Informed financial consent

The principles in the Standard for Informed Financial Consent will be applied depending on where you treat patients, the resources available to you and what you currently do to support informed financial consent. Regardless, the aim is to provide patients with all information required to make an informed decision about their care and reduce financial burden.

Examples of how you may apply the principles of the Standard for Informed Financial Consent:

• Commit to bulk billing any patient who has a health care card issued by the Department of Social Services.
• Routinely re-advise patients of the service fee at the time of booking, and any expected rebates from Medicare.
• If you work routinely with other health care professionals, encourage those members to also be transparent about providing information about their costs to assist informed decision making and reducing the burden on patients to find this.
• Be familiar, or use other members in your practice or hospital, with financial support options available to patients that you can refer them to.
• If you work in private practice, make it standard practice to let your patients know that the public system is an alternate option for their care.

The Australian Competition and Consumer Commission (ACCC) enforces the Competition and Consumer Act 2010 (Cth). The ACCC has provided guidance that the Standard for Informed Financial Consent does not lead health professionals to breach their obligations under the Act.

What are clinicians’ obligations under the Competition and Consumer Act 2010 (Cth)?

The Competition and Consumer Act 2010 (Cth) (Act) aims to enhance the welfare of Australians by promoting fair trading, competition and consumer protections. The Act applies across industries, including to health professionals and practices. The Act prohibits cartel conduct, which includes price fixing and concerted practices that have the purpose or effect of substantially lessening competition. For health professionals, this means they must set their fees independently of competing health professionals.

Guidance from the Australian Competition and Consumer Commission

Cancer Council sought guidance from the ACCC to address concerns about the ability to provide information about their fees publicly, and to other health professionals for the purpose of obtaining informed financial consent from their patients, using the Standard for Informed Financial Consent. In particular, Cancer Council sought guidance about Principle 1 (Transparency of service details) of the Standard.

Clinicians can be confident that the Standard for Informed Financial Consent is not inconsistent with their obligations under Australian competition and consumer laws. The ACCC has confirmed that merely being aware of competing health professionals’ fees does not breach the Act. The ACCC provided further guidance that in its interpretation of the Standard:

“The ACCC supports the purpose of Principle 1, and the Standard generally, to ensure patients are informed upfront about fees and out-of-pocket costs.

A doctor undertaking the key tasks listed in Principle 1 will not, without more, breach the Competition and Consumer Act 2010 (Cth). The key tasks appear to set out how a doctor can assist a patient in identifying all the costs associated with their treatment, including the fees of other doctors involved in that treatment. The key tasks, as written, do not require clinicians’ to agree to act together, or cooperate with each other, in determining their fees.”

The ACCC has discretion about the matters it investigates and how it resolves concerns, and that it will only take action where it considers it is in the public interest to do so, on a case-by-case basis.

For more detailed information about fee setting and clinician obligations under the Act visit the ACCC website.

Please note that this guidance is not intended to be legal advice. Specific cases relating to compliance with the Act will be considered on an individual basis.

Unexpected out-of-pocket costs can cause financial hardships and have significant impacts on patients’ health and well-being, so it is important they are made aware of the costs of their treatment as part of the informed consent process.

Informing patients of the likely cost of their treatment and care is an ethical responsibility for health professionals and obtaining informed financial consent from patients is already an obligation for health professionals, such as doctors, under professional codes of conduct. Failure to disclose the costs of treatment to a patient and to obtain a patient’s informed financial consent may constitute a breach of these professional standards and health professionals may risk disciplinary proceedings and reprimand if they fail uphold professional standards of conduct.

Despite these existing professional and ethical obligations to discuss costs of care and obtain informed financial consent from patients, people affected by cancer (and other illnesses) continue to report experiencing unexpected out-of-pocket costs and associated financial distress.

