Disparity between Medicare claims for botulinum toxin for facial synkinesis/hemifacial spasm in Australian metropolitan and non-metropolitan areas

Introduction

Hemifacial spasm (HFS) is a peripheral neuromuscular disorder characterised by irregular, involuntary, unilateral contractions of the muscles of facial expression (1). Typically commencing with the orbicularis oculi, it can occur either spontaneously or via triggers (emotional, stressors). HFS is associated with higher rates of depression and significantly reduced health-related quality-of-life, related to poorer perceptions of their self-image (2,3). HFS has a clear female predominance, affecting 14.5 per 100,000 women as compared to 7.4 per 100,000 men worldwide (4).

HFS is broadly classified into primary HFS or secondary HFS, with the former being four times more common than the latter (5,6). Primary HFS is thought to be caused by compression of facial nerve near the brainstem by ectopic or pathologic anatomical structures (such as vascular loops) resulting in ephaptic transmission (4,7). Secondary HFS results from a degeneration-regeneration process following facial nerve palsy from either idiopathic, infections, inflammatory or iatrogenic means (6).

First-line therapy for secondary HFS is facial physiotherapy with botulinum toxin (BTX) injections, which has shown to resolve symptoms of spasm in 85–100% of patients and improve quality of life (8-15). Despite this, BTX therapy is not without its drawbacks, with over-injection leading to excessive facial ptosis and facial asymmetry (4), and the need for repeat injections with BTX therapy typically lasting 3 months.

The provision of BTX therapy for HFS within Australia is federally funded by Medicare Benefits Schedule (MBS). Whilst the treatment is funded nationally, the provision of this treatment is postulated to be contingent on the available expertise in the region of the patient requiring the care. The Rehabilitation Medicine Society of Australia claims “only the well-resourced or those who are lucky enough to live near well-funded public services have access to the toxin” (16). To date, there is no published Australian data on comparing the access to BTX therapy between metropolitan and non-metropolitan settings. We aim to compare the BTX therapy provided in metropolitan areas with their regional and rural counterparts and assess for any potential correlation in availability of specialty services.

Methods

An observational study is reported according to the STROBE reporting guidelines (available at https://www.theajo.com/article/view/10.21037/ajo-24-18/rc). The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). As this publication analyses publicly available data at a deidentified population level, this study was deemed ethics exempt by Chris O’Brien Lifehouse. The MBS item number 18350 was used as the representative billing code for BTX treatment provided for managing HFS. This item number is defined as “Botulinum Toxin Type A Purified Neurotoxin Complex (Botox), injection of, for the treatment of HFS in a patient who is at least 12 years of age, including all such injections on any one day”. In the Australian setting, primary HFS is generally managed by neurology and secondary HFS, or facial synkinesis after facial palsy is generally managed by plastic and reconstructive (PRS) surgeons, or to a lesser degree, neurologists and other surgeons subspecialising in facial plastics (otolaryngology head and neck surgeons, ophthalmologists). For the purposes of this scoping review, PRS surgeons was the only specialty selected for comparison. Hence, in this study, we believe that the item number 18350 could be used as a surrogate billing code for us to assess the access to treatment for facial synkinesis in Australia.

MBS item number reports were obtained from the Health Management Information Section from Services Australia (17) in December 2021 for the period 1^st July 2015 to 30^th June 2016; the most recent report mapped to Medicare Local Geographical Areas (LGAs). Age, gender as well as total number, value and location of claims were recorded Australian Census data for August 2016 (18) was used for both population (to calculate claims per 100,000 population in each region) and map Medicare LGAs into “Greater Metropolitan” and “Outside of Greater Metropolitan” for all states and territories. The number of PRS surgeons and their geographical distributions at this time period were obtained from the Health Workplace Data Tool for 2016 (19).

Statistical analysis

Descriptive statistics are presented as mean and standard deviation for normally distributed data and median and interquartile range for non-parametric data. The co-efficient of determination (R-squared) was calculated to assess correlation between number of PRS surgeons and number of claims.

Results

Number of claims

A total of 9,253 claims for item number 18350 (treatment of HFS) were identified and represented $1,002,244 (11.8%) of $8,497,226 spent on BTX related claims (for any indication) at the national level between July 2015 and June 2016 (see Table 1). New South Wales had the highest number of claims at 3,276 (35.4%) and the Northern Territory had the lowest at 24 (0.3%). After adjusting for population, South Australia had the highest with 46.9 claims per 100,000 population compared to the Northern Territory which was the lowest at 10.5 claims per 100,000. The proportion of total spending on BTX spent on HFS was similar between states, ranging from 7.8% (ACT) to 13.7% (WA).

