The cost of cancer – not all treatments are covered by the PBS

Most Australians would have faith in our health system. We do not have the tiered system that plagues the United States and leaves many unable to afford treatment.

But despite the protections of Medicare and a perception of a universal healthcare system here, it seems that when it comes to certain cancer treatments, to borrow a concept from George Orwell, some people are more equal than others.

Peter Gourlay is one such person, and he feels guilty about having gained access to treatment that many simply could not afford. He was 65 when, having been diagnosed with a metastatic tumour in his right shoulder, he accessed his retirement savings to pay for immunotherapy recommended by his oncologist.

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A course of 26 treatments of the drug Nivolumab would cut the chances of a recurrence of the tumour by as much as 40 per cent. Unsurprisingly, Mr Gourlay decided to jump at the chance. Then he discovered the “mind-blowing” cost. For the full course of the intravenous drug, sold under the name Opdivo, the total would be $160,000.

This was later reduced to $60,000, which is still a prohibitive price for many. But at the time Mr Gourlay made his decision, the treatment was not available for that specific use through the federal government’s Pharmaceutical Benefit Scheme (PBS).

The government last year invited responses to its Review of the National Medicines Policy (NMP). The Cancer Council took up the challenge, particularly with respect to the concept of equity of access, emphasising “circumstances in which equity considerations are particularly important, such as First Nations people, people living with poor mental health, people living with disabilities, refugees, people from culturally and linguistically diverse backgrounds, people living in low socioeconomic communities and people living outside major cities”.

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In its submission, the Cancer Council echoed the concerns raised by Mr Gourlay, that the scheme has the potential to create a two-tiered system.

The submission states: “When medicines are not funded on the Pharmaceutical Benefits Scheme for the intention required for cancer treatment (as per clinical guidelines), it causes inequity for those individuals and families who cannot pay the private prescription costs. This can create a tiered health system where access to potentially critical medicines is determined by the individual’s ability to pay, providing a substantial barrier to optimal cancer care, and contributing to increasing inequity in cancer outcomes.”

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Addressing this issue is perhaps easier said than done. For example, where will the funding to add these treatments to the PBS come from?

Professor Fran Boyle, president of the Clinical Oncology Society of Australia, believes the solution, at least partially, is relatively simple. Reforming the system would add to the federal budget, she said, but this would be offset by savings gained from reducing the recurrence of cancers.

Mr Gourlay completed his treatment about four years ago and displays no signs of the disease. But for those who do not have the funds to access such treatments, the prognosis might not be so rosy.

Have you missed out on treatment because it was not covered by the PBS? Why not share your experience in the comments section below?

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Andrew Gigacz
Andrew Gigacz
Andrew has developed knowledge of the retirement landscape, including retirement income and government entitlements, as well as issues affecting older Australians moving into or living in retirement. He's an accomplished writer with a passion for health and human stories.
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