This indicates that more guidance is needed to facilitate open discussions between health professionals and their patients about the costs of their treatment and care options. Patients may not have a good understanding of their treatment and care costs for several reasons, including a lack of familiarity and understanding of the health care system or how the public and private health systems, including insurance, operate and interact. Some patients may feel embarrassed or uncomfortable raising the issue of costs with their health professionals. So, it is up to health professionals to proactively lead this discussion, as part of their professional and ethical obligations - patients are entitled to expect that the costs of their care will be discussed with them.

This Standard for Informed Financial Consent provides health professionals and health services with useful and practical guidance to facilitate and support patient understanding and awareness of their treatment and care options, the costs of these options and the impact of these costs. The Standard for Informed Financial Consent is not meant to be prohibitive or create additional burdens on the health professional or service provider. Instead, it acts as a quality of care standard to help health professionals meet their existing requirements to discuss costs of care.

Patients often feel emotional, vulnerable and stressed after a cancer diagnosis, and financial pressure related to paying for care, or reduced household income can exacerbate this stress. Unexpected or unplanned bills leave patients feeling frustrated and confused and feeling they do not have an option but to pay it. Patients often expect that treatment costs will be covered by the public health system or their private health insurance. However, this is not always the case.

Disruptions to usual work arrangements are common for patients. Family members also often reduce their paid work hours to care for their loved one which further reduces household income at a time when they have increased living costs. Financial stress can result from both initial high costs and accumulation of out-of-pocket costs related to follow up care and modifications to living arrangements. It can lead to difficulties in paying for basic living expenses such as housing, food and bills, and influence decisions about their health or finances including increasing debt, or drawing on financial security, such as selling a house or withdrawing superannuation.

Although financial stress can affect anyone, higher stress is likely experienced by low income households, where even a small out-of-pocket cost can have a significant impact.

Australia does not currently have a standard guidance for health professionals to facilitate discussing costs and obtaining informed financial consent from patients. Patients may not know what to ask, be aware of the different options available to them, or consider the impact different decisions may have on their financial situation.

Aligning your practice with Standard for Informed Financial Consent provides an opportunity to deliver quality care to patients, drive transparency and communication between patients and health professionals about service charges and potential out-of-pocket costs, and enable patient participation in an informed discussion regarding their options. It can be used to reflect on how you currently support patients to understand the costs of care, and where there may be opportunities to further ensure the delivery of quality care to patients. Additionally, the Standard is a way to encourage your colleagues and other service providers to implement initiatives that promote discussions between patients and health professionals that includes cost.

Australians often perceive public care as free. Working in a public setting, out-of-pocket costs incurred by your patient may not be known or made obvious to you. Currently, fees and payment discussions are often conducted by hospital administration staff, and therefore you may feel removed from the process. You can be an advocate for patients and work with hospital administration staff on the importance of informed financial consent, ensuring the information provided about the fees charged is transparent, accurate, and understood by the patient.

The Standard for Informed Financial Consent also acknowledges the responsibility of practices or hospitals, and health systems to enable these initiatives. Each hospital should help you to understand the services provided by the hospital. In some circumstances public hospitals may not provide the service to which you have referred your patient and outsourcing this to a private provider will incur a cost to the patient. Similarly, if the reason for the service is not recognised by Medicare, this will not be covered by a Medicare rebate, and incur an increased cost to the patient.

Out of pocket costs are influenced by a range of variables, most importantly the fee you charge. If the service is provided privately, then it is also influenced by whether your patient has private health insurance, the extent of their cover, and any gap arrangements between the insurer and who and where the service is performed. You should encourage your patient to discuss their cover with their insurer and provide information to the patient which will assist in their conversation to understand the likely out-of-pocket costs, such as details of the services to be performed, by who and the location. You can also refer patients to Questions to Ask Your Private Health Insurer. Inform the patient of all options for where the treatment can be provided, as gap arrangements vary which creates a difference in out of pocket costs. Asking the right questions, and getting the right information is a partnership between patients, health professionals, health services and private health insurers. You must always inform patients of their options, including that they can have their care conducted in a public setting.