Demographics of patients

Of all the claims, 67.2% were in relation to female patients, in line with the known female preponderance of HFS. This is outlined in Table 2. In each state and territory, males had a lower age at treatment compared to females, at a national mean of 25 vs. 51 years respectively. The Northern Territory had the lowest number of both total claims and lowest age for males and females, at a mean age of 3 and 17 years, respectively.

Metropolitan vs. non-metropolitan areas

As shown in Figure 1, 90.3% of claims for BTX for HFS were recorded within the metropolitan areas. When adjusted for population, the mean number of claims in metropolitan areas was 40.0 per 100,000 compared to 13.2 per 100,000 in non-metropolitan areas. South Australia had both the highest number of adjusted claims in metropolitan areas at 49.0 per 100,000, and outside of metropolitan areas at 26.5 per 100,000. The Northern Territory, Tasmania and the Australian Capital Territory data were not sub-categorised, hence comparisons were not performed.

Figure 1 Comparison between 18350 claims per 100,000 within and outside of greater metropolitan areas across Australia. 18350: MBS item number for BTX therapy for hemifacial spasm. BTX, botulinum toxin; MBS, Medicare Benefits Schedule.

Correlation between PRS surgeons distribution and claims

There were 457 PRS surgeons registered in Australia in 2016, as shown in Table 3. Victoria recorded the highest number of PRS surgeons at the census date with 147 (32.2%) and the Northern Territory recorded the lowest with 2 (0.4%). The average population adjusted number of PRS surgeons in Australia is 1.95 per 100,000, with the highest at 2.56 per 100,000 in South Australia and lowest in the Northern Territory at 0.87. Claims were adjusted in each state or territory as a proportion of the total and compared to the proportion of PRS surgeons. The distribution of claims for 18350 across each state and territory strongly correlated to the distribution of PRS surgeons in the same location (Figure 2), with a coefficient of determination (R-squared) value of 0.93.

Figure 2 Scatter plot of number of 18350 claims versus number of plastic and reconstructive surgeons by state/territory. 18350: MBS item number for BTX therapy for hemifacial spasm. ACT, Australian Capital Territor; BTX, botulinum toxin; NSW, New South Wales; MBS, Medicare Benefits Schedule; NT, Northern Territory; QLD, Queensland; SA, South Australia; TAS, Tasmania; VIC, Victoria; WA, Western Australia.

Discussion

Claims disparity in metropolitan vs. regional/rural areas

Figure 1 shows the discrepancy between claims per 100,000 population in metropolitan and non-metropolitan areas in all states of Australia, with some areas such as metropolitan Queensland demonstrating over a ten-fold increase in claim rates over their regional counterparts. This disparity is evident across all states where the data of metropolitan vs. non-metropolitan was available. It is important to note that claims are recorded in the location of where treatment occurs and not from the usual residential address of the patient. Assuming the incidence of HFS is consistent between metropolitan and non-metropolitan areas, this disparity highlights that patients with HFS in regional and rural areas of Australia have to either travel to more urban areas with to access care, or simply forgo appropriate treatment altogether.

Prevalence and access to BTX providers

There are a number of possible factors that may contribute to this inequality between patients with HFS in metropolitan and non-metropolitan areas, with both the prevalence and access to clinicians trained, comfortable and accustomed to administering BTX to patients with HFS likely a major contributor. In Australia, PRS is the surgical specialty predominantly associated with providing BTX therapy, with a lesser degree of otolaryngology, head and neck surgeons (OHNS), ophthalmologists and neurologists trained in providing this service. Hence, with that assumption, we explored the correlation of BTX therapy and the prevalence of PRS.

The coefficient of determination (R-squared) value between numbers of PRS surgeons and 18350 claims of 0.93 demonstrates a high degree of correlation between number of PRS surgeons and number of claims. This illustrates that each state manages a comparable number of HFS patients with BTX when adjusted for 100,000 population and the amount claimed per practitioner is approximately equal across all states and territories (Table 3). Given this similarity in numbers of PRS and claims between states, the difference between metropolitan and non-metropolitan 18350 claims is more likely to be due to differences in access to BTX-administering specialists rather than variations in treatment practices between different states or territories. The higher per capita services in metropolitan areas may also be attributed to the ease in which metropolitan patients can return for repeat treatments, in contrast to the added logistical difficulty for regional/rural patients to do the same.

