EXPLANATORY STATEMENT
Issued by the Authority of the Minister for Health and Ageing
Health Insurance Act 1973
Health Insurance (Faecal Incontinence and Peutz-Jeghers Syndrome) Determination 2009
Subsection 3C(1) of the Health Insurance Act 1973 (the Act) provides that the Minister may determine in writing that a health service not listed 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 listed. The Table is set out in the Health Insurance (General Medical Services Table) Regulations 2008 which are re-made each year.
A determination made under subsection 3C(1) of the Act is a legislative instrument (see subsection 3C(4) of the Act and paragraph 6(d) of the Legislative Instruments Act 2003).
The Health Insurance (Faecal Incontinence and Peutz-Jeghers Syndrome) Determination 2009 (the Determination) will permit the payment of Medicare benefits for capsule endoscopy for Peutz-Jeghers Syndrome (PJS) and artificial bowel sphincter for the treatment of severe faecal incontinence.
The Determination provides for three new items (item 11823, 32220, and 32221). Items 32220 and 32221 will provide for services for the insertion, removal or revision of an artificial bowel sphincter for the treatment of severe faecal incontinence, for a patient for whom conservative and other less invasive forms of treatment are contraindicated or have failed. Item 11823 will provide for a service for capsule endoscopy to conduct small bowel surveillance of a patient who has been diagnosed with PJS. A two-year service limitation applies to the capsule endoscopy item.
Currently the Table lists item 11820, for capsule endoscopy for obscure gastrointestinal bleeding.
11820 | CAPSULE ENDOSCOPY to investigate an episode of obscure gastrointestinal bleeding, using a capsule endoscopy device approved by the Therapeutic Goods Administration (including administration of the capsule, imaging, image reading and interpretation, and all attendances for providing the service on the day the capsule is administered), (not being a service associated with double balloon enteroscopy), if: (a) the service is performed by a specialist or consultant physician with endoscopic training that is recognised by The Conjoint Committee for the Recognition of Training in Gastrointestinal Endoscopy; and (b) the patient to whom the service is provided: (i) is aged 10 years or over; and (ii) has recurrent or persistent bleeding; and (iii) is anaemic or has active bleeding; and (c) an upper gastrointestinal endoscopy and a colonoscopy have been performed on the patient and have not identified the cause of the bleeding; and (d) the service is performed within 6 months of the upper gastrointestinal endoscopy and colonoscopy
Fee: $1,883.90 Benefit: 75% = $1,412.95 85% = $1,815.80 |
This Determination has been made following evaluations of capsule endoscopy for PJS and artificial bowel sphincter for the treatment of severe faecal incontinence by the Medical Services Advisory Committee (MSAC). The MSAC recommended that public funding be supported for capsule endoscopy for PJS and artificial bowel sphincter for the treatment of severe faecal incontinence. The MSAC provides advice to the Australian Government on evidence relating to the safety, effectiveness and cost-effectiveness of new medical technology and procedures.
The Determination will cease on 30 June 2009.
Details of the Determination are set out in the Attachment.
Consultation
Consultation took place with Medicare Australia, the Department of Veterans’ Affairs and the Australian Medical Association, Colorectal Surgical Society of Australia and New Zealand, General Surgeons Australia and the Gastroenterological Society of Australia. All parties were consulted on the appropriateness of the item descriptors, fees and accompanying explanatory notes, which were supported by all parties. In addition, Medicare Australia, the Department of Finance and Deregulation, and the Department of Veterans’ Affairs were consulted on the costs associated with the implementation of these items, with the costs agreed to by all agencies.
ATTACHMENT
Notes on sections in the Determination
Section 1
Section 1 provides the name of the Determination.
Section 2
Section 2 provides that the Determination commences on 1 March 2009 and will cease to have effect at the end of 30 June 2009.
Section 3
Section 3 defines terms used in this Determination. These terms are referred to in section 4 of the Determination.
Subsection 3(2) provides that a reference to a provision of an Act or regulations, is a reference to the provision as in force from time to time (as authorised by subsection 3C(3) of the Act).
Section 4
Subsection 4(a) provides that a relevant service specified in the Schedule to the Determination will be treated as if it were both a professional service and a medical service for the purposes of the provisions of the Act, the National Health Act 1953 and regulations made under each Act which provide for medical services or professional services.
Subsection 4(b) provides that a relevant service specified in the Schedule to the Determination is to be treated as if there were an item in the General Medical Services Table related to the service and specified a fee for that service, being the fee specified in the Schedule to the Determination in relation to the service.
Schedule
The Schedule to the Determination sets out the relevant services, assigning the applicable item number, item descriptor and fee for each service.