Medicare limitations causing preventable blindness

For many years, the Royal Australian and New Zealand College of Ophthalmologists (RANZCO) and other eye health organisations have highlighted the massive scale of preventable blindness in Australia, including increasing diabetic retinopathy, glaucoma, cataracts, macular degeneration, and uncorrected refractive error.

After three years of reduced patient access to preventive eye care and elective eye surgery due to the coronavirus disease 2019 (COVID-19) pandemic, medical practitioners at the front line of health care are increasingly recognising the dire impact of undiagnosed and untreated visual impairment.

This includes falls, motor vehicle and other accidents and injuries, medication error, deterioration of other comorbid disorders due to inactivity, mental health problems, loss of independence and prolonged hospitalisation to name a few.

Based on what is known about the increasing prevalence of diabetes and diabetic retinopathy, cataracts, glaucoma and macular degeneration in our aging population, it is likely millions of Australians are missing out on routine eye screening, follow-up and treatment, particularly in regional and rural areas.

As many disadvantaged people continue to have inadequate access to health care as we emerge from the COVID-19 pandemic, it is also impossible to estimate the true extent of undiagnosed eye disease in vulnerable groups, including Aboriginal and Torres Strait Islander peoples, ethnic minorities, and those with lower incomes.

Current workforce

The current eye health care workforce is not equipped to address the massive scale of undiagnosed and established eye disease.

There are only about 1000 full-time equivalent ophthalmologists in Australia, and only 13% of specialist ophthalmology care occurs in the public sector.

There are only 174 ophthalmology trainees spread across the five years of the program.

About 4800 full-time optometrists work mainly in private eye clinics in Australia, but the cost of retinal imaging deters patient access, and, as with all health professionals, there are increasing workforce shortages in rural and regional areas.

Practitioners under pressure

Eye specialists have long considered how best to increase routine eye examinations in patients at risk of blindness by general and other practitioners.

Unfortunately, the acute chronic clinical workforce shortage is putting many practitioners under extreme pressure at a time of increasing patient morbidity and mortality related to the neglect of many non-COVID-19 conditions during the pandemic.

Eye health is only one of a large list of priorities, including cardiovascular disease, stroke, diabetes, renal disease and cancer – all of which may predispose patients to impaired vision.

Asking practitioners to do more and more with less and less in this situation is fraught, particularly at a time when many are reducing bulk billing due to the lack of private practice viability.

For all these reasons, the uptake of Medicare incentives (12325 and 12326) for retinal screening by medical practitioners other than an optometrists or ophthalmologists has been poor across Australia, with only 1730 services claimed between July 2021 and June 2022.

Our first-hand experience

At the front line of rural hospital medicine and general practice, we are currently confronting all these barriers firsthand as we attempt to establish an eye health pilot to help upskill general practitioners in rural areas with acute health workforce shortages and disadvantaged populations with poor access to primary care eye screening and specialist services.

In this environment, it is challenging to overcome the systemic barriers in primary care for the following reasons:

• Medicare funding for eye health screening is restricted. The criteria for claiming Medicare items 12325 and 12326 are limited to “the medical practitioner (other than an optometrist or ophthalmologist) providing the primary glycaemic management of the patient’s diabetes … and the patient does not have i) an existing diagnosis of diabetic retinopathy; or ii) visual acuity of less than 6/12 in either eye; or iii) a difference of more than 2 lines of vision between the 2 eyes at the time of presentation”.
• There is also no source of funding for upskilling in eye health and retinal imaging, or to set up the necessary patient recall systems, access previous screening to detect deterioration in retinal conditions, integrate eye care with care of other comorbid disorders or purchase expensive retinal cameras.
• If eye health checks including retinal screening are successfully implemented, there are limited options for referral of patients with diabetic retinopathy, cataracts, macular degeneration and glaucoma to specialist care in the public system due to the severe shortage of ophthalmologists.

Recent studies have suggested these barriers are Australia-wide.

What are the solutions?

We believe there needs to be a whole-of-government approach to reform the health system and to boost the ophthalmologist, optometrist, GP and other primary care workforces, which will take time.

However, the severe workforce shortage and the massive scale of preventable blindness in vulnerable groups and in those living in rural and remote areas are so acute, urgent action is required to address the systemic funding and other barriers (listed above) deterring access to eye health care — a fundamental human right.

Ophthalmologists in the RANZCO Vision 2030 and Beyond, have built a powerful case for equitable, comprehensive and affordable screening and treatment for common causes of preventable blindness.

The Vision outlines practical ways to improve collaborative service delivery and preventive eye health care, workforce maldistribution, training, sustainability and a comprehensive approach to addressing inequity in eye health in Aboriginal and Torres Strait Islander peoples.

Importantly, RANZCO recommends “the Commonwealth work with the Australian Indigenous Doctors’ Association (AIDA), the Coalition of Peaks, National Aboriginal Community Controlled Health Organisation (NACCHO), the jurisdictions, the Colleges, and other stakeholders to develop special measures that facilitate access to healthcare services (not just ophthalmology) for Aboriginal and Torres Strait Islander peoples”.

There is a compelling case for other medical colleges, including GP colleges, to support RANZCO in their vision and to include eye health in any submissions to the May federal Budget 2023–24 to make “the right to sight” in disadvantaged communities a reality.

In the meantime, as a rural hospital medical officer and GP, we are determined to partner with others to overcome the systemic funding and other barriers deterring basic eye screening in rural and remote primary care.

We also determined to assist patients with heightened risk of eye disease, such as Aboriginal and Torres Strait Islander peoples and those with diabetes, access basic primary and tertiary eye care.

Overcoming the limitations in Medicare and other funding, engagement with existing services to build sustainable rural models and adoption of new technologies including artificial intelligence are the keys to overcoming the barriers.

The status quo is not acceptable. It’s time to overcome our medical and other silos because our whole health system is under extreme pressure. The only way to tackle the massive scale of preventable blindness is with united advocacy and a groundswell of community action.

Dr Gifar Hassan is a hospital medical officer, having recently worked in metropolitan Melbourne at Austin Health and Peninsula Health, and the rural Murrindindi Shire. She also has a Master of Public Health and a Biomedical Science Degree.

Clinical Professor Leanne Rowe AM is a rural GP, co-author of Every doctor and past Chairman of the Royal Australian College of General Practitioners and Deputy Chancellor of Monash University.

The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated. 

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