What is wrong with Medicare?

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Letters
169MJA 196 (3) · 20 February 2012
The Medical Journal of Australia ISSN:
0025-729X 20 February 2012 196 3 2-2
©The Medical Journal of Australia 2012
www.mja.com.au
Letters
What is wrong
with Medicare?
TO THE EDITOR: Since the claims
made by Webber in his recent article1
were, in his own words, not based on
any substantiated data, it is
disappointing that the Medical Journal
of Australia did not seek to contact
either the Australian Society of
Ophthalmologists (ASO) or the Royal
Australian New Zealand College of
Ophthalmologists (RANZCO) for
comment.
Certainly, considerable work can
be done to improve the operation of
Medicare. We are on record as having
raised our concerns with successive
governments.2 However, Webber’s
generalised, sensationalist and
unsubstantiated claims add nothing to
constructive debate about Medicare.
It is disappointing that the Journal
would risk damaging its reputation, by
choosing to publish a perspective
without offering an alternative view to
demonstrate balance and evidence, as
one would expect in a peer-reviewed
journal.
Ophthalmology involves more than
just removing cataracts, and while
technology has made cataract
procedures safer and less invasive,
they remain complex and the
technology very expensive.3
The RANZCO and ASO have
worked with government through the
Medicare Benefits Schedule Review to
address concerns and shortcomings,
as well as providing supportive
evidence.4 On at least two occasions,
we have offered revisions to the
funding of treatment of macular
degeneration that could save many
millions of dollars in the health
budget.
Additionally, our proposal to
reinvigorate the key subspecialty
of paediatric ophthalmology has
been accepted by government.
Arthur Karagiannis Preside nt1
William J H Glasson President2
1 Australian Society of Ophthalmologists,
Brisbane, QLD.
2 Royal Austra lian and New Zealan d College of
Ophthalmologists, Sydney, NSW.
president@aso.asn.au
Competing interests: No relev ant disclosu res.
doi: 10.5694/mja12.10146
1Webber TD. What is wrong with Medicare?
Med J Aust 2012; 196: 18-19.
2Austral ian Societ y of Opht halmologist s.
Grandma’s not happy Mr Rudd! Brisbane: ASO,
2009. http://www.grandmasnothappy.com.au/
(accessed Feb 2012).
3Access Economics. Ophthalmology practice costs
study, 2008–2 009. February 2011. Report by
Access Economics for Australian Society of
Ophthalmologists Incorporated. Canberra:
Access Economics 2011. http://aso.asn.au/
images/stories/Ophthalmology_practice_costs_
study_2008-09.pdf (accessed Jan 2012).
4Mundy T, Merlin T. Draft protocol. Review of
Medicare-funded ophthalmology services
(second stage) . July 2011. Canberra: Australian
Governme nt Departme nt of Health and Ageing,
2011. http://www.msac.gov.au/internet/msac/
publishin g.nsf/Content/65A4239557E05 A98
CA2579260078E8ED/$File/Final%20protocol_
stage%202_PDF.pdf (accessed Jan 2012). ❏
TO THE EDITOR: Webber ra is es so me
well meaning points in his recent
viewpoint article, some of which were
taken out of context by the media.1
With respect to his comments on
ophthalmologists, I would like to place
on record some facts.
The Access Economics
ophthalmology practice costs survey,2
commissioned by the Australian
Society of Ophthalmologists (ASO) in
2011, analysed the costs of delivering
ophthalmic services for the financial
year 2008–09. The report showed that
the average overhead cost per full-
time-equivalent ophthalmologist was
$506 000, compared with $232 617 in
19993 — an average annual increase of
9%, during which time fees for
ophthalmology items on the Medicare
Benefits Schedule (MBS) increased by
only 2.1% annually.4 Thus, the MBS
items become increasingly irrelevant in
the context of a small private
ophthalmic business model.
The cost to the taxpayer of a
cataract procedure in New South
Wales public hospitals is about $3500
(diagnosis-related group), compared
with a Medicare schedule fee of $731
(item 42702). Thus, the procedure can
be performed privately for about 20%
of the taxpayer cost. Clearly, private
surgery is a very efficient use of
taxpayer money for an operation with
a quality-of-life-adjusted score of
Letters
about 30 times what is considered
cost-beneficial.5
The average eye surgeon performs
fewer than half the cataract
procedures per week than the 20
which Webber anecdotally claimed
(and then multiplied by the entire
cost of the procedure, presumably
including the theatre fee and
prosthesis).
Webber is to be congratulated
for speaking his mind, but ought to
factually balance his writings. The
ASO encourages other craft groups to
commission their own practice-cost
surveys when fiction needs to be
separated from fancy.
Peter M Su mich Eye Su rgeon
Hunter Street Eye Specialists, Sydney, NSW.
psum12 5@bigpond.com
Competing interests: No relevant disclos ures.
doi: 10.5694/mja12.10210
1Webber TD. What is wrong with Medicare?
Med J Au st 2012.196: 18-19.
2Access Economics. Ophthalmology practice costs
study, 2008–2009. Feb ruary 2011. Rep ort by
Access Economics for Australian Society of
Ophthalmo logists Inco rporated. Canberra:
Access Economics, 2 011. http://aso.asn.au/
images/stories/Ophthalmology_practice_costs_
study_2008-09.pdf (accessed Feb 2012).
