A recommendation by the Medicare Benefits Schedule Review Taskforce to assess an “expansion of intravitreal injections to include appropriately trained nurse practitioners and optometrists, working to updated guidelines,” has been welcomed by Optometry Australia, but dismissed by the Australian Society of Ophthalmologists.
Released on 30 August, the Taskforce recommendations included “a review of the broader ophthalmology workforce, with a particular focus on assessing supply issues, and the benefits of expanding the workforce qualified to deliver particular ophthalmology services”.
The recommendation has been made in the interests of increasing access to treatment via intravitreal injection for patients across Australia, in the face of maldistribution and expected undersupply of ophthalmologists.
Optometry Australia President Darrell Baker said the recommendation “further acknowledges that optometrists are highly trained and skilled eye professionals.
“It also recognises the benefits to the community of ensuring optometrists can work to their maximum scope whilst identifying that we can enhance optometry-ophthalmology collaboration to enhance community access to needed eye care,” he said.
“Optometry Australia has recently indicated to the Royal Australian and New Zealand College of Ophthalmologists (RANZCO) and the Australian Society of Ophthalmologists (ASO) our interest in working collaboratively to enhance patient access to intravitreal injections in a manner that upholds patient safety.
“We believe there is an important and enhanced role for optometrists who want to make a positive impact for the community in this way.”
However, Peter Sumich, President of the ASO said his organisation “is absolutely opposed to the substitution of non-ophthalmic (especially non-medical) personnel for ophthalmologists” and that the Australian Medical Association supports its position.
Reduced Rebate Recommended
The Medicare Benefits Schedule Review Taskforce has also recommended adjusting the rebate on intravitreal injection items “to a level in line with the more complex peri/retrobulbar injections, item 18240” noting that intravitreal injection items could be co-claimed with a consultation.
Dr Sumich said this recommendation had not been made by the Ophthalmology Clinical Committee but instead had been “taken out of its hands” by the Taskforce Chair Professor Bruce Robinson.
“The MBS Taskforce recommended that the Medicare Benefit Schedule Fee for intravitreal injection items 42738, 42739, 42740 be reduced by 70% – to the same value as that of peribulbar or retrobulbar injection (item 18240) ie from $305.55 to $95.10 (85% = $80.83). The Committed stated that the primary rationale for the recommendation is to align the rebate with the relative complexity of the procedure.”
“The recommendation would have a devastating impact on service provision. I have no doubt that consumer representative organisations such as the Macular Disease Foundation and Diabetes Australia will be making it quite clear how unacceptable these changes are. ASO will of course also play its role in defending the rights of our patients,” he said.
Slashing Funding Does Not Work
Dr Sumich pointed to New Zealand, where the government has “slashed its funding” for intravitreal injections. “This has resulted in a flood of patients overflowing public services and reduced service provision in remote and rural areas. It is creating a macular degeneration service disaster of their own creation.”
Dr Sumich warned that reducing the rebate in Australia would have the same affect.
He said a reduced rebate would mean patients who currently access intravitreal therapy through the private system would not be able to afford to do so.
“Private ophthalmology practices, and clinics that employ ophthalmologists to provide injection therapy, particularly in regional areas, would not be able to absorb the reduced rebate – they would have to pass the additional cost on to patients. But many private patients would not be able to afford this and so would turn to the public system, which in turn would not be able to manage the increased demand.
“In Australia 25% of injections are bulk billed. That’s 105,000 injections. The public system would not cope with these extra cases and remote regions would lose services.
“This loss of service provision is exactly what we have warned the Health Minister and Health Department and MBS Review committee about should there be any significant cut in the intravitreal rebate by the MBS Review. New Zealand has demonstrated what disarray such policy change brings. New Zealand patients may tolerate this situation but Australian patients would not,” said Dr Sumich.
Dr Sumich said lowering clinical standards by allowing non ophthalmologists to provide injection therapy is not the answer when public services are unable to cope with demand.
“We (ophthalmologists) are the standard setters. We should instruct governments on what we regard as best practice. It is up to governments to provide what we recommend; not the other way around. If rebates are cut, if public hospitals cannot cope, it should be thrown back at government to provide the service funding. It does not require us to lower our standard to meet their expectation of a cheaper service… If we are to avoid a two tier medical system in Australia, it is not appropriate that public patients are treated by nurses but private patients receive medical care,” said Dr Sumich.
He said “reasoned argument” he had presented to the Ophthalmology Clinical Committee had been ignored by Professor Robinson. “The MBS Taskforce was intended to clean up and modernise the schedule of items. This is how it was sold to the profession three years ago. Along the way, it has become a Medicare cuts razor gang, slashing AU$500 million out of Medicare spending, yet to do has cost over $40 million thus far.”
UK Experience
Evidence from the United Kingdom supports the safety of intravitreal injections by trained health professionals who are not medical specialists.
A literature review published in Nursing Standard,1 identified five studies which audited a total of 31,303 injections delivered by nurse practitioners between January 2007 and November 2013.
The authors reported that “visual outcomes and the rate of complications from intravitreal injections delivered by trained ophthalmic nurse practitioners were comparable to intravitreal injections delivered by ophthalmologists. Four of the five studies reported increased patient satisfaction, patients consenting to nurse-delivered intravitreal injections, favourable pain experience, and absence of complaints.”
The study author was Emma Gregg, a theatre sister at Moorfields Eye Hospital in England where injections are given either by an ophthalmologist, a registered nurse practitioner or an optometrist, who have undergone the appropriate training.2
The Taskforce is currently consulting on the recommendations made in the report on ophthalmology. Following the consultation phase, final recommendations will be put to the Minister for Health.
RANZCO has stated that it will not be making comment on the recommendations until after they have been fully considered.
References:
1. Gregg, E. Nurse-led ranibizumab intravitreal injections in wet age-related macular degeneration: a literature review. journals.rcni.com/nursing-standard/nurseled-ranibizumab-intravitreal-injections-in-wet-agerelated-macular-degeneration-a-literature-review-ns.2017.e10344
2. www.moorfields.nhs.uk/sites/default/files/uploads/documents/Patient%20information%20-%20intravitreal%20injections%20for%20AMD.pdf
