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News & Trends - MedTech & Diagnostics

Health insurer unveils GUI funding plans post removal from Prescribed List

Health Industry Hub | March 11, 2024 |

MedTech & Diagnostics News: More than 500 General Use Items (GUIs) will no longer be included on the Prescribed List (PL) from 1 July 2024. The recent Senate Estimates honed in on the controversial decision by the government to abandon ship, shifting the GUI funding negotiations to private hospitals, health insurers, and medtech companies. The move has sparked questions about the scope of the negotiations and the future implications for patients.

“After the sector believed that there will be funding of General Use Items by a different mechanism, the Minister of Health said that was no longer the case,” said Senator Anne Ruston, Shadow Minister for Health and Aged Care, referring to the backtracking on announced plans by the Federal Minister of Health, Mark Butler.

GUIs include (but are not limited to) staples, staple applicators, clips and glues to close wounds. More than 70% of surgeries impacted by this funding change are performed on women, such as breast cancer operations, caesareans, and bariatric surgeries.

Bupa, the nation’s second-largest private health insurer, has announced its strategy regarding GUI funding post-July 1, with a transition to be completed by 2027.

The private health insurer stated “This ensures all Australian hospitals and our members continue receiving the same benefits and coverage for Listed GUIs on and from July 1 until Bupa has bundled the Listed GUIs with the benefit we currently pay for applicable procedures that use GUIs.

“This variation will be reflected in our agreement with contracted hospitals. From the date we vary our agreements with contracted hospitals, the hospital will cease claiming the applicable GUI benefits as the GUIs will be funded in the benefit we pay for the procedure claimed.”

For non-contracted hospitals, Bupa will also continue to fund Listed GUIs according to the existing schedule until the transition for bundling is finalised.

While Bupa acknowledged the evolving medtech sector and the innovative medical technology landscape, it is unlikely that the private insurer will pay higher benefits for new GUIs.

To illustrate their intention, Bupa provided two descriptive examples. The first involved a new generation GUI replacing an existing one by the same medtech company, and the second illustrated a new supplier offering a similar technology to an existing medtech company. Bupa emphasised that these claims would be processed at the same benefit rate or lower.

At the Estimates, Senator Ruston delved into the potential ramifications for patients, questioning, “Is the Department [of Health] satisfied that there won’t be any impact on patients as a result of this change in how General Use Items are being dealt with?”

The impact of this shift in GUI funding remains a topic of interest, with stakeholders closely monitoring negotiations as private health insurers take a more prominent role in shaping the funding criteria.

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