EXPLANATORY STATEMENT

Health Insurance Act 1973

Health Insurance (B-Scan Ultrasonography and Holmium:YAG Laser Enucleation of the Prostate) Determination 2013

Subsection 3C(1) of the Health Insurance Act 1973 (the Act) provides that the Minister may determine in writing that a health service not specified in an item in the General Medical Services Table (the Table) shall, in specified circumstances and for specified statutory provisions, be treated as if it were so specified.  The Table is set out in the Health Insurance (General Medical Services Table) Regulation (the Regulation), which are re-made each year.

The purpose of the Health Insurance (B-Scan Ultrasonography and Holmium:YAG Laser Enucleation of the Prostate) Determination 2013 (the Determination) is to introduce two new Medicare items (item 37245 for holmium laser enucleation of the prostate (HoLEP), and item 11244 for ophthalmic B(brightness)-scan).  The Determination also revokes the Health Insurance (Endovenous Laser Therapy) Determination 2012 (No.2).  Items in the Health Insurance (Endovenous Laser Therapy) Determination 2012 (No.2) are being moved directly to the Table by the Health Insurance (General Medical Services Table) Amendment Regulation 2013 (No.1), as recommended by the Medical Services Advisory Committee (MSAC) and approved in the 2011-2012 Budget.

B(brightness) Scan (or B-scan)

From 1 March 2013, the Australian Government will introduce a new Medicare item for B-scan, which is a diagnostic service used by ophthalmologists to diagnose various ocular diseases.  There are existing Medicare items for B-scan available through the Health Insurance (Diagnostic Imaging Services Table) Regulation 2012, but to date, these have mainly been available for radiologists, on referral by a medical practitioner. 

The new B-scan item enables specialist ophthalmologists to perform a similar Medicare service to radiologists (without the need for referral), within Group D1, Subgroup 2 of the Table.  As with other ophthalmic diagnostic tests within this subgroup, B-scan is a specialised test only performed when clinically indicated.  Because ophthalmic B-scan is an ultrasound technology, it has traditionally been necessary for ophthalmologists to refer patients for a scan using item 55030 of the Health Insurance (Diagnostic Imaging Services Table) Regulations, or provide a lower rebated service through item 55031 of those regulations.  Those items are designed for use by diagnostic imaging practices and not for specialist ophthalmic practices.

Holmium Laser Enucleation of the Prostate (HoLEP)

From 1 March 2013, the Australian Government will introduce a Medicare item for a new treatment for benign enlargement of the prostate.  Holmium laser enucleation of the prostate (HoLEP) is a method of completely removing the enlarged prostate gland, via the urethra.  It is used to treat lower urinary tract symptoms in benign prostatic hyperplasia (BPH).  BPH is the non-cancerous growth of tissue that causes enlargement of the prostate, causing urinary obstruction.  Untreated BPH may result in damage to normal function of the bladder and kidneys.  HoLEP is less invasive than existing treatments and will reduce the length of hospital stay for patients. 

Endovenous Laser Therapy (ELT)

ELT, a minimally invasive procedure to treat severe varicose veins, is currently funded through Medicare items 32520 and 32522, in the Health Insurance (Endovenous Laser Therapy) Determination 2012 (No.2) (the ELT Determination).  From 1 May 2013, these items will be listed directly on the Table.  Consequently, the ELT Determination can be revoked from midnight 30 April 2013. 

In August 2012, after considering evidence on cost-effectiveness and patient affordability, MSAC recommended that ELT continue to be publicly funded and therefore moved from its interim funding status (in the existing ELT Determination) to ongoing funding through its listing on the Table. 

In providing its advice, MSAC supported minor re-wording of the ELT item descriptors.  From
1 May 2013, existing advice contained in the explanatory notes to the Medicare Benefits Schedule (that ‘reflux of 0.5 seconds or longer (within the great or small saphenous vein, as relevant) be documented by duplex ultrasound’) will be incorporated into the item descriptors for the two ELT items.  This re-wording simply reinforces existing clinical best practice, as intended by MSAC, and prevents possible future use of the items for cosmetic conditions.

The Determination applies several provisions found in the Table to new B-scan item 11244 and HoLEP item 37245:

• as for all other surgical services in the Table, the HoLEP item will require personal attendance by a single medical practitioner on a single patient on a single occasion, and the attendance must be by a medical practitioner who is not employed at a public hospital or, if employed at a public hospital, is exercising his or her right of private practice (subsection 7(2) of the Determination);
• the B-scan item may be provided by a medical practitioner or a person acting under the supervision of a medical practitioner in accordance with accepted medical practice (subsection 7(1) of the Determination);
• as for all other items in Group D1 of the Table, Medicare will not be payable for the B-scan item if it is provided at the same time as, or in connection with, home-based sleep studies (subsection 7(1) of the Determination);
• as for all other items in the Table, Medicare will not be payable for the B-scan or HoLEP items if they are provided in contravention of a law of the Commonwealth, a State or a Territory (subsection 7(3) of the Determination).

Consultation

During MSAC’s assessment of evidence in relation to the safety, clinical effectiveness and cost effectiveness of HoLEP, the Department assisted in the exchange of information between MSAC and the Urological Society of Australia and New Zealand (USANZ) and the Australian and New Zealand Association of Urological Surgeons (ANZAUS).  Since MSAC’s decision in December 2012 to recommend public funding for HoLEP, the Department has continued to consult with USANZ and ANZAUS in relation to implementation issues.

In relation to B-scan, the Department has consulted with the Royal Australian and New Zealand College of Ophthalmologists (RANZCO) via exchange of letters, emails and through telephone conversations.  RANZCO supports the proposed funding arrangements.

In relation to ELT, since MSAC’s decision in August 2012 (and well before that, dating back to 2008), the Department has been involved in ongoing consultation with the Australasian College of Phlebology, Australian and New Zealand Society of Phlebology, Australian and New Zealand Society for Vascular Surgery (within the Royal Australasian College of Surgeons) and the Royal Australian and New Zealand College of Radiologists.  Earlier consultation occurred with the Royal Australian College of General Practitioners, who deferred opinion to medical organisations representing vein specialists.

Consultation occurred via exchange of letters, emails and through telephone conversations.  These groups support the ongoing listing of ELT on the Table and minor re-wording of item descriptors from 1 May 2013.

Sections 1 to 3 and 5 to 7 and the Schedule to the Determination commence 1 March 2013.  These sections provide for the creation of the HoLEP and B-scan item and the cessation of the Determination.  Section 4, which revokes the ELT Determination, commences at midnight 30 April 2013.  The Determination ceases at 12:01 am 1 May 2013.  It is currently intended that the HoLEP and B-scan items will be listed directly on the Table from 1 May 2013.

This Determination is a legislative instrument for the purposes of the Legislative Instruments Act 2003.