The claim

The final leaders' debate on May 8 saw the major party leaders again lock horns, as they sold their competing visions for the country.

Cancer funding emerged as a particular friction point, with Opposition Leader Bill Shorten challenging Prime Minister Scott Morrison to match Labor's $2.3 billion pledge to cut out-of-pocket costs for cancer patients.

During his response, Mr Morrison said: "If you're in a public hospital at the moment, all of your cancer treatment is free".

Challenged about out-of-pocket costs in public hospitals, he went on to say: "No, if you're receiving public treatment for your cancer, it is fully covered."

Is cancer treatment completely free for public hospital patients?

RMIT ABC Fact Check investigates.

The verdict

There is more to the story.

Public hospitals provide free treatment to cancer patients who are formally admitted as public inpatients.

However, public patients may need to pay for other cancer services.

In some states and territories, public patients receiving outpatient services at public hospitals may have to partly cover treatment costs, such as for chemotherapy.

And in hospital, public patients may be offered tests and drugs not yet covered by Medicare or the Pharmaceutical Benefits Scheme, which they would have to pay for.

Although patients can opt to use the public or private system, public options may not be easily accessible to patients in regional and rural Australia.

Cancer patients in the public system can also face significant non-clinical costs such as travel, accommodation and hospital car parking.

While public hospitals provide free treatment to cancer patients who are formally admitted as public inpatients, they may need to pay for other cancer services. ( Phil and Pam Flickr 2.0 Generic CC BY 2.0 )

The context of the claim

Mr Morrison made his claim when asked if he would match Labor's cancer plan, which Mr Shorten claimed would lower out-of-pocket costs to "practically nil".

In reply, Mr Morrison said he would, if re-elected, be "happy to assess" the proposal in the next budget.

He also accepted that people with cancer faced a financial hit: "There are out of pocket expenses, of course, when it comes to dealing with the challenges of meeting the cost of ... being sick and having cancer."

However, he appeared to limit this observation to patients in the private system when, after an interruption, he went on: "But the point I was going to make is, to meet those out-of-pocket expenses for those Australians who are doing it through the private system, other systems, then you need your private health insurance."

This is consistent with other comments following Labor's announcement on April 4.

At a press conference, on April 5, he said all the treatments in Labor's cancer package were "available in public hospitals free of charge today".

Asked about this three days later in a radio interview, he praised "amazing" healthcare providers in the public hospital system and added "Now, that's not to say that there aren't out-of-pocket expenses for those doing it outside".

What is Labor proposing?

Labor's cancer package aims to cut costs paid directly by cancer patients.

It promises to fund up to six million diagnostic scans such as MRIs through Medicare, and three million bulk-billed appointments with cancer specialists.

The plan also proposes to reduce waiting times for cancer patients in public hospitals and establish new treatment facilities around Australia.

Finally, Labor has guaranteed that once a drug is recommended for cancer treatment, it will be subsidised through the Pharmaceutical Benefits Scheme (PBS).

The public system

There are two hospital systems in Australia: public and private.

As the Government's healthdirect website explains: "Everyone in Australia with a Medicare number is entitled to free treatment as a public patient in a public hospital, paid for by Medicare."

Public hospitals provide a range of services covering acute care, elective surgeries and other specialist services, and this is set out in the National Health Reform Agreement between the state and federal governments.

During the leaders' debate Mr Morrison said: "If you are receiving public treatment for your cancer it is fully covered. That is the rules in the state system and it's funded by the Commonwealth and supported as well."

Under the federal-state agreement, public hospitals offer patients the choice of being admitted as private or public patient.

If they choose to go public, "components of the public hospital service (such as pathology and diagnostic imaging) will be regarded as a part of the patient's treatment and will be provided free of charge," the agreement says.

The Melbourne Institute's Professor Philip Clarke said that for public patients treated in a public hospital, the experience is free except for extras such as TV.

However, he pointed out that public hospitals also take private patients, "and these patients may incur out-of-pocket costs including any gaps if fees for specialists exceed the Medicare rebate".

Health Program Director for the Grattan Institute, Dr Stephen Duckett, said that so long as a person is treated as a public patient, Mr Morrison was "absolutely right".

Inpatient vs. outpatient

Mr Morrison referred to treatment "in" public hospitals, though this isn't as straightforward as it sounds.

Public patients can be formally admitted to the hospital as inpatients, or treated as non-admitted outpatients. When it comes to cancer treatment, radiotherapy and chemotherapy services are often provided as outpatient services.

The federal-state agreement explains the basis on which a public hospital outpatient department will treat public patients free of charge.

