Surgery - your choice of prosthesis
The Federal Government has made it easy to choose an effective surgically implanted prosthesis that won't leave you out of pocket.
What is a prosthesis?
A prosthesis is an artificial or substitute component such as a pacemaker, defibrillator, cardiac stent or joint replacement.
Before you have surgery, your surgeon will tell you if a prosthesis is required. For most surgical procedures, there is a choice of prostheses available. They can vary in cost and comparative benefits. Until now, there has been no simple way to compare the costs and benefits.
What has changed?
The Government, together with a panel of doctors and other health specialists have evaluated prostheses available in Australia and determined which ones are clinically comparable. The evidence shows that the most expensive prostheses are not necessarily the most appropriate ones.
As a result of this initiative, from 31 October 2005, you and your surgeon will be able to choose a prosthesis for every Medicare procedure which will be fully covered by your private health insurance – that is, you will have no gap amount to pay.
Other more expensive prostheses may be available for your surgery but if you agree to have one of these, you will have to pay a gap amount. The gap amount is the difference between the prosthesis chosen by you and your surgeon and the ‘no gap’ alternative.
Examples of prosthesis choice:
- Bill is going to have a knee joint replacement operation.
Bill's surgeon has recommended a brand of prosthesis (Brand A) which is a no-gap prosthesis costing $3,000. Because it is a no-gap prosthesis, Defence Health will pay the full cost for the item.
- Sharon is going to have a knee joint replacement operation.
Sharon's surgeon has recommended an alternative brand of prosthesis (Brand B) which costs $200 more than the no-gap prosthesis. Defence will still pay the $3,000 towards the cost of the prosthesis. Sharon will be billed the balance of $200.
(The examples above are made up and do not take into account any waiting periods on your policy.)
Why has the change been introduced?
The reason for the change is twofold:
- Until now, there has been no formal independant clinical evaluation of prostheses in Australia. This Government and industry initiative allows benefits paid and prices charged to be more closely linked to the clinical effectiveness of the prostheses.
- Health fund expenditure on prostheses has been increasing at an average rate of 25% per year over recent years. This has contributed to increasing premiums for all health fund members.
The new arrangements will ensure that you will continue to have access to safe and clinically effective prostheses that are fully covered by Defence Health, while helping to ease the pressure on premiums.
What do I need to do?
- Before you have any surgery, check that your private health insurance covers you.
- If your surgery requires a prosthesis, ask your surgeon which prosthesis whill be the best one for you and which no-gap prostheses are available.
- If the surgeon recommends a prosthesis for which a gap is payable, ask why this one is being recommended. You will have to pay part of the prostheses cost if you agree to have one of these devices.
- Ask the surgeon to explain the costs of the surgery including the prosthesis gap payment, if any, and any other expenses involved. If there are any gaps for you to pay, ask for a written cost estimate.
- Contact Defence Health again to confirm the amount of any gap payment.