3PricewaterhouseCoopers. Medicare Schedule
Review Board. A resource-based model of private
medical practice in Australia — final report.
Volume 2 — th e model p ractice for each speci alty.
December 2000. http://www.health.gov.au/
interne t/main/publis hing.nsf/Content/
D5805C64E0C2D09ECA256F180048DBDA/
$File/pcsvolumetwo.pdf (accessed Feb 2012).
4Australian Me dical Association. AMA Gaps
Poster. 16 May 2011. http://ama.com.au/node/
4387 (accessed Feb 2012).
5Access Economics. Cataract treatment in
Australia. Report by Access Economics Pty Limited
for Alcon Laboratories Australia Pty Ltd. Canberra:
Access Economics, 2009. http://www.aso.asn.au/
images/stories/Alcon_cataract_FINAL_
290909.pdf (accessed Feb 2012). ❏
“
Webber is to be
congratu lated
for speaking his
mind, but ought to
factua lly balance
his writings
”Sumich

Letters
MJA 196 (3 ) · 20 February 2012170
TO THE EDITOR: The “thinking
doctor’s” Journal has degenerated to
one for doctor’s random thoughts.
The commissioned and peer
reviewed article by Webber1 was
disappointing. For many
disenfranchised colleagues, the
usual whinge over a cuppa at the
local meeting is now plainly
inadequate after this Medical Journal
of Australia offering.
The unsubstantiated claim about
billions in Medicare “wastage”1 was
reckless. The implication that the
current cataract surgery rebate was
poor value and had never changed
was just plain wrong.
Since the introduction of the
Schedule of Medical Benefits,
cataract surgery now requires
entirely different surgical skills,
implants a lens, and requires
expensive, sophisticated equipment
(for examples, see websites2-4).
Patients can now expect vastly
improved vision without the need
for full-time visual aids. The rate of
significant sight-threatening
complications is now less than 7 in
1000 — one of the lowest
complication rates in surgery.
The rebate was reduced by about
40% in 1987, 10% in 1996, and 12%
in 2009. Even before the last
reduction, the total cost provided a
significantly better gain (that is,
lowest cost) in quality-adjusted life-
years than any other surgical
procedure,5 something conveniently
ignored by the then Health Minister
Roxon when cutting costs.
With more than 500
ophthalmologists performing over
200 000 operations a year, the
statistical distribution will certainly
include the few surgeons performing
high volumes of procedures or
charging high fees, as it does with
any other procedure listed on the
MBS. Webber’s implied
generalisation is totally invalid, as
the distribution tail in no way
represents the average.
I am afraid that Webber has only
provided us with sloppy commentary
and cheap shots — nice if you can
get away with it, but it is poor
editorial policy.
Nigel Morlet Chairman
Indepe ndent Opht halmic Net work, Sydney, NSW.
n.morlet@idrs.com.au
Competing interests: No relev ant disclosure s.
doi: 10.5694/mja12.10179
1Webber TD. What is wrong with Medicare? Med J
Aust 2012.196: 18-19.
2Alcon Worldwide Site. Products. Surgical. Cataract
surgery. http://www.alcon.com/en/alcon-
products/cataract-surgery-products.aspx
(accessed Febr2012).
3Abbott Medical Optics. Products. http://
www.amo-inc.com/products (accessed Feb 2012).
4Bausch and Lomb. Cataract surgery. http://
www.bauschsurgical.com/cataract/default.aspx
(accessed Feb 2012).
5Lansingh V, Carter MJ, Martens M. Global cost-
effecti veness of cataract s urgery. Ophthalm ology
2007; 114:1670-1678. ❏
TO THE EDITOR: Webber is to
be congratulated for his concise
statement of the ills of Professional
Services Review (PSR) audit,1 but his
estimate of multiple billions being
wasted each year is unsupported
by evidence.
This remark has already been
picked up by several of the nation’s
daily newspapers, and well suits
those of certain political persuasions.
However, it is also essential that the
operation of the PSR be subject to
scrutiny.
The past performance of the PSR
must be examined — including the
correctness and consistency of the
information it uses, its investigative
processes, the defence evidence it
does and does not accept, and the
available avenues of appeal. These
issues are all of great concern to
doctors who have come to the PSR’s
attention.
I note that the most recent edition
of Medicare’s Forum promises more
Medicare audits.2 The fun has only
just begun.
A Stuart Ree ce Adjunct Asso ciate Professo r
University of Western Australia, Perth, WA.
sreece@bigpond .net.au
Competing interests: I was once investigated by the PSR,
and am a member of the Australian Doctors’ Union.
doi: 10.5694/mja12.10099
1Webber TD. What is wrong with Medicare?
Med J Aust 2012; 196: 18-19.
2Medicare Australia. New comp liance program to
be released. Forum 2011 ; Summer: 1, 4. ht tp://
www.medicare australia.gov.au/provider/pubs/
news/forum/files/forum-summer-2011.pdf
(accessed Jan 2012). ❏
“
The
unsubstantiated
claim about
billions in Medicare
“wastage” was
reckless
”Morlet