Evaluation of the National External Breast Prostheses Reimbursement Program

1. Introduction and background

Page last updated: 05 November 2010

In June 2009, the Department of Health and Ageing (the department) commissioned Urbis to undertake an evaluation of the National External Breast Prostheses Reimbursement Program. The intent of the program is to provide financial support to women who wear an external breast prosthesis as a result of a mastectomy due to breast cancer, through a nationally consistent reimbursement program.

1.1 Breast cancer in Australia
1.2 The National External Breast Prostheses Reimbursement Program
1.3 This evaluation

1.1 Breast cancer in Australia

Breast cancer is the most commonly diagnosed cancer among females in Australia according to a report from the Australian Institute of Health and Welfare (AIHW) in 2009, 'Breast Cancer in Australia: An overview'. While breast cancer also affects males, the incidence rate is much lower than amongst women, about .11% of cancer deaths for males. Latest data shows that in 2006, 12,614 women were diagnosed with invasive breast cancer and projections suggest that this figure is likely to rise to around 15,400 cases by 2015 due to the ageing of the population. The number of new breast cancer cases in women has more than doubled in the 25-year period from 1982, rising from 5,289 new cases to 12,614 new cases in 2006. AIHW also note that in 2006, the number of cases diagnosed was 3% higher than the number diagnosed in the previous year and is the largest number of new breast cancer cases in women reported in any year to date. Data on the estimated incidence rates of breast cancer around the world by region show Australia to be in fourth place, following North America, New Zealand and Western Europe. The average age of diagnosis of breast cancer in Australia is approximately 60 years and women living in the areas of highest urbanisation reportedly have higher rates of diagnosis. There are significant variations in the rates of diagnosis between different racial and cultural groups in Australia, with Indigenous Australians having lower rates of diagnosis than non-Indigenous Australians, and some migrant groups having higher or lower rates of diagnosis depending on country of origin (Australian Institute of Health and Welfare, 2009).

1.1.1 Detection, treatment and impact

Early detection of breast cancer produces better chances of survival. BreastScreen is one of three national screening programs that have been implemented to raise awareness and early detection of the disease. Since the introduction of BreastScreen in 1991, deaths from breast cancer have decreased from 31 per 100,000 in 1991 to 22 per 100,000 in 2006 (Australian Institute of Health and Welfare, 2008).

In 2007–08 a simple mastectomy was the eighth most common procedure for female patients with a principal diagnosis of breast cancer with 5,187 separations, after excision of lesion of breast which was fifth most common with 10,035 separations. The four most common procedures for breast cancer-related hospitalisations included (in order): administration of pharmacotherapy, cerebral anaesthesia, loading of drug delivery device, and excision procedures on lymph node of axilla (Australian Institute of Health and Welfare, 2008).

A mastectomy involves the removal of the whole breast and is performed as part of the treatment procedure for breast cancer. In some cases women are given a partial mastectomy depending on the nature, location and severity of the cancer. Some women choose to have a mastectomy as their first surgery to avoid having radiotherapy or further surgery to the breast (Australian Institute of Health and Welfare 2009).

Breast cancer not only affects women physically (through surgery, chemotherapy and radiotherapy), but their social and emotional wellbeing, and everyday lives. Cancer care today often provides state-of-the­science biomedical treatment, but fails to address the psychological and social problems associated with the illness, which can compromise the effectiveness of health care and adversely affect the health of cancer patients (Committee on Psychosocial Services to Cancer Patients/Families in a community setting, 2007).

It has been argued that major psychological and social stressors experienced by women with breast cancer are related to a woman's understanding of her disease, its prognosis, the complexity of treatment, and her access to care and/or choice of providers (Ganz P, 2008). Even the most psychologically strong individuals can be overwhelmed by the number of medical visits, procedures and waiting times during initial diagnostic processes (Ganz P, 2008). Distress exists on a continuum beginning with the 'normal' and expected feelings of fear, worries, sadness and vulnerability in coping with cancer and its treatment; however distress can extend to more severe and disabling forms leading to a formal diagnosis of major depression (Hewitt M, Herdman R & Holland J, 2004). Top of page

Common psychological concerns experienced by woman with breast cancer include (Ganz P, 2008):
  • fear of recurrence
  • body image disruption
  • sexual dysfunction
  • treatment-related anxieties
  • intrusive thoughts about illness/persistent anxiety
  • marital/partner communication
  • feelings of vulnerability
  • existential concerns regarding mortality.
Research conducted in the United States found that around 30% of women with breast cancer show significant distress at some point of the illness; the number is greater in women with recurrent disease whose family members are also distressed (Hewitt M, Herdman R & Holland J, 2004). The loss of a breast and the consequent body disfigurement can not only cause physical discomfort but affect a woman's self-image and identity. Women may choose to re-construct their figure in a number of ways in order to regain a sense of wholeness.

1.1.2 Reconstructive surgery and breast prostheses

Women who have a mastectomy or partial mastectomy can choose to have reconstructive surgery to rebuild the size and shape of the breast, either at the time of mastectomy or following radiation treatment once the tissue has healed. This involves the insertion of silicon gel bags into the breast or tissue flaps from other parts of the body to build up the breast, and is performed by a plastic surgeon. Most women are able to have reconstructions, however people with conditions such as obesity, circulation problems, diabetes and high blood pressure are at risk of serious complications. Some women are also put off at the prospect of having another major surgery following their mastectomy.

