PHI 9/20 Review of the General Miscellaneous Category of the Prostheses List

Page last updated: 04 February 2020

PHI 9/20 Review of the General Miscellaneous Category of the Prostheses List (PDF 153 KB)

This circular is to provide an update on the Review of the General Miscellaneous Category of the Prostheses List.

The Department of Health has engaged EY to assist with the Review. The Department and EY will be working together to seek feedback and input from interested parties throughout the Review.

In the first instance, a number of questions have been developed to which interested parties are asked to respond through the Department of Health’s Consultation Hub by midnight Tuesday, 18 February 2020.

Further opportunities for input or feedback into the Review will occur in March 2020.

It is anticipated that the Review will be finalised by June 2020.

The Department will continue to provide updates on the Review through PHI Circulars. Any queries relating to the Review should be emailed to prosthesesreform@health.gov.au.

INPUT INTO THE REVIEW OF THE GENERAL MISCELLANEOUS CATEGORY OF THE PROSTHESES LIST

1. Are there any sub-categories or product groups/sub-groups within the General Miscellaneous Category that should not be included on the Prostheses List?

    a. If so, why?
    b. If not, why not?

2. Would any of the sub-categories (or groups or sub-groups) within the General Miscellaneous Category of the Prostheses List be better listed elsewhere in the Prostheses List?
    a. If so, where and why?

3. Are there any General Miscellaneous category items that were funded through non Prostheses List arrangements prior to being listed on the Prostheses List?
    a. Were patients left out-of-pocket through this non-Prostheses List arrangement?
    b. Where patients were not previously out-of-pocket through a non-Prostheses List arrangement, what advantage did patients receive from the inclusion of such a product on the Prostheses List?
    c. Were there any other effects that have been identified as a result of listing this product?
In addition to answering the above questions, you may wish to provide specific examples of where you believe there are anomalies or inconsistencies in the General Miscellaneous Category, including examples to support your claims.

Background
Within the General Miscellaneous Category of the Prostheses List, there are eight sub-categories of prostheses:

  • 03.01 – Brachytherapy,
  • 03.02 – Drug Delivery Devices,
  • 03.03 – Enteral Tubes,
  • 03.04 – Gastric Bands,
  • 03.05 – Haemostatic Devices,
  • 03.06 – Luminal Stents,
  • 03.07 – Pulmonary/Peritoneal Devices, and
  • 03.08 – Closure Devices.
Each of these sub-categories may be further broken down into groups and sub-groups. The entire Prostheses List, including the General Miscellaneous Category, can be found on the Department’s website.

Purpose of the Prostheses List / Listing Criteria
The Department is currently working with industry working groups and the Prostheses List Advisory Committee (PLAC) to better define the purpose of the Prostheses List and the relevant listing criteria.

The current understanding of the purpose of the Prostheses List is to ensure that privately insured Australians have access to clinically effective prostheses that meet their health care needs.

The current criteria used by PLAC when considering whether or not to recommend a prosthesis for listing are below:

1. The product must be entered and current on the Australian Register of Therapeutic Goods;
2. The product must be provided to a person as part of an episode of hospital treatment or hospital-substitute treatment;

3. A Medicare benefit must be payable in respect of the professional service associated with the provision of the product (or the provision of the product is associated with podiatric treatment by an accredited podiatrist);

4. A prosthesis should:
    a. be surgically implanted in the patient and be purposely designed in order to
      i. replace an anatomical body part; or
      ii. combat a pathological process; or
      iii. modulate a physiological process; or
    b. be essential to and specifically designed as an integral single-use aid for implanting a product, described in (a) (i), (ii) or (iii) above, which is only suitable for use with the patient in whom that product is implanted; or
    c. be critical to the continuing function of the surgically implanted product to achieve (i), (ii) or (iii) above and which is only suitable for use by the patient in whom that product is implanted; and
5. The product has been compared to alternative products on the Prostheses List or alternative treatments and
    a. assessed as being, at least, of similar clinical effectiveness; and
    b. the cost of the product is relative to its clinical effectiveness.