Prostheses changes

Prostheses changes

An overview of Prosthesis Benefit Setting Arrangement Changes.


Funding arrangements for surgically implanted prostheses devices

Should you or others listed on your membership ever require a device listed on the Commonwealth's Prostheses list, this information will be of importance. Some of the most common surgically implanted prostheses devices are hip and knee joint replacements, cardiac stents, cardiac pacemakers and intra-ocular lenses used for cataract surgery.

Overview of Prosthesis Benefit Setting Arrangement Changes:

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

The HTA review was reported to the Federal Government in February 2010. The purpose of the review was to recommend ways to improve the prosthesis listing process and reduce regulatory burden for the Federal Government whilst facilitating innovation, and access to technology that will improve health outcome in a safe and cost effective way.

The Prosthesis List contains all the prostheses and devices that have been approved by the Minister for Health for the payment of benefits by Private Health Insurers, the list also states the benefit that must be paid by the insurer. There is over 9000 items on this list. Previously each item required individual negotiation to determine what benefit would be paid and this included a minimum benefit that the fund must pay and a maximum price that the supplier could charge. The difference between the minimum benefit and the maximum price was the gap that the member had to pay. This process has been in place since the 2004 prosthesis reforms. Our experience has been that our members have rarely been charged ‘The Gap” for any prosthesis.

The HTA review changes will result in the grouping of prostheses and devices that have similar clinical effectiveness and deliver similar health outcomes. Once the groups are established a single group benefit will be set and all items will have the same listed benefit and there will no longer be a minimum and a maximum benefit.

The Prosthesis List Advisory Committee (PLAC) is responsible for this process and making recommendations to the Minister regarding the items that should be listed and the benefits that should be paid. The final decision lays with the Federal Minister for Health. The PLAC includes expert clinical advisors and prosthesis suppliers are consulted on the grouping and proposed benefit prior to submission to the minister.

The work to develop groupings and benefits is being undertaken in 3 overlapping phases.

Phase 1: Includes hip, knees, some specialist orthopaedic and neurosurgical products

Phase 2: Includes cardiac, vascular, ophthalmic, some specialist orthopaedic and spinal products

Phase 3: Includes general and miscellaneous, ear nose and throat, cardiothoracic, urogenital, some specialist orthopaedic and plastic and reconstructive products

All 3 phases have commenced, but will take different lengths of time to complete.

What does this mean for Latrobe Health Services Members?

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 gap for the members to pay.

However the 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.

What do Latrobe members have to do?

If you or anyone on your membership is planning any medical treatment it is vital that you discuss the possible need for prosthesis with your treating doctor. Be informed but not alarmed as it is expected that most prosthesis suppliers will accept the group benefit.

Some specific questions you need to ask your specialist are:

  • Do I require the use of any surgically implanted prostheses devices?
  • What are the prosthesis item numbers that are planned to be used?
  • Does the supplier charge a gap for these items?
  • If they have a Gap item, what is the reason that they are being used rather than a clinically equivalent item that has the same outcomes that has no gap?
  • What is the gap cost that I will have to pay as an out of pocket?
  • If there is a gap cost you will need to consider whether you are prepared to pay this gap?
  • Ask why you can't have the clinical equivalent item that doesn’t have a gap charged by the supplier?
  • If you agree to the gap item, provide your written consent to pay this
  • What other out of pocket costs will be charged in relation to your hospital stay such as medical costs for the surgeon, assistant surgeon, anaesthetist or any other medical provider involved with your care?

When you are admitted to the hospital

  • Ensure that the hospital confirms the planned use of any prosthesis and whether any of the planned prosthesis will have a gap
  • Ensure that the hospital provides you full and detailed IFC regarding all aspects of your hospital stay
  • 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).

How can Latrobe help?

  • Ensuring that our members are kept informed and providing guidance to our members as they navigate through their health care.
  • 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.
  • 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

Of course should you have any queries regarding your admission to hospital please contact Latrobe Health Services on 1300 362 144.