After more than five years and four applications, New Zealand’s largest private insurer, Southern Cross Health Society (SCHS) has added minimally invasive glaucoma surgery (MIGS) devices to its members’ policies.
The long-awaited policy change came about after several meetings with Ophthalmology New Zealand (ONZ) and because the financials finally made sense, said Dr Stephen Child, SCHS’s chief medical officer. Clinical efficacy has never been an issue with MIGS, said Dr Child, it’s always been about cost, affordability and benefit to members when compared with the many other medical products and procedures vying for approval. Given the definition of what constitutes a MIGS device or procedure is quite broad and can be quite fluid, it’s also quite a complex issue, he said. “It’s been really hard to write a business case when it's so kind of nebulous: what is MIGS, what is not MIGS, how are we going to price this, what's the volume going to be?”
To address these issues and allow flexibility in provider-patient choice, SCHS’s new MIGS policy covers all MIGS devices and procedures, however defined, said Dr Child, but the procedure and device will be charged separately. The procedure will be contracted via SCHS’s Affiliated Provider (AP) agreements, individually brokered with each ophthalmologist and roughly based on rates for similar surgeries, such as vitrectomy, he said. About 68% of all SCHS claims are paid through AP contracting, with contracts calculated at the 66th percentile, said Dr Child. “In other words, we offer basically what 66% of them have been charging, or higher. Everyone won’t be happy, but it's a negotiation. The majority, though, I think will be happy.”
The MIGS devices will be split into three price brackets or ‘prosthesis limits’, based on what the suppliers charge for their products and what SCHS has paid in the past. “There’s been a few MIGS procedures that have come through under fees-for-service - through back doors - so we’ve got some data, plus we've spoken to the companies, and ONZ has helped us. We're going to pay up to this amount for each device and then a member can pay the difference.”
Though SCHS doesn’t allow ‘top-ups’ for procedures, members can pay extra for prostheses. “But obviously we’ve picked these prosthesis limits at what we think is reasonable,” said Dr Child, stressing the rates are carefully worked out to be as fair as possible to members.
