The MBS item previously used by doctors for the insertion of stents was originally listed with the intent for treating primary congenital glaucoma of the eye. This did not include the insertion of stents, or MIGS devices. The Australian Government has therefore restricted the use of this item on the advice of the Medical Services Advisory Committee (MSAC). This advice has determined that MIGS devices represent a new service, and as such should be assessed on all available and relevant evidence by MSAC for safety, effectiveness and cost-effectiveness before receiving public funding. Further information about the MSAC is available on its website.
From 1 May 2017 the Government provided benefits for MIGS procedures through an interim Medicare item (42705) for the insertion of particular eye stents through MIGS while the MSAC considered two applications seeking public finding for MIGS procedures. After considering the strength of the available evidence in relation to comparative safety, clinical effectiveness and cost-effectiveness, MSAC supported the inclusion in the MBS of MIGS stent implantation for patients with open-angle glaucoma (OAG) who are also undergoing cataract surgery, with an MBS fee set at $911.10. For cases where there is failure of the original stent placement, MSAC suggested a single MBS item with a fee of $300.75 for stent removal regardless of whether it is undertaken with or without stent replacement.
MSAC did not support listing of MIGS as a standalone procedure due to insufficient evidence of effectiveness and because the population who would be eligible for the service could not be adequately defined.
MSAC’s recommendations are currently being considered by the Government. However, the interim item will remain in place until these considerations are complete. Patients should discuss the appropriateness of surgery under this interim item number with their treating doctor.
While the MSAC did not support the MBS listing of a standalone MIGS procedure based on the available evidence, the MSAC will re-consider listing of this service if the applicant(s) or the profession can provide sufficient evidence in support this service. It is not uncommon for proposals for new services to require more than one submission to MSAC before a recommendation can be made in support of the service.
Australia receives international recognition for its approach to funding universal health care, and the MSAC plays a vital role in applying health technology assessment processes to ensure sound evidence-based funding outcomes for both patients and the Australian taxpayer.
In relation to out-of-pocket costs, while the Government is responsible for setting MBS fees and associated rebates, it cannot compel doctors to observe the MBS fee for a particular service. Medical practitioners are free to set their own value on their services, which may exceed the Medicare rebate. The actual fee is a matter between the patient and their doctor. Practitioners are encouraged to consider the personal circumstances of their patients when determining the fees they charge, and many do so. If a patient is not satisfied with the proposed fee, they can exercise their consumer rights and seek a second opinion if they feel they can secure a better price for a medical service.
When a patient is admitted to a hospital or licensed day surgery centre as a private patient, Medicare covers 75 per cent of the MBS fee and private health insurers cover the remaining 25 per cent. In circumstances where doctors charge above the MBS fee, patients are responsible for any additional amounts, either directly or through private health insurance. Insurers can pay more than the 25 per cent of the MBS fee to reduce, or eliminate, any gap if the doctor has a ‘gap cover arrangement’ with the insurer.
Some doctors choose not to be involved in gap cover arrangements; in this case patients will usually have a gap to pay. Doctors are free to decide on a case-by-case basis whether they wish to use an insurer’s gap cover arrangement.