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Streamlining the optometric Medicare schedule

With optometrists performing three-quarters of all eye exams in Australia, the optometric Medicare schedule has a major bearing on the quality of eye health in this country. Insight dives into the MBS Taskforce’s endorsed report that could reshape primary eyecare for decades to come.

A desire to reduce red tape for optometrists and a raft of measures affecting computerised perimetry – where concerns have been raised over potential misuse as a screening tool – are among the key Medicare reforms likely to impact optometrists.

In its endorsed report to the Federal Government published late last year, the MBS Taskforce backed 11 of 14 recommendations by the Optometry Clinical Committee, with the most notable exclusion being its decision not to support more frequent eye exams for middle-aged Australians.

During the course of its work, the committee – chaired by Adjunct Associate Professor Phil Anderton from UNSW – reviewed 32 MBS items. These items related to consultations, contact lenses, domiciliary services, removal of embedded foreign body and telehealth. In the financial year 2017-18 these items accounted for approximately 9.4 million services at a cost of $438 million.

In the period 2012/13 to 2017/18, compounded annual growth for optometric service volumes remained at 4.6% and total cost of benefits at 3.6%. The population increased at a lower 1.6% annually, but the ageing population is likely to be behind costs increasing at a higher rate than rate of population growth.

In the financial year 2017-18 the optometry items under review accounted for approximately 9.4 million services at a cost of $438 million.

In keeping with the purpose of the review, the taskforce and committee signalled their intent to streamline and simplify the optometric schedule. This included joining the similar ametropic (contact lens) items and amalgamating the change of visual function and new symptoms items and removing a ‘same practice’ restriction.

With the rise of online contact lens retailers, the Federal Government has also been asked to sign off on rewording the explanatory notes for all 10 contact lens prescription and fitting items, removing the requirement for the optometrist to deliver the lens.

Computerised perimetry 

An intriguing point to emerge from both the optometry and ophthalmology taskforce reports was the apparent excess use of computerised perimetry among Australian optometrists.

Computerised perimetry has reportedly become the standard of care in optometric and ophthalmic practice to monitor glaucoma-related visual field defects. These tests, however, aren’t intended for screening purposes via the MBS. The optometry committee, along with the ophthalmology committee, was concerned about variation in service provision across the ophthalmic and optometric items, particularly the variation in services per capita by age group.

Figures show service growth for item 10940 in optometry are double the rate of comparable ophthalmology items (8% and 4% per year, respectively).

In its investigation, the committee found computerised perimetry services performed by ophthalmologists appear to be in line with expectations, with the rate of servicing increasing exponentially with age. This is in a similar way to glaucoma prevalence rates.

However, service rates by age and growth for optometric item 10940 haven’t aligned with expectations. It also didn’t increase exponentially with age; instead, dropping off for patients aged 80 years and above, and higher than expected for those aged 50 and below.

The committee felt this may indicate that computerised perimetry is being used as a screening tool.

This concern was also the basis for the taskforce ultimately rejecting one of the committee’s original proposals to create a new item for a brief consultation (not more than 15 minutes) to be co-claimed with computerised perimetry (items 10940 and 10941).

It was proposed the item would only be claimed when monitoring suspected or diagnosed glaucoma, with elements of a short consultation – such as intraocular pressure measurement or slit lamp examination – often necessary at the same visits as a visual field examination.

The taskforce rescinded this recommendation because of concern for misuse of computerised perimetry as a screening tool without a clear rationale. To avoid unnecessary screening, it then endorsed a separate proposal to reword the explanatory notes for these items to emphasise the need for practitioners to document their rationale for performing a computerised perimetry test.

The optometry committee was asked to explain why perimetry usage was higher than expected among optometrists. It attributed the rise, among other things, to greater patient awareness of the asymptomatic nature of eye diseases and the importance of early detection.

It stated optometrists are primary eyecare practitioners who use visual fields as part of a diagnostic test regime on indication as per the schedule. They conduct more than 75% of all eye exams in Australia and need to differentiate the normal and healthy against conditions and diseases of the eye and visual pathway.

There’s also an increasing number of therapeutic optometrists skilled at detecting, monitoring and treating various eye diseases. More than 62% of all optometrists are therapeutically qualified, and each year 350 optometrists qualify while 150 older non-therapeutic optometrists retire. The current trend indicates 85% will be therapeutic qualified and managing more complex cases by 2029.

