Patient Access to Quality Services

Regional and rural patient access to cancer care services, including radiation oncology services, are adversely impacted by a number of key factors such as distance from facilities, financial burden caused by the cancer and the added emotional distress if there is a need to stay away from family and friends whilst undergoing treatment⁹.

Financial impact of cancer on patients

Cancer treatments, including radiotherapy, may impose financial pressures on patients, carers and their families. Examples of additional expenses include:

• The cost of travel and accommodation when treatment is sought from a facility away from home. Reimbursement of travel and accommodation can be process oriented and time consuming, and not reflecting the full costs;
• The cost of accessing alternative treatment providers, i.e. private or public facilities. In the former case, it may be gap payments and upfront expenses for the treatment; in the latter it may the cost of travelling and staying away from home;
• The loss of income for patients, carers and their families; for example if travelling for treatment requires taking leave from work or bearing the loss of income for small business owners;
• Extra expenses such as child care fees while parents travel to metropolitan centres and stay away from home for the duration of treatment.

In many cases, radiotherapy treatments follows a significant number of medical investigations and services, at the time when the patient has already reached or is about to reach the Extended Medicare Safety Net thresholds. In some instances, patients may be required to pay significant out of pocket costs as gaps or may have to pay upfront for treatment. It was noted during consultation that there is not sufficient information about costs associated with treatment, alternatives and reimbursements, particularly for patients in rural and regional area where treatment options can be limited.

Of significant concern to all stakeholders is that financial pressures regularly influence the choices that patients from rural and regional areas make with regards to their treatments. Without doubt, these pressures contribute to the poorer health outcomes experienced by cancer patients in rural and regional areas.

Patient travel and accommodation schemes

The State and Territory governments offer travel and accommodation assistance to patients living in regional and rural areas of Australia to access specialist services. These patient travel and accommodation assistance schemes (PTAS) are essential to patients and carers as they reduce some of the financial barriers for accessing appropriate clinical care.

Submissions from professionals, peak groups and experts working in rural and regional health services consistently commented on the fundamental importance of PTAS funding. The current schemes across Australia were criticised for their complexity and their insufficiency. The issues highlighted during consultation were supported by existing research⁹,¹⁰ and include:

• Significant differences in the eligibility criteria and reimbursements between jurisdictions;
• The reimbursements not reflecting the commercial cost of travel and accommodation;
• The complexity of procedures to access PTAS and delay in processing PTAS applications;
• Cross border jurisdictional issues complicating patient access to travel and accommodation assistance;
• Shortages of supported accommodation facilities linked to the radiation oncology centres.

Appendix III provides a snapshot of the PTAS arrangements as of 1 April 2012 across the Australian jurisdictions illustrating the differences in eligibility and rate of reimbursements and the gaps between the rate of reimbursement and the actual cost of travel and accommodation.

In 2007 the Senate Standing Committee on Community Affairs made sixteen recommendations on the PTAS in their report ‘Highway to health: better access for rural, regional and remote patients’¹⁰, which highlighted many of the issues raised above. The Commonwealth Government’s response to the Senate report supported many of the recommendations¹¹ yet the matter was largely deemed to be the responsibility of State and Territory governments. Since the publication of the Senate report, PTAS across jurisdictions have been reviewed, however, as the consultation for the Tripartite Plan has highlighted, significant shortcomings remain.

Although a detailed examination of PTAS is outside the scope of this Plan, the findings of the Senate report remain current and a further streamlining of the schemes is required to improve patient access to essential radiation oncology services.

Use of innovations to aid service provision

Innovative approaches to provide consultation, treatment and follow-up for patients should be incorporated into regional and rural patient service models. Telemedicine, enabled by the National Broadband Network, provides significant opportunities to improve professional support to regional radiation oncology services, outreach services and patient follow up¹². Telemedicine is vital to extending the benefits of multidisciplinary care to regional patients and reducing the associated cost of care. Although this is already established in Australia, the level of use of remote/telemedicine in radiation oncology is well behind other countries such as Canada and other medical disciplines in Australia.

There are existing initiatives in radiation oncology capitalising on the potential of telehealth, for example:

1. The North Coast Cancer Institute in NSW runs nurse-led phone follow-ups, doctor-led phone follow-up clinics, and video-conferenced clinics with patients.
2. Radiation Oncology Queensland are enabling nurses to follow-up patients about skin conditions two weeks after treatment using tablet computers, so patients do not have to travel to facilities once their treatment is completed.

Lessons learnt¹³ from successful telehealth projects in other health disciplines suggest that telemedicine has the potential to:

• Improve access to specialist health services;

• Reduce patient travel;
• Encourage local case management;
• Improve staff training and support;
• Improve recruitment and retention of staff.

Cancer care is increasingly multi-modal and multidisciplinary team (MDT) care is the gold standard of treatment. It is not always possible for regional and rural health services to support every discipline that makes up an MDT. In this context, telehealth can also alleviate some of the pressures that specialist shortages in rural areas create. The use of videoconferencing or web-conferencing technology can enable access to tumour-specific MDTs¹⁴. Patient access to these telehealth innovations are further supported by the Medicare Benefits Schedule item numbers, making it a feasible and practical direction for regional health planning.