Overall, the evaluation results indicate that the program is operating effectively, and that claims are being processed in accordance with the business rules. In addition, those women who have accessed the program have indicated satisfaction with the program and the provision of a nationally consistent reimbursement scheme.
While generally positive, several key areas for improvement were raised across the range of evaluation respondents. These related to:
- further promotion and communication about the program
- consideration of the up-front payment
- frequency of the reimbursement
- provision of support for women of an Aboriginal and Torres Strait Islander or culturally and linguistically diverse background.
5.1 Further promotion and communication about the programAlthough the program has been demonstrated to improve women's access to external breast prostheses, a general lack of awareness about the program suggests that not all eligible women have been able to take advantage of the program.
The business rules estimated that 50,000 reimbursements would be made in the first year. In reality, 19,962 reimbursements were made, roughly 39% of the estimated figure. It may be that the 50,000 figure was an over-estimate, or it may be that women were not aware of the program. Data from Medicare Australia does indicate a gradual increase in claims over the year, presumably as awareness of the program increased (see section 3.2.3).
It was agreed by respondents that breast care nurses and breast prosthesis fitters are the primary means by which women learn about the program. However, for those who have not recently had a mastectomy, or who may not previously have used an external prosthesis, information about the program is harder to access. Whilst women who are more involved in breast cancer networks, organisations and support groups may gain information about the program through these avenues, conversely women who are not involved in these networks and groups may not be learning of the program. Respondents provided a number of suggestions for greater promotion about the program:
- brochures at prosthesis suppliers, hospitals and Medicare Australia offices
- radio and television commercials, particularly targeting non-English speaking communities
- providing general practitioners, practice nurses, breast surgeons, oncologists, breast care nurses and consultants with up to date information
- advertising at breast cancer events, such as the Mother's Day Classic Marathon in May.
Medicare Australia's October promotion of the program during Breast Cancer Awareness Month was noted by several women. Promotional activities need not be costly, but should be targeted to specific groups for most effective access. For example, general television advertisements may be costly without a clear return, but targeted radio promotions on non-English stations can be very inexpensive and reach a specific audience which might not access mainstream promotional materials. Occasional articles in newspapers or community magazines might also raise awareness without incurring the cost of advertising.
There does not appear to have been a significant budget for promotion in the first year, however the lower numbers of women accessing the program may suggest a need to invest further in this area. The increase in promotion would most likely increase the number of women accessing the program, and therefore the overall costs of the program. Top of page
5.2 Consideration of the up-front payment for some womenA number of respondents conveyed concern that the up-front cost of a breast prosthesis (prior to reimbursement) was a significant financial outlay for many women. It was felt to be particularly the case for women who are on pension or health care cards, who are elderly, who are single parents, Aboriginal and Torres Strait Islander or financially disadvantaged.
As noted earlier, it is not possible to quantify how many women may experience financial hardship. Many of those who commented on this were not referring to themselves but to the potential for others to be disadvantaged. The paradox remains that in speaking with women who have accessed the program, we are not reaching those who have not tried to access the program because of financial reasons.
In recognition of the lack of clarity regarding this concern, no recommendation is made regarding changes to the structure of the reimbursement scheme. However, this is an issue which would warrant further consideration, perhaps in a years' time when the program is further established and promoted. One possibility could be a focussed research project working with breast care nurses to attempt to quantify the proportion of women who experience financial hardship which prevents them in purchasing a breast prosthesis. Top of page
5.3 Frequency of the reimbursement for some womenThe two year frequency of reimbursement was considered by some respondents to disadvantage some women, particularly those who had either gained or lost significant amounts of weight during treatment. Some respondents suggested that requests from these women for intermittent reimbursements be assessed by the department on a case by case basis.
The business rules specify the policy structure for the program and it is recognised that the ability to 'bend the rules' will have cost implications. The ability to allow discretion for claims made, for instance one week short of the two-year mark, or within one year due to significant treatment consequences, is unlikely to create a large number of additional claims, but may improve the quality of life for a woman.
In order to make some assessment of how great a cost consideration this discretion might be, it could be valuable to monitor over a year the number of claims or queries regarding the time limitations, and the reasons for such requests, and to seek to quantify the extent of the need, before making a definitive policy change. Top of page
5.4 Support for women within particular language and cultural groupsThere were few Aboriginal and Torres Strait Islander women or women of a culturally and linguistically diverse background who participated in the survey. As noted in section 3.1.1, challenges were faced by the evaluation team in gaining feedback from women of a culturally and linguistically diverse or Aboriginal and Torres Strait Islander background about their experiences with the program, and as such it was difficult to determine to what extent these women have accessed the program. Few respondents were able to estimate the numbers of culturally and linguistically diverse or Aboriginal and Torres Strait Islander women who may be aware of or access the program.
The single focus group with Arabic-speaking women, while not representative, did suggest that further information about the program needs to be disseminated amongst specific language groups. It was also suggested that greater focus be given to ensuring that culturally appropriate information is available.
The costs of this promotion need not be extensive, as discussed above in section 5.1, but has the potential to increase the number of women who access the program, which in itself will increase the reimbursement costs of the program. Top of page
5.5 Summary of program objectives and principlesThe evaluation of the National External Breast Prostheses Reimbursement Program provides evidence that the program has achieved its guiding objectives 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.
- 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.