For other women, the costs associated with reconstruction, the waiting list in the public health system to have a reconstruction, and the thought of having another major surgery, mean that the choice of wearing an external prosthesis is an easier alternative. Some women also choose to wear a prosthesis while they decide whether they would like to have reconstructive surgery. A breast prosthesis is an artificial breast worn inside the bra which helps gives shape to clothes, improves balance and posture, and can restore body image for women who have had a mastectomy. It is different to a temporary breast form which is a temporary pillow-like breast shape given to women in hospital after surgery. Breast prostheses are commonly made from silicon gel and are available in a variety of sizes, shapes and colours to match the remaining breast or tissue. Prostheses need to be fitted professionally so that they are properly weighted to the remaining breast and to the contours of the body. The prosthesis is worn inside a specially made bra and closely copies the natural shape of the breast. Women are also able to use a self-adhesive prosthesis that sticks to the chest using special glue. These do not last as long as non-adhesive prostheses however. Generally a prosthesis will last up to two years (with the majority of manufacturers providing a warranty for this period), however in many cases prostheses can last up to five years with proper care. The cost of a prosthesis (depending on materials used) ranges from $130 to $400 (Breast Cancer Network Australia, 2010).

The Breast Cancer Network Australia (BCNA) estimates that around 6,000 women each year will require a breast prosthesis following surgery for breast cancer. Top of page

1.2 The National External Breast Prostheses Reimbursement Program

1.2.1 Program overview and objectives

Funding for the National External Breast Prostheses Reimbursement Program was announced by the Commonwealth Government in May 2008 and the program was announced by the Minister later in 2008. The program has been operating since December 2008. Prior to the implementation of the national program, all states and territories arranged their own schemes for women who purchased breast prostheses as a result of breast cancer.

The objectives for this national program are to:
  • provide financial support towards the costs of external breast prostheses for women who have undergone a mastectomy as a result of breast cancer
  • ensure national consistency in the provision of support towards the cost of breast prostheses
  • improve the quality of life of women who have undergone a mastectomy as a result of breast cancer.

1.2.2 Administration of the program

The program is administered by Medicare Australia on behalf of the department under the terms of a service arrangement and business rules. Under the service arrangement, the department is obliged to provide policy advice to Medicare Australia in a timely manner and to respond to queries and complaints that relate to policy issues under the program.

Medicare Australia is required to provide monthly and end-of-financial year statistics to the department on a number of items identified on the program claim form, including: the number of reimbursements, amount reimbursed, demographic data and process performance. Medicare Australia is required to process 90% of all claims within ten days of lodgement, as part of its obligations as administrator of the program.

Women claiming for the reimbursement through Medicare Australia can do so by downloading and completing a claim form from the Medicare Australia website, going to a Medicare Australia branch for a hard copy, or calling Medicare Australia. Those receiving financial assistance from the Department of Veterans' Affairs (DVA) are able to claim their entitlement through DVA. Top of page

1.2.3 The principles for the administration of the program and eligibility criteria

The principles for the administration of the program are:
ease of access to reimbursement for all eligible women
  • efficiency of reimbursement to eligible women
  • efficiency of implementation of the program through minimal additional infrastructure costs
  • appropriate accountability structures in place to monitor and audit the program
  • consistent national approach across all jurisdictions
  • sensitivity to the needs of the eligible women accessing the reimbursement.
The eligibility rules for the program are:
  • women who have had a mastectomy as a result of breast cancer – the mastectomy may be recent or in the past (no time limit)
  • women who have purchased a first or replacement breast prosthesis on or from 1 July 2008
  • women who are permanent residents of Australia and have current Medicare Australia entitlements
  • women who have not received financial assistance for the claimed prosthesis from the Department of Veterans Affairs (DVA)
  • women who have not received financial assistance for this prosthesis from a private health insurer, state or territory or other organisation, or have received a refund or financial assistance through their private health insurer, state or territory or other organisation less than the maximum Commonwealth reimbursement.
Eligible women can claim up to $400 reimbursement for each new or replacement external breast prosthesis. This limit applies for each prosthesis for each breast. If a claim under the program has been made, a subsequent reimbursement can be claimed no earlier than two years from the date of purchase. Top of page

1.3 This evaluation

This evaluation involved two parts – a review of the administration of the program; and a review of the impact of the program on the lives of women who have had a mastectomy as a result of breast cancer.

The administration review evaluated the appropriateness, effectiveness and efficiency of the program's administration in reference to the business rules and the principles for the administration of the program for the first twelve months of its operation (December 2008 to December 2009). This review also explored opportunities for future improvements or directions to the program's administration.

The impact review evaluated the impact of the program in meeting its objectives which include, but are not limited to, improving the quality of life of women who have undergone a mastectomy as a result of breast cancer. The impact review also heard from women regarding issues of concern and suggestions which may strengthen the program's effectiveness and maximise its potential for success.