Solutions

In addressing this disparity, a combination of both short and long-term strategies can be used. In the long term, ideally this would include increasing local provision of services with more regional and rural representation of specialist services. In the short term, to mitigate this disparity, strategies such as incentivising regional care and the use of telehealth would be effective.

Since coronavirus disease 2019 (COVID-19) pandemic, there has been a shift towards the provision of healthcare through virtual and online means. This has extended to several different fields since the pandemic. Given the demonstrated disparity between metropolitan and non-metropolitan areas with regards to PRS services (and likely other subspecialities such as OHNS and neurology), telehealth presents a unique opportunity by which HFS patients in non-metropolitan areas can be seen and assessed by suitably qualified clinicians. Tan et al. (20) demonstrated that there was no significant difference in the assessment of the facial nerve via three common facial nerve grading systems (House-Brackmann, Sydney and Sunnybrook) over a real-time video platform. Patient satisfaction with this type of virtual, telehealth clinic was also high, with Hayler et al. (21) demonstrating that patients felt their concerns were heard and addressed similarly well, with 75.6% of patients rating their experience as either good (4) or excellent (5) on a 1 to 5 Likert scale.

Further research is needed in this area; however, literature currently suggests that telehealth may be a method by which the aforementioned disparity is addressed. Patients from regional/rural areas can be initially worked up via teleconference, have their management in a metropolitan centre with the appropriate expertise, and have their progress reliably and accurately reassessed at follow-up. This would not just reduce both the financial and logistical burden of co-ordinating transport to, and accommodation in a metropolitan centre for the initial and subsequent visits for the patients but may also reduce the overall financial burden to the healthcare system itself.

Limitations

With our population based analysis of Medicare claims, there are inherently limitations to our study. Patients who are non-Medicare eligible and patients who are billed privately without the use of Medicare are not reported on in this analysis. Also, not all botox-prescribing practitioners are included in analysis, as some neurologists, ophthalmologists and OHNS also provide this service to patients with secondary HFS. Despite this being a clear limitation of our dataset, the inequity is highly unlikely to be solely due to the inability to analyse all botox-prescribing practitioners; with persisting inequity of representation of almost all specialty services in regional/rural areas.

In our dataset, the LGA that individual Medicare claims are classified to is determined by the location of the practicing physician, rather than the location of the patient. As such, rural patients who travel to metropolitan areas for treatment would be classified under the clinician’s metropolitan LGA, rather than their rural origin. This, however, further exacerbates the discrepancy between metropolitan and non-metropolitan papers; perhaps to a greater extent than suggested by the figures calculated in Figure 1.

The MBS and LGA data in this publication is 8 years old, and billing practices are not necessarily completely accurate. This is highlighted by mean age of males receiving treatment in Northern Territory being 3 years old, which may be a result of billing error or practitioner unfamiliarity with the item code being for patients over 12 years of age; especially given its infrequent use in the region. However, this is the latest complete dataset available from the MBS which can be correlated with a complete dataset from the Australian Bureau of Statistics (ABS) from an LGA perspective. More contemporaneous and audited data would be ideal; however this is not currently available.

Conclusions

BTX treatment is commonly used to treat HFS and facial synkinesis. Clear differences lie in claim numbers between metropolitan and non-metropolitan areas in states and territories, even when adjusted per capita. Access to services appears to be a barrier, with the number of claims correlating to the number of PRS surgeons within the region. Telemedicine may represent a suitable method to increase accessibility, so patients in regional and rural Australia can BTX-providing clinicians for management of their HFS.

Acknowledgments

The authors would like to thank Gillian Heller (University of Sydney) for the statistical support. This paper has been accepted for presentation on 10^th June 2022 at Australian Society of Otolaryngology Head and Neck Surgery—Annual Scientific Meeting (ASOHNS ASM) 2022, Adelaide, Australia.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://www.theajo.com/article/view/10.21037/10.21037/ajo-24-18/rc

Peer Review File: Available at https://www.theajo.com/article/view/10.21037/ajo-24-18/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://www.theajo.com/article/view/10.21037/ajo-24-18/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). As this publication analyses publicly available data at a deidentified population level, this study was deemed ethics exempt by Chris O’Brien Lifehouse.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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