.”
That is why it believes a small investment of $11.1 million into Medicare would save the country $140 million annually in disability, aged care and other related health system costs.
Under the MDFA proposal, all ophthalmologists who bulk bill eye injections for eligible pensioners with neovascular age-related macular disease would be eligible to receive an incentive payment from the Federal Government.
That would be $100 per eye injection service per patient with a pension card.
If the patient needs injections in both eyes and this is performed on the same day in the same service, the reimbursement is $50 for the second eye.
Dr Chauhan and Prof Gillies both believe the incentive could make a difference and increase the number of specialists prepared to bulk bill for the injections. Although the former is a little sceptical that professionals used to charging $1,000 or more for the procedure will be happy to take half of that, even with the extra incentive.
Sustainable business models
But they insist bulk-billed injections are viable from a business perspective, even without that incentive. Even if both have different ways of arriving at that conclusion.
Every Tuesday at Dr Chauhan’s Boronia clinic, he and a colleague are solely focused on intravitreal injections.
The procedure itself takes barely five minutes, but the patient will spend about 30 minutes in the clinic as they see several people for tests and consultations.
“They go in to see an orthoptist or a technician, who will measure their visual acuity and ask them some questions about their health,” he says.
“They also get their intraocular pressure measured, have questions asked about how their eyes are going, and whether they have any problems at all. If there’s something that needs attention, I see them before we even consider having an injection.
“Everybody gets a scan of both eyes every visit.
“And then they’ll go through and have anaesthetic drops, antiseptic washes – then they’ll come through and we work between two rooms, assessing their scans and making decisions about their treatment before injecting.”
The testing and access to diagnostic equipment are free.
With Dr Chauhan and his colleague getting through between 100 and 120 patients a day, the practice can make up to $32,000 from the bulk billing.
The rest of the week is devoted to other retinal and general ophthalmology services, and those wanting injections who were unable to make the Tuesday clinic.
Many of those people will be back in a few weeks, and frequently, with MDFA numbers showing that people receiving eye injections for nAMD have, on average, six treatments per year, usually for the rest of their lives.
Dr Chauhan acknowledges that might sound a little like “factory work”, but “patients appreciate the efficiency, consistency and respect for their time; they are in the clinic for 30 minutes or less”.
But he believes it is a good, sustainable business model, one that supports a clinic and eight staff, all while helping patients to hold on to what vision they have left.
Prof Gillies and his colleagues at Sydney Eye Hospital and Safe Sight Institute take a very different route to the bulk-billed patient journey – a public-private partnership.
He says the public health system is not set up to do intravitreal eye injections.
“The trouble with the injections is that they came in about 15-20 years ago, whereas public hospitals are modelled on diseases and their treatment from about 40 or 50 years ago, and the traditional way you learn in medical school.
“The public hospitals just didn’t want to know about it,” he says. “It was too difficult to cope with; they would have had to set up big clinics and motivate doctors to do injections in these clinics . . . and it’s monotonous and quite hard work.”
Monotonous, hard, but important.
So patients at Sydney Eye Hospital are referred to the private Save Sight Institute, which conducts injecting clinics funded by Medicare.
“They can do high-volume clinics where people just do nothing but inject, inject, inject.”
That volume – a professional at the clinic can do about four injections every 15 minutes, 16 an hour – means the clinic is financially sustainable.
Those patients are then monitored by Prof Gillies and his colleagues in the public system. “We’ll see them around their third injection and assess them – is the lesion active, is the injection interval too long, do we need to shorten the interval? Or is it stable?”
He says it is no secret why many of Australia’s healthcare specialists – not just ophthalmologists – do not offer bulk billing. And not just for intravitreal eye injections.
“Most specialists in any area of medicine in Australia do not choose to make less money.”
He believes the incentive promoted by MDFA might encourage more to lean on Medicare to fund the injections.
“If it does cost you $10 million, so that means you subsidise 100,000 injections, then that is probably worthwhile.”
But the government needs to address fundamental inadequacies in the Medicare system.
“Specialists hardly bulk bill at all because the rebate doesn’t go up with inflation,” says Prof Gillies. “It’s a cost-cutting thing. So if it doesn’t go up, the doctors aren’t going to bear the cost. I don’t think that’s fair.”
Australian Society of Ophthalmologists president Dr Peter Sumich agrees.
“Ophthalmologists don’t offer bulk billing as a standard, due to the same reasons they generally don’t rebate every patient,” he says. “The Medicare rebate schedule is out of date and an imaginary number.
“In general the schedule fee in Medicare for all item numbers hasn’t been indexed or increased to represent inflation, wages and the Consumer Price Index. I’m never quite sure whether the proponents of the MBS actually realise that it is like trading in 1948 shillings rather than 2025 dollars.”
He believes the MDFA proposal might be good for “an adjunct public hospital clinic set up nearby where infrastructure is provided by the hospital”.
But it may not work in private ophthalmology because it is simply a lump-sum practice incentive payment that would not allow for “difference billing”, the ability of a practice to seek a top-up from the patient to cover costs.
Show me the money
Whether the government takes up the MDFA proposal remains to be seen. Whether it might be a success is yet to be tested.
The current reality is that the system relies on the innovation and altruism of a handful of professionals, including Dr Chauhan and Prof Gillies, to try to prevent too many people falling through the gaps and losing their vision.
Other specialists do allow some of their patients to pay through Medicare.
They make judgements based on what they see before them, says Prof Gillies.
“I probably bulk bill about a third of my patients based on a personal basis. I’m not sure if I’ve got it right or wrong, maybe I’m charging people who are poor, you never know. It’s very difficult – people aren’t going to declare their income to you, but you just make a judgment.”
Dr Chauhan says many specialists do this so they can feel like they are making some contribution.
But perceptions can be wrong. And dangerous.
“Older blokes, particularly, and women too, will dress up to see the doctor,” he says. “And they would not dream of saying to a doctor, ‘oh, it’s expensive. I can’t afford it’. So they just shut their mouths, and then they’re suffering outside the clinic.”
Suffering internally as well.
He sees plenty of patients from other clinics who should be having the injections every four to six weeks but have probably pushed it out to eight or more, simply because of the prohibitive cost.
Both Dr Chauhan and Prof Gillies are adamant that this is about one thing: money. But both are also adamant that there’s enough to be made, even if practices don’t go down the high-volume route.
Dr Chauhan wants it made clear that he’s not against specialists making money.
He acknowledges he’s certainly not struggling: he’s working from home as he talks with Insight, in the wealthy, pinot-producing Red Hill region of the Mornington Peninsula.
The success of his career, practice, even the bulk billing arrangement, has allowed him the freedom and time to develop Macuject – clinical decision support software to help “optimise treatment” for wet AMD patients.
He’s hoping to sell it into the massive US healthcare market, where healthcare costs are even more prohibitive.
It’s just that he and Prof Gillies believe professionals and practices can make enough while not undermining their patients’ health.
“I’m very happy to contribute towards patients not losing out, not having to choose between losing their vision and eating or keeping their vision and not eating,” says Dr Chauhan.
More reading
Liberal and Labor vow to maintain intravitreal injection MBS rebate
Annual out-of-pocket eye injection costs to double to $3,900 under rebate cut – modelling
MBS Taskforce keeps controversial eye injection proposals in final report