Associate Professor James Gillespie, Deputy Director of Sydney University's Menzies Centre for Health Policy, told Fact Check that while public inpatients were paid for by state governments, services at outpatient clinics at public hospitals were instead charged through Medicare and the PBS.

That could lead to out-of-pocket costs for patients, he said.

As Breast Cancer Network Australia wrote in 2016: "For people receiving treatment in the public system, costs can include copayments that some state and territory public hospitals charge for chemotherapy treatment".

Explaining the situation for public patients in NSW, Associate Professor Kees Van Gool, with Sydney University of Technology's Centre for Health Economics Research and Evaluation told Fact Check:

"[You go home after surgery], you get better, and then you have some chemotherapy. You go back to the hospital, but you are treated as an outpatient, and the hospital will bill Medicare for that ... Now, usually they bulk bill, but they don't have to. And of course the oncologist will visit as well and they will usually bulk bill as well but that's not a given either.

Extra treatments

Cancer Council Australia CEO Professor Sanchia Aranda also told Fact Check that admitted patients received free care in public hospitals, but said they may be offered tests or drug treatments not covered by Medicare which can cost patients extra.

As Deloitte Access Economics wrote in their 2016 study on the cost of breast cancer treatment:

"Physicians and surgeons may order more diagnostic tests for their patients in the private system which do not attract a Medicare rebate such as Oncotype Dx molecular test during treatment planning and/or MRIs and PET scans during pre-surgical work-up. Patients in the public system can also elect to have these tests done."

The Oncotype DX test it referred to can help determine whether chemotherapy is necessary. According to the report, it costs patients $4,000 to $5,000.

The study also said doctors may recommend drugs that are approved for sale but not yet listed on the PBS.

According to a 2015 survey by the Breast Cancer Network, women with secondary breast cancer spent an average of $5,277 on non-PBS medicines.

The longer journey

Experts said there was more to cancer treatment than hospital care.

Dr Duckett said Mr Morrison's point was a non-sequitur because Labor's policy "was principally addressed at people who are not in hospital".

And Dr Van Gool said Mr Morrison was "technically correct", but there were "many other costs involved in a patient's treatment as they travel through all the different phases of cancer care".

These phases could include diagnostic services, specialist consultations, chemotherapy, surgery, post-chemotherapy, post-radiation then possibly years of follow up checks, he said.

"Aside from that acute phase [in hospital] ... that patient stands the risk of having out-of-pocket costs on all other things," Dr Van Gool said.

As the Australian Institute of Health and Welfare explains: "Medicare does not always cover the full cost of medical services. Doctors and other health care providers are free to set their own fees for consultations and procedures and the patient may need to contribute to the cost of those services."

Some services and drugs are covered by Medicare and PBS safety nets, which kick in when annual out-of-pockets accumulate past a certain threshold.

Patient experiences

Studies offer a glimpse into what patients can expect to pay themselves for their cancer treatment, sometimes indicating payments by public patients.

The 2015 Breast Cancer Network survey said women with secondary breast cancer treated in the public system paid an average monthly out-of-pocket cost of $531.

The same women reported total out-of-pocket costs of $900 on surgery, $1500 on radiotherapy and $922 on scans.

Both the Royal Australasian College of Physicians and Cancer Council Australia directed Fact Check to research by the advocacy group Consumers Health Forum of Australia.

The group's April 2018 survey found more than a quarter of respondents treated for cancer had paid more than $10,000 in out-of-pocket costs in the previous two years. This finding did not distinguish between patients in the public and private systems.

A 2018 peer-reviewed study that investigated two-year treatment costs for Queenslanders with a major cancer found uninsured patients paid $1035 in out-of-pocket treatment costs. Similarly, it did not distinguish between patients in the public and private systems.

Patients spent the most on therapeutic procedures (such as radiation therapy and chemotherapy), followed by consultations, then PBS medicines.

According to the 2016 report by Breast Cancer Network, 88 per cent of the women it surveyed paid for out-of-pocket costs.

Limited choices

In theory, patients can elect to choose treatments in the public or private system, but those choices can be constrained.

Dr Gillespie noted that people in rural and regional areas, for example, did not always have easy access to public treatment options.

In 2014, then-director of the National Rural Health Alliance, Gordon Gregory, told a parliamentary inquiry into patient costs that regional patients had to travel further for every treatment and often lacked public transport options.

"These transport costs—including accommodation, income forgone and logistical complexities—often dwarf standard out-of-pocket costs for families in more remote areas," he said.

A 2016 audit by Cancer Council Victoria suggested the average patient in a Victorian metropolitan treatment centre faced car parking costs of $1,100 per year.

The Deloitte study found that women spent an extra $3,200, on average, on non-clinical costs.

Principal researcher: David Campbell

Sources