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Tuesday / August 16.
HomeminewsAnti-Vegf Changes Highlight Need for Health Cover Reform

Anti-Vegf Changes Highlight Need for Health Cover Reform

Ophthalmologists have been encouraged to perform routine intravitreal injections for macular degeneration in rooms as opposed to doing the treatment in day surgeries or private hospitals. The recommendation has come as one of the “top five” messages from The Royal Australian and New Zealand College of Ophthalmologists (RANZCO) as their contribution to the ‘Choosing Wisely Australia’ campaign.

According to the campaign statement from RANZCO, “Intravitreal injections may be safely performed on an outpatient basis. Don’t perform routine intravitreal injections in a hospital or day surgery setting unless there is a valid clinical indication.”

Macular Disease Foundation Australia has voiced concerns over the recommendation, because it impacts accessibility and affordability of treatment for some Australians. Only patients who receive intravitreal injections in private hospitals /day surgeries have the gap payment associated with treatment covered by private health insurance.

Julie Heraghty, Chief Executive Officer of Macular Disease Foundation Australia said the issue typifies a basic systems failure in private health insurance. “It is timely that the issue of treatment for macular disease has arisen in the midst of the government initiated private health insurance review, chaired by Professor Graham Samuel. The existing legislation does not allow for people to claim the gap payment for in-rooms treatment of macular degeneration from their private health insurer,” she said, adding that this should be changed.

More and more costs are being transferred onto the patient, in this case the private health insured patient, in effect disadvantaging them for taking responsibility for their own health requirements

“More and more costs are being transferred onto the patient, in this case the private health insured patient, in effect disadvantaging them for taking responsibility for their own health requirements.

“This situation is compounded by the recently approved average 5.59 per cent increase in private health insurance premiums from 1 April. The problem is that 85 year olds, who have been dedicated life-long customers of health insurance providers, have paid their premiums for a package that they believe will provide for their needs, especially chronic disease in older age. Now they find that at a time when their income has fallen, their health costs are rising and in many cases, the gaps will not be covered by their health insurance.”

She said Minister Ley’s solution is to shop around private health insurers to get a better deal, however comparing the cost of private health insurance can be likened to comparing contracts for mobile phones, especially for those with multiple chronic conditions. Additionally, Ms. Heraghty said, it is problematic that a for-profit health insurer would want to take on a client who is high risk in terms of cost and will most probably not be paying premiums for a long period of time.

Asked whether patients may not pursue treatment if they cannot afford to have treatment in rooms, Ms. Heraghty said, “That is always a risk given various individual circumstances and at this point we are relying upon an ophthalmologist not allowing this to occur.”

Ms. Heraghty said the private health insurance system needed a radical overhaul. “The Foundation made a strong submission and attended a round table with Professor Graham Samuel in Canberra. We raised the issue of the anomalies in the private health insurance system and the radical change needed to accommodate the changing landscape of diagnosis, testing and treatment. This requires a complete overhaul of private health insurance with legislative change to ensure no- or minimal-gap reimbursement for private health members for sight saving treatment than can be performed in rooms.”

Back to the Future

The Choosing Wisely Australia campaign was developed by RANZCO’s member ophthalmologists and is aimed at ophthalmologists and other health professionals, with the goal of improving eye health practices through revisiting old practices based on current best-practice evidence.

Key campaign messages are:

  1. In the absence of relevant history, symptoms and signs, ‘routine’ automated visual fields and optical coherence tomography are not indicated.
  2. AREDS-based vitamin supplements only have a proven benefit for patients with certain subtypes of age-related macular degeneration. There is no evidence to prescribe these supplements for other retinal conditions, or for patients with no retinal disease.
  3. Don’t prescribe tamsulosin or other alpha-1 adrenergic blockers without first asking the patient about a history of cataract or impending cataract surgery.
  4. Intravitreal injections may be safely performed on an outpatient basis. Don’t perform routine intravitreal injections in a hospital or day surgery setting unless there is a valid clinical indication.
  5. In general, there is no indication to perform prophylactic retinal laser or cryotherapy to asymptomatic conditions such as lattice degeneration (with or without atrophic holes), for which there is no proven benefit.

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