See the below correspondence from one of our members:- MEDIBANK PRIVATE & COSMETIC SURGERY: IMPLICATIONS FOR ONCOPLASTIC AND RECONSTRUCTIVE BREAST SURGERY IN AUSTRALIA Medibank Private is Australia’s largest private health insurer and in June 2014 introduced a new system requiring written pre-approval for 58 MBS item numbers relating to facial, truncal, genitourinary but also breast surgeries deemed “potentially cosmetic procedures” in an effort to eliminate claims for cosmetic procedures and thereby mitigate the rise in benefit claims. Medibank Private define cosmetic treatment after the “Cosmetic Medical and Surgical Procedures: A National Framework” report of the Australian Health Minister’s Conference 2011 which reads: “Any treatment to revise or change the appearance, colour, texture, structure or position of normal bodily features with the sole intention of achieving what the patient perceives to be a more desirable appearance or boosting the patient’s self-esteem and includes any follow up care associated with Cosmetic Treatment. Cosmetic medical and surgical procedures are lifestyle choices, undertaken to enhance appearance – they are not driven by medical need.” Although previously thought to be safe from such exclusions recent media attention has focussed on the denial of coverage for breast cancer patients requiring reconstruction: abc.net.au/news/2014-08-07/reconstruction-treatment-delayed-by-medicare-cosmetic-clause/5655346 Medibank Private has identified the following breast item numbers as potentially cosmetic: • Breast reduction, whose item numbers 4552/2 may be incorporated into therapeutic mammaplasty procedures • Symmetrising procedures secondary to breast cancer surgery (breast reduction, augmentation 45553/4/5 and mastopexy 45556/7/8/9) • Revision of breast augmentation (45553/4/5) • Removal of breast prosthesis (45548, 45551/2) • Nipple reconstruction (31566, 45545, 45546) (Despite media reports suggesting otherwise, item numbers for autologous and implant-based breast reconstruction are not included in the current list needing pre-approval). Under this pre-approval scheme surgeons wishing to utilise any of these item numbers must submit formal written paperwork to Medibank Private justifying the medical necessity of the procedure at least 3 weeks prior to surgery, specifically: 1. The underlying medical reason for the surgery 2. How this impacts on health and ability to function 3. How the proposed surgery benefit the patient’s health 4. Attachment of copies of the referral letter from the GP, radiology reports and recommendations from other health practitioners. Failure to obtain written pre-approval means that private hospitals have to charge the patient the uninsured rate and payment will be required prior to surgery. Implications of this new pre-approval system should be a source of concern for all BreastSurgANZ members and the patients they treat, not to mention plastic surgeon colleagues whom we might collaborate with when treating breast cancer patients. Current implications include: • Prolonged approval times for affected item number usage when treating patients with malignancy • Upfront costs borne by the patient if proceeding with surgery before pre-approval is granted and having to seek rebate from Medibank Private during the postoperative period • Anxiety and uncertainty for patients newly diagnosed with breast cancer regarding their eligibility for health fund rebates for breast reconstructive and oncoplastic procedures • A trend for health funds to intercede in patient-surgeon decisions on appropriate surgery, so-called American-style “managed care” • Additional paperwork for item numbers which was not previously required Future potential implications: • The widespread adoption of pre-approval practices by other/all health funds, eg: BUPA has already indicated interest in heading down the same track • Migration of oncoplastic and reconstructive patients to already burdened public Medicare–funded operating waiting lists, cheaper unaccredited centres or overseas hospitals • Disincentives for new and established breast surgeons to undertake oncoplastic and reconstructive procedures How the practice of breast oncoplastic and reconstructive surgery in this country is affected will only be known over the coming weeks and months and meanwhile the semantics of what constitutes “cosmetic surgery” will prove a point of contention between clinician and insurer with the breast cancer patient caught in between. Our colleagues in the Australian Society of Plastic Surgeons (ASPS) have already voiced their rejection of this style of managed care by Medibank Private plasticsurgery.org.au/linkservid/649B732A-F15F-5B77-B922DE9BC563F49A/showMeta/0/. Although this may presently only affect Medibank Private, depending on the outcome of this move by the country’s largest insurer, other funds may soon follow suit thus posing significant challenges to the provision of optimal surgical care for our patients diagnosed with breast cancer. Chilton Chong Breast SurgANZ Member and Breast Surgeon
Posted on: Sat, 09 Aug 2014 08:28:46 +0000
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