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Australian Optometry December 2004

It’s time for all good people to come to the aid of the party

by John Mountford, Brisbane optometrist

The “good people” are optometrists and ophthalmologists and their respective governing bodies, and the “party” is those thousands of Australians who suffer from keratoconus. The accompanying article from Matt Vaughan of Keratoconus Australia was a real eye -opener for me. During the course of a normal week, I see on average 6 new keratoconus patients, and another twenty or so for routine aftercare and management. As a practitioner, I’d come to the conclusion that my role was to make sure that the lenses I fitted were the best I could do, and that my keratoconus patients were seen on a regular basis and referred for ophthalmological review when needed.

Matt’s article, however, puts an entirely different perspective forward, and I have now decided that my current standard of care is inadequate. It’s time to come to the aid of the party.

There is always greater strength in numbers, so here’s what I suggest WE do to help our keratoconus patients.

The OAA is a very effective body. It has been very successful in dealing with government bodies such as Veteran’s Affairs and Medicare and instrumental in getting Optometrists involved in Indigenous health care. A concerted effort to help Keratoconus Australia in it’s efforts to overcome some of the inadequacies of the system with respect to item 10924 and the deplorable state of private health fund reimbursement for contact lenses would be a good start. What Matt describes in his discussion paper is nothing short of active discrimination by the health funds, and benign neglect by Medicare.

Why is it that cosmetic soft lens wearers can get a maximum rebate of up to $200.00 per year for disposable lenses, yet my keratoconus patients, who pay the same levy, have to put up with a lousy $80.00 per annum refund on their RGP lenses because the health funds consider them to be “old technology”.

So, I’d like to float the following ideas for discussion, and hopefully encourage the OAA and RANZCO to come to the aid of KA.

At the practice level:

  • Active recruitment of keratoconus patients to join KA. Every keratoconus patient will be asked to fill in a Membership form at the practice, which we will then post to KA. If keratoconus affects 1:2000 people, then there are approximately 10,000 people in Australia with the condition. An association with that number of members gets listened to.
  • Active distribution of literature from KA to patients. Another great source is the
  • National Keratoconus Foundation (www.nkcf.org).
  • . Active support of keratoconus patients in helping maximize their health fund rebates by writing letters explaining their unique position and need for a higher refund.
  • Seek out those health funds that give a realistic refund to keratoconus patients and encourage the patient and all family members and relatives to switch to that fund.
    Once again, multiply 10,000 by the number of people in the extended family, and the health funds will start to take notice.

At the professional level.

  • Increase the clinical contact lens fitting expertise and care of the keratoconic patient by supporting education seminars that actually teach practitioners how to fit   keratoconus properly. There is a contact lens lab in every major city of Australia, each with their own design of lens. They should be approached to conjointly support meetings where practitioners can be exposed to the variety of lens designs available and how they are fitted.
  • Approach the Contact Lens Society to actively support the courses by having      Fellows give the lectures and workshops.
  • Approach KA to have patients available for the workshops.
  • Approach the Corneal Specialists in each city to lecture at the courses.
  • Run local “information” evenings for keratoconus patients in conjunction with KA.
  • Encourage research into keratoconus at the university level. Even with RGP lenses, the acuity and contrast sensitivity of keratoconus patients is lower than normal. Surely all the research into higher order aberrations can be put to a practical use and used to design contact lenses that improve the VA of the keratoconus patient.

At the organization level.

The OAA and RANZCO have a distinct obligation to help KA end the discrimination that its members suffer as a result of government policy and health fund rules. There are two main areas that need attention.

 Item 10924

As Matt points out, the refund for fitting a patient with keratoconus bears no resemblance to reality, such that the cost of the lenses increases in order to compensate for the time sent. A complex case can take up to 12 visits and numerous lens changes to get to the stage where the fit is acceptable. This is exacerbated by the fact that the advanced contact lens designs only come with a maximum of 2 exchanges. In reality, a fee of $175.00 for fitting and $500.00 for lenses can easily turn into a cost of $800.00 for the number of exchanges required for the advanced cases.

Then there are the cases when a colleague has “had a go” at it and failed. The following referral then drops the 10924 to a 10930. Also, an interval of 36 months between re-fits may be fine for the normal contact lens population, but it does not take into account the rapid changes that occur in keratoconic eyes. In these cases, the fee defaults to a 10930 again, but this is totally inadequate when the re-fit, as usual, turns out to be difficult and time consuming due to the nature of advancing keratoconus.

The KA approach of having a sliding scale depending on the severity of the individual case has distinct merit.

A realistic fee for fitting keratoconus patients would lead to a drop in the cost of the lenses, especially if the contact lens labs come to the party and extend the warranties for the lenses. The OAA in conjunction with KA is the body to try and implement these changes.

Health Fund rebates.

I find it amazing that, every Christmas, I see TV advertising advising   the population to hurry on in and get their health fund rebates for spectacles before the New Year, or “miss out”. So, spectacle wearers, who, let’s face it, don’t need a new pair of glasses every year can and do get their money’s worth out of their fund, even if it is a false saving. The funds encourage this. But if you happen to have keratoconus and need new lenses, the refund is a lousy $80.00 in most cases. Yet, the funds all advertise that they have a maximum refund of $200.00. Just try to get it and see what happens.

The ideal situation for a patient with keratoconus is access to the maximum rebate and the ability to accrue the rebate if lenses are not required. Early keratoconus is relatively stable, and if lenses are fitted correctly, have an expected life of approximately three years. If the maximum refund were allowed, and accruable, the patient would be entitled to a refund of $600.00 over the three-year period.  This is especially important if gas permeable scleral lenses are used. These lenses range in price from $2,000.00 to $3,000.00 a pair, and on average can last 6 to 7 years. The refund scheme outlined above would therefore dramatically lessen the burden on those patients who need scleral lenses.

At present, there is no item number for scleral lenses. This could be funded by decreasing the refund on soft disposable lenses, or alternatively, decreasing the yearly benefit of spectacles to a two year interval.

Negotiations with health funds are notoriously unproductive. However, as stated above, there is strength in numbers. If we can increase the membership of KA and then get behind them, things could really change for the better for our keratoconus patients. It is our ethical and moral duty to help them.