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Australian Optometry December 2004

Keratoconus: Towards fairer rebates on contact lenses

By Matt Vaughan and Larry Kornhauser

Most people who wear contact lenses for keratoconus are distinctly disadvantaged by current Medicare and Private Health Insurance (PHI) policies. They now want recognition of their potentially-disabling eye disease and in particular that contact lenses worn to correct their vision are medical, not cosmetic, devices.

Those with rigid gas permeable lenses (RGPs) require them to do the most basic things like study, work, drive and even care for themselves and their families. And pay taxes! People denied access to RGPs properly adapted and fitted for their condition risk becoming handicapped or disabled by poor vision. The costs to taxpayers of subsidizing extra services to assist these otherwise healthy people will simply place further unnecessary strain on Australia’s already overstretched healthcare budget.

The problem was highlighted in a recent survey of 150 of Keratoconus Australia’s (KA) 480 members. Around 75% of survey respondents use some form of contact lenses for visual correction, with over 60% specifically requiring RGPs to gain any useful vision. They are spending annually an average $272 on lenses plus another $285/annum on cleaning disinfecting and wetting solutions - a total of $557. Alarmingly, 94% of respondents felt they had to spend what they did in order to gain “useable” vision.

These same people outlay an average $1,338 per year on PHI. Yet Australia’s 40-odd Private Health Insurers provide only around $180 per year in total rebates for optometric items. Even then, the average rebate is only $50-60 per RGP lens. At a cost of $272 per RGP lens, a patient would need to spend some $900/annum on lenses to receive the full $180 rebate. Incredibly, the funds generally refund more for a pair of simple reading glasses than a pair of RGPs for keratoconus! Not surprisingly, 92% of respondents are not satisfied with the current PHI rebates on RGPs for keratoconus.

This situation is unacceptable and stems largely from a lack of recognition that RGPs are an essential medical device used in restoring useable vision to keratoconus patients. Medicare defines those with keratoconus by the fact that they can gain better vision with contact lenses rather than glasses. So why don’t Private Health Insurers, who are subsidized by the same government that runs Medicare, provide rebates that are relevant to the cost of RGP lenses?

The private health funds have defended their rebate policies by shifting the blame for the high cost of RGPs for keratoconus onto the optometrists. They claim that prices of $250-$350 per lens do not represent the actual cost of the RGP but are inflated by the markup added by the contact lens fitter.

The optometrists respond that these markups are necessary because of low schedule fees paid by Medicare, which fail to compensate them adequately for often long and difficult fitting sessions required for people with moderate to severe keratoconus, or who have had a corneal transplant. (The KA survey confirms that 40% of respondents spend over 30 minutes per session with their optometrist.)

Irrespective of who is right in this debate, keratoconus patients are bearing the cost. Ironically the high cost of expertly-fitted RGP lenses means patients may be avoiding the group of optometrists who are providing the best service due to the “added” costs associated with seeing them. As ill-fitting RGPs can eventually damage the cornea, often leading to a premature corneal transplant, this behaviour may ultimately lead to higher costs for both the patient and the community.

KA believes that Medicare item number 10924 (which distinguishes keratoconic consultations from others) does not broadly enough define the distinctions within the group of keratoconic patients. We think Medicare should survey keratoconus patients’ specific requirments to allow a more accurate assessment of the time and cost issues involved in treating them. It could then formulate fairer funding allocations within the keratoconic group and properly determine required changes in the Medicare consultation item numbers and Private Insurance Rebate system.

It may be that people with severe keratoconus and corneal graftees need to be recognized through a subsection of 10924 or a completely new item number. The extra mark ups put on lenses for severely affected patients should be absorbed through more strategic funding on Medicare’s behalf. This may not necessarily imply more funding; but better targeted funding through a restructuring and scaling of the 10924 schedule fee.

The optometric community believes that the best way to treat most keratoconus patients is through properly-fitted RGP contact lenses. Keratoconus Australia believes it is now time for optometrists to ensure that keratoconus patients receive an equitable deal on their treatments. We believe this can be achieved at little extra cost to the existing system.

3 November 2004