Hearts4heart takes aim at health insurers leaving patients to pay the price

Persistent advocacy by patient groups has prompted the Medical Services Advisory Committee (MSAC) to review the funding gaps for pulsed field ablation (PFA), a move that will improve patient access to atrial fibrillation (AF) treatment in private hospitals.

AF, the most common cardiac arrhythmia, affects around 500,000 Australians and is associated with an increased risk of heart failure, stroke and death, contributing to more than 200,000 hospital admissions each year.

MSAC oversees Medicare Benefits Schedule (MBS) funding for cardiac ablation procedures. While PFA is currently billed under existing MBS item numbers developed for older radiofrequency and cryoablation technologies, stakeholders argue the reimbursement does not reflects the full cost of delivering the newer technology in private hospitals.

Hearts4heart has been a leading advocate for reform, highlighting the key barriers preventing equitable access to PFA and urging MSAC to review the funding mechanism for privately insured patients.

“We are increasingly hearing from patients and clinicians that access to ablation in the private system is under significant strain. Patients tell us of longer wait times, being asked to consider the public system (where wait times can sometimes extend to four years) despite holding private health insurance, and uncertainty about whether newer, safer technologies recommended by their electrophysiologist will be available at the hospital where they receive treatment,” Tanya Hall, CEO of hearts4heart told Health Industry Hub. “These are not theoretical concerns. They reflect the real-world consequences of a funding system that has failed to keep pace with advances in clinical practice, creating unnecessary barriers to timely, evidence-based care for patients.

Access to PFA differs markedly between the public and private healthcare systems. In public hospitals, patients often face waiting times of one to two years for AF procedures. In the private sector, the financial shortfall associated with delivering PFA restricts the number of procedures hospitals are able to provide or leaves insured patients and private hospitals facing the burden of absorbing the cost gap.

“When reimbursement arrangements do not sufficiently cover the costs of providing recommended treatment, the resulting financial gap does not disappear; it is often transferred to patients through increased out-of-pocket expenses,” Hall explained. “For many Australians, particularly in the current cost-of-living environment, these additional costs can create significant barriers to accessing care. Patients may be forced to make difficult decisions about whether they can afford the treatment recommended by their clinician, accept delays in receiving care, compromise on the technology available to them, or be redirected to an already overstretched public hospital system.”

Beyond the immediate impact on individual patients, these challenges also risk undermining confidence in the value of private health insurance. Australians who invest in private health insurance reasonably expect that it will provide timely access to clinically appropriate care when they need it. When reimbursement settings create barriers to accessing recommended treatments or result in substantial unexpected costs, patients question the value of their cover and reconsider whether private health insurance continues to meet their healthcare needs.

MSAC’s review is expected to inform future funding arrangements for PFA in private hospitals.

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