TIM WOODRUFF. Cancer is horrible; so is death from any cause.

Apr 9, 2019

The Opposition Leader has announced the biggest investment in Medicare for a generation, $2.3 billion to be spent eliminating the co-payments faced by those with cancer who see specialists, need diagnostic imaging and radiotherapy. It is also guaranteeing all new drugs approved by the Pharmaceutical Advisory Committee (PBAC) will be listed for subsidy. The latter means prescription costs will be a maximum of about $6 or $40 a month for pensioners and health care card holders or non card holders respectively. Cancer is scary. It is debilitating. It is life changing. It is often fatal. Furthermore, as Mr Shorten correctly pointed out “cancer makes you sick and all too often makes you poor”. Labor is to be commended for addressing this challenging issue.

How will it work and are there any potential negative impacts of such a policy?  It is proposed that the Medicare rebate to see a cancer specialist or surgeon will be increased possibly by about $80 on the proviso that the patient will be bulk billed. If the increase in the rebate is much less than what the specialist currently charges, it is likely nothing will change. My neurologist colleague who charges a $200 co-payment for a review visit for a pensioner is unlikely to bulk bill if the rebate increases by $80. Specialists decide what gap fees they charge. Labor hopes that competition will then work to prevent or minimise this. Competition between specialists is very limited. In regional and rural areas where there are such specialists, it is often a choice of one. Specialists decide how much they charge on the basis of a variety of factors including patients’ financial situations, practice costs, the failure of the rebate to be adjusted for inflation over many years, the specialist’s own sense of entitlement and what colleagues charge. None of these will change under the proposed scheme.

Then there is the very strange situation of an oncologist being paid more than a similarly trained cardiologist or other specialist who delivers the same high quality service but receives less because he/she has picked the wrong specialty.

There will also be increased rebates for diagnostic imaging with the same aim, that they will all be bulk billed. The same concerns apply. Co-payments for MRIs are frequently many hundreds of dollars. It will also result in the ridiculous situation that a radiologist reporting an MRI of a cancer patient will be paid more for that report than his/her next report on a patient with kidney failure, even though identical skills are required and indeed the report might even be identical.

Another concern with this proposal is the potential cost blow out due to over-servicing. Some doctors might say ‘I might just get an extra ultrasound or MRI as it might help and won’t cost the patient ’, even though his colleagues would say it is not necessary. Will the radiologist sometimes say when reporting a CT scan ‘I recommend an MRI’ whilst the next radiologist says it is quite unnecessary? Some degree of over-servicing is inevitable in a fee for service model. How much of a problem that might be with this proposal is unknown.

The other major plank of this proposal is that all drugs recommended by the PBAC will be approved for subsidy. The pharmaceutical industry executives will probably vote Labor just on that alone. It’s a blank cheque and despite protestations by the Shadow Minister that there would be hard bargaining, that happens already and in a recent Sky television interview she had no suggestions about how she would prevent a cost blowout. When one has stated that a drug will be approved quickly, the seller calls all the shots.

But there is another curious aspect to this policy. Our public hospitals provide timely access to world class care for those with immediate life threatening conditions like cancer. Prescription costs are probably the biggest challenge for them and there is no suggestion that they will be eliminated. The patients targeted by Labor’s policy who are affected by the huge out of pocket costs have chosen to seek care privately for a multiplicity of reasons. One is the wish to go to a doctor of their choice. This is very understandable especially for some of the common cancers like breast cancer. However, such choice is currently denied to those many Australians who know from the start that they can’t afford private. Another is a wish to be involved in a drug trial offered by private oncologists. These can be and are run in and by public hospitals and universities, avoiding out of pocket costs. Another is a belief that private is better despite the complete lack of evidence except in terms of timely access for elective treatment. But cancer treatment is not elective in either public or private systems. The belief that private cancer treatment is better is thus a myth fostered by the current government which wants us all to see public care as a safety net.

Whilst cancer is the leading cause of years of life lost in Australia, our patients suffer and die from heart disease, strokes, kidney failure, diabetic complications, arthritis complications, asbestosis, mental illness, suicide, motor neurone disease, multiple sclerosis and many other treatable and often preventable conditions. As doctors we see the lot. Cardiovascular disease is the leading cause of death. Mental illness is the leader when it comes to years of quality life lost. Patients without cancer often suffer as much or more than cancer patients because they live longer. To ensure excellent affordable access to care for patients who suffer from cancer is fantastic. To deny similar access to all the other patients with the many causes of pain, suffering, and death is an insult to doctors and their patients. It goes against every principle which guides our profession. We treat patients, not diseases.

This policy may be very helpful for those who wish to access private care. It will have minimal impact on those cancer sufferers who use the public system. It will have no impact on those who struggle with the delays and costs for non cancer illnesses. It is worth noting that Labor has flagged an increase in specialists of all kinds in public outpatients which is to be commended. This cancer policy may work but at what cost as it is rolled out? It is divisive and inequitable. It may be good politics. Is it good policy?

Dr Tim Woodruff is president of the Doctors Reform Society, an organisation of doctors and medical students promoting measures to improve health for all, in a socially just and equitable way.  On twitter @drsreform



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