RACS advocating for appropriate reform to Prostheses List

For more than a year RACS has been engaging with the Federal Government regarding proposed reforms to the Prostheses List—writing to the Minister for Health, advocating directly to the Department of Health and Ministerial office, and responding to consultations with detailed submissions in collaboration with a number of surgical societies.

As many will be aware over the last 18 months or more, the government has been looking at reforming the Prostheses List—the list of medical devices for which private health insurers are required to pay a benefit when a member has the relevant coverage. Earlier this year a government options paper proposed the replacement of the Prostheses List (PL) with a Diagnoses Related Group-type (DRG) funding model. Led by Professor Mark Frydenberg, Chair of the Health Policy and Advocacy Committee (HPAC), RACS submitted a response to a government consultation, which was critical of this approach. RACS was concerned that with a DRG model, funding would be capped with the prosthetic cost incorporated within the DRG. There would then potentially be an incentive to choose prosthetic items which were cheaper but less appropriate to a given patient's care. With RACS and other stakeholders opposed to the DRG model, the government eventually decided against pursuing this approach. Instead, it is pursuing changes focused around ‘better defining the Prostheses List purpose, definitions, and scope’. This approach has also provoked concerns, as it has the effect that many general use surgical items will be removed from the Prostheses List. A consultation paper released in August stated that such items, ‘would continue to be funded through other mechanisms, such as contracts between insurers and hospitals.’ However, these ‘other mechanisms’ were not detailed. HPAC again took the lead in developing RACS response, drawing heavily on the views of surgical societies and associations. Because of the types of items expected to be removed from the list, certain subspecialties may be affected more than others. For example, citing specific impacts on their Fellows, General Surgeons Australia (GSA), and allied groups such as Australian and New Zealand Oesophageal and Gastric Surgery Association (ANZGOSA), and the Australian and New Zealand Metabolic and Obesity Surgery Society (ANZMOSS) made strong submissions, which RACS endorsed. GSA’s submission noted that many items required for general surgery are bundled under ‘general miscellaneous’ category on the Prostheses List, ‘most of which have been flagged for removal’. To quote GSA, ‘removal of these items does not recognise their essential nature in specialised general surgery practice, compromises patient safety, and also means that Specialist General Surgeons would no longer be able to choose the product that is required for particular operations.’ With the first items slated for removal from March 2022, RACS plans to continue to engage with the government to advocate for reforms, which reduce costs, while ensuring patients continue to have access to the medical devices best suited to their particular clinical circumstances. In the event the changes go ahead, RACS’ position is that it would be appropriate for access to, and use of, devices removed from the Prostheses List to be independently monitored, with a focus on the views of clinicians. Should monitoring find that clinicians believe their clinical choices have been significantly impacted, then it is RACS’ view that the changes should be revisited.

For nearly two years the government has been looking at the List, which requires private health insurers to pay a benefit when a member has the relevant coverage