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Prostheses – what are they and who pays?

5 August 2010

Prostheses, as far as the Medical Device industry in Australia is concerned, are generally understood to be those medical devices that are included on the Department of Health and Ageing’s Prostheses List.

According to the Prostheses List, these medical devices are those that totally or partially replace, facilitate or block a bodily function. They are generally surgically implanted in or surgically applied to the patient during a hospital procedure.

While items such as artificial legs and wigs are commonly referred to as ‘prostheses’ they are not included on the Prostheses List as they do not meet the criteria listed here.

Prostheses can cost many thousands of dollars. So if you need one, you might be interested to know how the funding arrangements work.

There are three ways in which prostheses and the surgical procedures used to implant or apply them are funded:

1. By the State public health system when the patient receives that prosthesis as part of a procedure in a public hospital. The availability of procedures using particular prostheses varies from hospital to hospital and state to state.   There may also be waiting lists for these procedures, and the number of procedures performed each year may be capped.

2. Through private health insurance when the patient receives that prosthesis as part of a hospital or hospital-substitute procedure for which the patient has an appropriate level of health cover, and where that prosthesis is included on the Prostheses List.  Patients should check their health cover for specific exclusions which may apply to some policies. In some instances, the patient may be required to pay a “gap” for the prosthesis. The patient may also be required to pay gap costs for the health care professionals involved in the procedure and hospital excess charges depending on their level of cover. Private hospitals do not cap the number of procedures they perform each year involving prostheses.

3. In instances where the prosthesis is not covered by private health insurance and not available through the public health system, the patient would be required to fund the full cost of the prosthesis themselves. In this instance the patient may also be required to pay for any associated healthcare professional and hospital fees etc.

There may be some changes to this system as a result of the recent HTA Review, but we will have to wait and see how they are to be implemented.

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