Essential Tremor affects 500,000 Australians over 45. Whilst only 2% develop severe debilitating tremors that fail to respond to drugs, half a million patients and families may live in fear of their condition deteriorating.
The ABC’s 7.30 Report covered the story of David Harvey, whose debilitating tremor was almost eliminated in just a few hours by what ABC described as ‘breakthrough’ incisionless Trans Cranial MRI guided Focused Ultrasound (tcMRgFUS) therapy at St Vincent’s Hospital Sydney. The piece attracted remarkably high viewership on air and online.
ABC presented tcMRgFUS as new – yet St Vincent’s is the 58th global site to adopt this now widely internationally used, therapy. tcMRgFUS has positive UK NICE guidance, reimbursement in US, Israel, Japan, Health Canada. Nearly 2,000 patients have been treated globally with zero deaths or intracerebral hemorrhages. Long term data is available. Compelling health economics and evidence has been published across multiple sources, 87 in 2018 alone, and includes the lead study on the front page of the New England Journal of Medicine.
The procedure is a ‘thalamotomy’ or the creation of a lesion in the thalamus. It has an MBS Item, over 1,500 publications and has been performed surgically since the 1950s. The tcMRgFUS innovation is an instrument that does not need to drill through the skull and push probes through the brain to perform a thalamotomy on the target, avoiding operative risks, increasing precision and neuromodulating to test effects before permanent changes are made. In the hands of a skilled operator, this combination dramatically changes the balance of efficacy and complications of performing a tcMRgFUS thalamotomy vs alternatives. In Australia, thalamotomy surgery is 3-5 times more expensive than performing the same procedure with tcMRgFUS.
Yet uniquely in the world, NSW public hospitals restrict tcMRgFUS thalamotomy use to clinical trials only – based on a HealthPACT analysis that curiously omitted the term ‘thalamotomy’ from the literature search. Unsurprisingly, this resulted in the erroneous finding of “no long term evidence for the long term effects of [thalamotomy] a lesion”. The report also did not reference a publicly available draft tcMRgFUS NICE guidance, tcMRgFUS Health Canada review, international Neurological Associations guidance documents, or long term tcMRgFUS data available. HealthPACT noted “no comparator costs available” but omitted reference to Australian MSAC data that gave both comparator costs for the standard of care ($120,000 per patient in 2008) and actually described “thalamotomy as the standard against which others should be judged”. These errors could have been avoided, perhaps by inviting comment on the final draft; or State Health authorities might consult their own clinicians they employ that are experts in a field, acknowledging HealthPACT’s reports are authored by generalists.
In turn, Private Health Insurers (PHIs) have refused to pay interested hospitals, despite the procedure having an MBS Item. Those PHIs who have provided reasons for rejection have included arguments such as the location of tcMRgFUS not taking place in the same room as open neurosurgery, even though the thalamotomy procedure is identical. Ironically, other PHIs use evidence of fewer complications and shorter length of stay to justify limiting funding. Whilst tcMRgFUS can avoid the need for $40,000 of implants, the tcMRgFUS procedure kit itself is not an implant so PHIs simply refuse to pay.
PHIs are acting rationally to maximise profits, with $534m for Medibank alone in 2018. So of course, PHI happily pocket the $120,000 of savings, including potentially $40,000 of prosthesis.
This means hundreds of patients, many of whom have spent a lifetime paying taxes and private health premiums, are paying 100% out of pocket for treatment that elsewhere is the standard of care. And while they await treatment, their severe tremor prevents them working, with many claiming government support for the care they require.
Can there be a clearer example that PHI, an industry motivated by profits, cannot decide on what it pays for? There is an urgent need for the government to follow through on their commitment to include devices that are non-implants on the Prostheses List. Or ordinary patients and their families, like David in this story, who have paid PHI all their lives, will keep needing to take out loans to prop up PHI profits.
Patients and wider society pay the price if profit-driven PHIs are in total control – the Federal Government must follow through on its promise to industry to reimburse non-implantable prostheses.
ABOUT THE AUTHOR
Christopher Selwa is Managing Director of MediGroup EBI. MediGroup EBI is an Australian, family-owned SME focusing on the introduction of groundbreaking medical technology into Australia and New Zealand.