The taskforce didn’t support increasing the frequency for comprehensive eye exams from three to two years for people aged between 50 and 64.

In another recommendation, however, the taskforce did recognise an additional, third visual field test in a 12-month period may be required in some circumstances to establish a reliable baseline estimate for future glaucoma progression or determine progression over a shorter period.

As a result, the endorsed report supported the formation of a cross professional departmental working group, including ophthalmologists, to develop a rationale and cost effective implementation model for this, with eligibility restricted to glaucoma patients at high risk of progression.

Another notable inclusion affecting computerised perimetry is the amendment of items 10940 and 10941 to allow the service to be performed by a suitably qualified person “on behalf of” the billing optometrist.

The committee recommended a cross professional working group be convened to develop appropriate training guidelines, but the taskforce went further and also requested a credentialing process that defines who is suitably qualified.

Eye exams for middle-aged Australians 

While the optometric community was largely positive about the outcomes of the report, there was disappointment over the taskforce’s refusal to support increasing the frequency for comprehensive eye exams from three to two years for people aged between 50 and 64.

The taskforce found “there was no clear justification” for this, despite the optometry committee laying out a detailed rationale, while accepting there would be “costs involved”.

Optometry Australia (OA) general manager of policy Ms Skye Cappuccio said: “We did provide a comprehensive review of the evidence and we felt that it made a strong case for this change but this evidence does not seem to have been recognised by the taskforce.”

Performing intravitreal injections 

Although intravitreal injections weren’t mentioned in the optometry review, the taskforce’s final review into ophthalmology items recommended consideration of appropriately trained nurse practitioners, optometrists and GPs to perform the procedure.

While this is opposed by ophthalmic bodies, OA stated it had been advocating for pilot initiatives for optometrists to support ophthalmologists with intravitreal injections, as a mechanism for better patient access.

“We were most pleased to see this recommendation as we believe that optometry working with ophthalmology can help support better access to treatment via intravitreal injection which can be critical to saving people’s sight,” Cappuccio said.

“We will continue to seek RANZCO’s support to work collaboratively on models of care that utilise appropriately trained optometrists in the provision of this treatment.”

Contact lenses 

The emergence of online retailers has led to a seismic shift in the way consumers purchase optical products, including contact lenses.

To align with this market trend and simplify the schedule, the endorsed report recommended rewording the explanatory notes for all 10 contact lens prescription and fitting items. Specifically, removing the requirement to deliver the lens (10921 to 10930).

This would allow for situations where patients purchase their contact lenses from a different point-of-sale. However, the clinical service of contact lens fitting, patient education and trialling of the lenses remains unchanged.

To further reduce red tape, the report also recommended combining the similar and low usage ametropic schedule fee items (10921, 10922, 10923 and 10925) into one item.

The committee considered this would continue to cover all contact lens fittings situations and simplify claiming processes.

Domiciliary visits 

With fewer than 21,000 services provided under items 10931 and 10933 with a spend of only $176,000, the report proposed introducing a single flag fall for domiciliary visits and replace both items with a single item covering all domiciliary visits.

It also recommended removing co-claiming restrictions by; allowing the billing of a short consultation (10916 and 10918) at domiciliary visits; and allowing billing of computerised perimetry (10940 and 10941) with an attendance.

The optometry committee stated there were many scenarios where a short domiciliary consultation is appropriate – such as the removal of ingrown eyelashes, dry eye management and dilated fundus examinations.

But current restrictions for visits to nursing homes disadvantaged this at- risk population, given the availability of modern portable visual field analysers.

“The change would support improved access for those at home or in residential aged care facilities, promoting the principle of appropriate and timely assessment, and improving outcomes for people where timely assessment can be crucial in early intervention,” the committee stated.

Telehealth endorsed 

According to OA, the taskforce endorsed all recommendations from the ophthalmology committee, including the establishment of two new telehealth items.

This included an item for a patient-only consult on referral from optometry only; and one for providing management advice via report to optometrist and patient.

OA CEO Ms Lyn Brodie added: “Optometry Australia has been advocating for the latter as an important support for optometrists and ophthalmologists to work collaboratively to ensure patients can have ready access to the care they need.”

More reading

Overhauling the ophthalmology Medicare schedule – is it worth it?

Endorsed optometry report released for government consideration

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

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