Buried in red tape: Why privately insured patients are denied cutting edge health technologies

Government committees like the Pharmaceutical Benefits Advisory Committee (PBAC) and Medical Services Advisory Committee (MSAC) publicly disclose their decisions when evaluating new health technologies. The Prescribed List (PL) process, in contrast, operates behind closed doors – no published outcomes, no explanations. Privately insured patients, who pay for faster access and the latest technologies, are instead met with silence, delays, and denied innovation.

In an attempt to uncover the dynamics behind the PL, the Medical Technology Association of Australia (MTAA) conducted a review of the 2024 Medical Devices and Human Tissue Advisory Committee (MDHTAC) papers and minutes. The goal? To answer critical questions about the types of applications submitted to the PL, their outcomes, and the real reasons behind those decisions.

The findings paint a troubling picture.

In 2024, 949 new applications were submitted to the PL – the highest for orthopaedic followed by spinal medical devices. An additional 410 amendment applications were made. Yet, only 33% of new applications were approved in their original form, highlighting the complexity of the current process. By comparison, the MSAC recommended Medicare funding for 39% of new applications on first evaluation.

According to the MTAA analysis, more than 20% of all PL applications – both new and amended – were deferred, causing listing delays of four months or more. In contrast, only 13% of MSAC applications face deferrals. These delays have real-world consequences for patients who are contributing significantly to private health insurance and expecting timely access to the latest medical technologies and treatments.

“When innovation is discouraged and listing delays persist, it undermines the value of private health insurance and leaves privately insured Australians waiting longer for access to the latest medical technology,” warned Ian Burgess, CEO of MTAA.

Despite TGA approval confirming the safety and efficacy of these medical technologies, 98 new PL applications for existing device groups were rejected due to insufficient clinical evidence.

“Excessive clinical evidence requirements for PL inclusion, often far exceeding overseas requirements, delays patient access to new and innovative medical device technology,” said Burgess.

“For example, many orthopaedic joints are required to have a minimum of 250 patients and 2 years’ of follow-up from one source just to achieve the same listing as current devices – sometimes delaying access by up to 5 years compared to the public system.”

It is concerning that not a single one of the 39 new or 7 amendment applications representing cutting-edge technologies and seeking higher benefits was accepted for PL listing. Even those routed through focused HTA reviews were ultimately rejected. Similarly, 110 new applications were only accepted on the condition that medtech sponsors accept lower benefits than what was originally applied for. This ongoing denial of higher benefits fails to recognise and appropriately value innovative health technologies.

“While there have been $290 million in PL benefit reductions in the last 2 years, pathways to secure higher benefits for new or innovative technologies remain very limited. That imbalance is discouraging innovation and investment in Australia’s MedTech industry,” Burgess said.

Despite the analysis findings, MTAA remains committed to working constructively with the government to address the PL listing challenges.

“This is essential to ensuring patient access to the latest medical technologies in the private system,” Burgess emphasised.

At a time when the viability of private hospitals and the value of private health insurance are under mounting scrutiny, failure to deliver on the promise of innovation and timely access risks undermining the very purpose of private healthcare – pushing more patients into the already overstretched public health system.

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