Fact sheet

Fact sheet

 

Surgically Implanted Prostheses

Following the Review of Health Technology Assessment in Australia (HTA review) the Federal Government have accepted 13 of the 16 recommendations made.

What does this mean for me?

In a minority of cases the changes may result in some prostheses requiring a patient gap to be paid. The Gap is the cost between the Group Benefit Listed Price on the Commonwealth Prosthesis Listing for a clinically equivalent device and the price that the supplier charges.

What is a Surgically Implanted Prosthesis?

It is a piece of equipment that is surgically implanted into the body during a hospital procedure, to replace or assist a body part or function. Examples of prostheses include pacemakers, defibrillators, cardiac stents, joint replacements and intraocular lenses.

What has changed?

  • Prostheses items have undergone a rigorous evaluation process to ensure that all items in a listed group are clinically equivalent and provide similar clinical outcomes.
  • Group benefit setting rather than individual item benefit
  • Prosthesis devices that are evaluated to be clinically equivalent are grouped together and one negotiated benefit determined to cover all these grouped devices. This then becomes the Listed Group Benefit
  • Suppliers will have the ability to charge a gap on any item if they decide that the group benefit is insufficient and as there is no longer any maximum price set there is no limit on the amount of gap the supplier can charge.
  • The obligation for detailed Informed Financial Consent (IFC) lies with the prosthesis suppliers, surgeons and the admitting hospitals. As there is no longer any maximum price as a Health Insurer we are only able to advise the benefit that will be paid and, as we have no access to the price and there is no control of the price that a supplier can charge, we are not in a position to advise you of the amount of gap you may incur.
  • It is expected that the vast majority of prostheses and device suppliers will accept the listed group benefit for their individual item, resulting in no out of pockets for our members to pay.

Why has this changed?

  • To improve the prosthesis listing process
  • To reduce regulatory burden for the Federal Government
  • To facilitate innovation, and access to technology that will improve health outcome in a safe and cost effective way.

What hasn't changed?

  • The clinical evaluation process has assured that a doctors/members choice is not limited
  • Listed prosthesis devices are subjected to a clinical review
  • Clinical review is attended by specialists in the clinical fields of practice

What should I do if I am planning surgery?

  • Be informed but not alarmed – it is expected that most prosthesis suppliers will accept the group benefit
  • Discuss the use and choice of prosthesis and/or device with your surgeon prior to your admission to hospital
  • Ensure you fully understand the type of prosthesis being used and whether that prosthesis has a gap to be paid. If it does have a gap, ask about the availability of a clinically equivalent prosthesis with the same outcomes as prosthesis that does not have a ‘gap’.
  • You can contact us with the prosthesis item number and we can advise you of the Listed Benefit for the prosthesis but we will not be able to advise you if you will have a gap or not or what that gap would be as we don’t have access to the suppliers prices.
  • On admission to hospital ensure that the hospital provides you with specific and detailed information on the types of prosthesis that are planned to be used and whether any of these will have a gap charged. It should be noted that the ability to provide exact quotes is extremely difficult as sometimes requirements change during a procedure. However, there is no reason that the hospital cannot provide you with detailed estimations that will provide you will a reasonable indication of the costs that you will incur.
  • Be aware some hospitals ask patients to sign a general financial consent form that the patients are liable for any costs without stating what these costs are. This is not Informed Financial Consent (IFC).

If you are charged a gap for your prosthesis we would ask that you provide us with copies of these invoices, together with the IFC, so that we can monitor the situation