Evaluation of the National External Breast Prostheses Reimbursement Program

Interview guide - Medicare Australia

Page last updated: 05 November 2010


Thank you for meeting with me today. My name is # from Urbis. As you are aware, we are carrying out an evaluation of the National External Breast Prostheses Reimbursement Program for the Department of Health and Ageing (DoHA). In undertaking this research project, we are looking at both the administrative aspects of the program, and the impact of the program on women who have undergone a mastectomy as a result of breast cancer, with reference to the program's principles and objectives.

The program's principles 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 and
  • Sensitivity to the needs of the eligible women accessing the reimbursement.
The program's objectives are to:
  • Provide financial support towards the costs of external breast prostheses for women who have undergone mastectomy as a result of breast cancer
  • Ensure national consistency in the provision of support towards the cost of breast prostheses and
  • Improve the quality of life of women who have undergone mastectomy as a result of breast cancer.
As the organsiation responsible for the administration of the program (through a service level agreement and business rules in place with DoHA), Medicare Australia is clearly a key stakeholder in the review of the program's administration. The focus of today's interview is the administration of the program. In particular, we will be asking about the systems and processes that Medicare Australia has in place to underpin the administration of the program.

As Medicare Australia also receives feedback from women about the program's impact, including through its customer service officers and written enquiries about the program, we also have some questions that relate to women's experience of the program.

Your responses in this interview will remain confidential to the research team and will not be attributed without your permission.

Do you have any questions before we start? Top of page


Administrative review

Role description

  1. To give me a clear understanding of your organisations' involvement in the program, please describe your organisation's role with respect to the program.

Administrative arrangements

  1. In the first 12 months of the program's operation, what processes and systems has Medicare Australia put in place for the administration of the program, under the program's business rules, including:
      • Establishing and managing appropriate consumer eligibility arrangements?
      • Meeting specified reporting requirements (prompt for monthly and annual statistics etc)?
      • Meeting specified performance indicators (prompt for processing timeframes)?
      • Establishing and managing appropriate claims assessment arrangements?
      • Establishing and managing appropriate payment arrangements?
      • Establishing and managing appropriate enquiry management arrangements?
      • Having adequate audit and access provisions?
      • Undertaking relevant communication activities in relation to the program (prompt for display of posters, brochures and/or other promotional material in Medicare Offices)
      • Consulting with the department in a timely way in relation to any changes to program administration arrangements (prompt for system enhancements, emerging policy issues etc)?
      • Consulting with the department in relation to any release of information about the program (prompt for statistics, responses to media enquiries etc)?
  2. What are the key outcomes achieved as a result of Medicare Australia administering the program? (prompt in areas such as: women's access to breast prostheses, reimbursement timeframes, consistency in processes and results across jurisdictions, capacity to monitor program outputs and performance)

  3. How accessible is the program for women? How has access been maximized through the program's administrative arrangements? (prompt for particular groups, and Medicare responses to emerging issues of access)

  4. What are the main reasons claims are refused? Are any of these preventable by Medicare Australia activity? (prompt for clearer information, reviewing eligibility criteria etc)

  5. Are there any 'gaps' in the program's administrative arrangements that impact on the effectiveness the program?

  6. What gains have been made in cost efficiency during the program (prompt eg infrastructure costs, efficiencies gained through Medicare Australia expertise in certain types of program delivery, fit with similar programs, ability to monitor outlay of resources centrally, etc)

  7. Are there areas in which cost efficiency could improve? What is being done to address this, if anything? (prompt any areas of the program administration where duplication could be reduced to improve efficiency)

  8. What sort of risk assessment and mitigation has been carried out by Medicare Australia in relation to the program? (prompt relating to cost, quality of customer experience, etc)

  9. In administering the program, does Medicare Australia come into contact with any other agencies? (prompt for DVA, other providers of reimbursement/ funding for breast prostheses) Are there any issues in working with these agencies (prompt eg are responsibilities clearly allocated)?

  10. Are there any 'gaps' that impact on the efficiency of the program?

  11. Is there any duplication in the program's administrative arrangements that that might be reduced to improve efficiency?
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Relationship with the department

  1. In the first 12 months of the program's operation, has the department provided appropriate support to Medicare Australia under the program's business rules, including:
      • Consulting with Medicare Australia in a timely manner in relation to aspects which may impact on MA's administration of the program (prompt for proposed changes to the program, promotion of the program etc)?
      • Provision of funding to Medicare Australia to administer the program?
      • Adhering to governance arrangement set out in the MoU and the BPA?

Future directions

  1. From Medicare Australia's perspective, are there any aspects of the program's business rules or administrative processes which might be amended to improve administration of the program?

Impact review

Feedback from women who have had a mastectomy and require a prosthesis

  1. What feedback, if any, has Medicare Australia received from women about:
      • The information available about the program? (prompt for availability, usefulness of claim form and information sheet)
      • The program's accessibility?
      • The claiming process? (prompt for ease of completing and submitting claim form)
      • Paying for the breast prostheses up-front and obtaining a reimbursement?
      • The amount of the reimbursement?
      • The timeliness of the program in making payments?
      • The frequency of reimbursements (2 years)?
      • Whether the program meets their needs (prompt re sensitive, responsive, appropriate etc)
      • Whether the program has had/is having an impact on their quality of life?
      • Have you received any feedback from Aboriginal and Torres Straight Islander women about whether the program is sensitive to their needs and circumstances? What about women from culturally and linguistically diverse backgrounds? Younger women?