By Dr Rachel David
Two years ago, the federal government made what looked like a straightforward, evidence-based decision about how a common medical procedure should be delivered. The plan was simple: move most intravitreal eye injections – used to treat conditions such as macular degeneration – out of hospital settings and into clinicians’ rooms where they are routinely and safely performed in Australia and around the world.
The proposal followed detailed advice from the Medicare Benefits Schedule Review Taskforce, which was established to ensure taxpayers are paying for appropriate, value-based healthcare. After extensive consultation with clinicians, consumer groups and professional bodies, the Taskforce concluded these injections rarely require hospital admission and should be classified accordingly.
The clinical position was clear. Even the profession’s peak body, the Royal Australian and New Zealand College of Ophthalmologists, agreed these injections are best delivered outside hospital unless there is a medical reason to do otherwise.
Under the proposed reform, injections billed under a specific Medicare code were to be reclassified as out-of-hospital procedures from July 2026. Importantly, an exception was built in: if a clinician determined that a patient genuinely needed hospital care, the treatment could still occur in hospital with private health insurance contributions available. In other words, the reform was careful, clinically grounded and flexible.
But the government has now backed away from it due to a scare campaign run partly by those profiting from hospital admissions.
The reason given by the government was concern about potential out-of-pocket costs for patients if injections were delivered outside hospital settings where private health insurers are not permitted to contribute to ophthalmologists’ fees.
At first glance that sounds compassionate. No government wants to see vulnerable patients facing unexpected medical bills. But the decision ignores the fact that ophthalmologists already get paid very well for their work and can choose not to charge patients an additional fee for the injection, which takes around two minutes in their consulting room.
It also creates a much larger problem: it preserves a system where patients, taxpayers and health insurance members pay approximately $100 million more per year for care delivered in a setting that is almost always unnecessary.
Performing intravitreal injections in hospital comes with an additional hospital fee on top of the specialist doctor’s fee. That hospital charge is typically paid by private health insurers. Those costs do not disappear; they are ultimately passed on to consumers through higher insurance premiums.
The reform the government has decided to abandon would have helped address that. It was estimated to save people with health insurance up to $75 million a year by avoiding unnecessary hospital admissions for injections that can be safely delivered in consulting rooms. It would also have saved the federal government around $15 million annually through lower spending on the private health insurance rebate.
Those savings are not trivial. They represent real pressure that could have been taken off health insurance premiums and public spending.
In effect, Australians with health insurance are now being asked to continue subsidising the delivery of a simple procedure in a higher-cost setting when clinical guidelines say it is not required.
That might be defensible if it protected patients from excessive out-of-pocket costs. But data suggests it may not protect patients from additional costs while enriching a small number of corporate day hospitals, including one owned by private equity.
A Private Healthcare Australia analysis of billing patterns shows around 85 per cent of the out-of-pocket costs charged to patients for intravitreal injections occur in facilities run by two corporate hospital groups: Cura Day Hospitals and Vision Hospital Group.
Cura Day Hospitals is owned by London-based private equity firm Intermediate Capital Group, while Vision Hospital Group is owned by Jangho Group Company, which is listed on the Shanghai Stock Exchange.
These hospitals receive a hospital payment from insurers for the procedure. Doctors performing the injection are also paid via Medicare, and in many cases, patients are also charged an additional out-of-pocket fee by the treating doctor.
That means the procedure can effectively be funded three times: by taxpayers through Medicare, by insurance members through hospital benefits, and by patients receiving the injections through direct charges.
By contrast, many ophthalmologists working in smaller facilities – including those associated with Acurio Health Group or ophthalmologist-owned clinics – generally do not charge out-of-pocket fees for these injections when they are performed in hospital.
In those cases, the procedure is funded twice: through Medicare and through hospital benefits paid by insurers.
Either way, the system is clearly capable of delivering this treatment without charging patients any extra. The question is why that is not happening more consistently?
The broader issue is that Australia already spends substantial amounts of money on healthcare that delivers little or no clinical value. The Grattan Institute has estimated around $1 billion is spent each year on low-value care in our private health system. That includes paying for hospital admissions when procedures could safely be performed in a clinician’s rooms.
Intravitreal injections are exactly the sort of procedure where the system should be moving toward the most appropriate and efficient setting.
If the government’s objective is to reduce out-of-pocket costs for Australians using our health system, there are more direct and effective ways to achieve that than abandoning a reform designed to deliver care in the right place.
Health policy inevitably involves trade-offs. But the guiding principle should be simple: high quality care should be delivered in the most clinically appropriate setting at the lowest sustainable cost.
Intravitreal injections are one of the most common procedures performed in Australia as our population ages. Even small inefficiencies in how they are delivered can translate into significant costs for patients, taxpayers and health insurance members.
Australians deserve a healthcare system that rewards appropriate care, not the most expensive location in which to deliver it.
This debate is about more than eye injections. It goes to the heart of whether Australia is willing to make the practical changes needed to keep healthcare affordable for all of us into the future.