A critical component of providing quality care is enabling the patient to make informed decisions about their care. This requires providing information about expected costs of treatment options, alongside risks and benefits of treatment, and support for patients to comprehend these options. Each patient's financial circumstance is unique. Decisions resulting in high upfront costs, as well as accumulation of out-of-pocket costs can lead to financial stress and poor health outcomes. Often patients are not aware of the importance of this conversation and the potential impact a cancer diagnosis can have on their finances, particularly when they are not able to work. For many patients this is their first major experience with the health system, and they seek guidance on where to go and what to do. They may be vulnerable and often do not feel comfortable to raise this or think it will be important. By taking a lead on conversations about cost and out of pocket expenses, you are supporting your patient to be in the best position to choose and receive optimal care.

Patients are entitled to ask about your fees however, many do not know they can or do not know how to approach this discussion. The cost of their care is also not likely front of mind, and often patients perceive that any care they need will be covered by either government funded public health or their private health insurance. It is important to provide patients with the opportunity to discuss any concerns they have, including financial implications, and to revisit this over time. It is important to make your patient aware of costs associated with their treatment and that you are open to discussing this with them. Some patients may not want to know or discuss costs, but it is still important to provide them, as well as their family with the necessary information and support to enable informed financial consent. Where feasible, it is best to provide patients with sufficient time to consider information and support before they make decisions.

Although patients have a right to know the cost of their care before treatment, many do not ask. This may be because patients are unaware of their rights and what they should expect because of a lack of familiarity with the health care system. They may also feel embarrassed or afraid to raise it with their treating health professionals.

Focusing on this right to ask still places the onus on the patient to be aware and ask about the potential costs associated with their treatment. The Standard for Informed Financial Consent requires health professionals to advise patients to ask about costs, to be active and engaged in decisions about their treatment and care. It acts as a quality of care standard to help health professionals meet their existing professional and ethical obligations to discuss costs of care and obtain informed consent.

Although you often are not aware of the fee charged by other services and health professionals, you will know where the patient can go to find this information. As the treating health professional, it is important to inform the patient that other health professionals or service providers will be involved in delivering care and that they will have their own fees. It is important that you encourage and support patients to contact additional health professionals or service providers involved in their care for their fee estimate. Similarly, you should refer patients to or involve other specialities to discuss the risks and benefits of care options and cost outside your specialty.

There are several factors which influence the end out-of-pocket cost a patient pays. You will not know all, but this is especially confusing for patients, so you can inform patients of what can affect how much they pay and support them to find out as much information as possible about this by:

• Providing patients with an itemised list of the services you will perform and your fee, including the Medicare item number and service description. Individual item numbers and an itemised bill enables the patient to see where costs are incurred which also helps if the patient needs to discuss if their treatment will be covered with their private health insurer. A list of other services involved in the delivery of care, similarly itemised where possible, and the contact details of the health professional or service provider who will conduct this should also be provided to patients. For example, surgeons could provide details regarding surgical assistants, anaesthesiologists and pathology services which will be used. You should encourage patients should seek out the fees charged by other providers to ensure they have a full picture of the costs they are likely to incur.
• Informing your patient that the estimate may change and telling them in what situation/s this may change, therefore minimising any unexpected costs later.
• Informing patients that gap arrangements between hospitals and private health insurers can influence out-of-pocket costs. Providing them with all options of where their treatment can be provided and guiding them to ask their private health insurer about the gap arrangement for each.
• Letting public patients know where recommended services are not provided within the public hospital, and when the hospital outsources this service to a private provider at a cost to the patient.

The aim is to provide patients with all the relevant information and encourage them to seek out information about costs from others to make an informed decision about their care.

You may have practice staff, administration staff, nurse practitioners, and others in your team who can assist in providing information about cost to patients. As the treating health professional, it remains your responsibility to ensure all information provided to the patient is accurate and understood by the patient. These arrangements will vary depending on where you treat patients, the resources available to you and the control you have in setting your own fees. Standardising how this information is provided to patients will enable consistent informed financial consent with all your patients prior to treatment and as situations change.

It is important not to assume a patient’s financial situation or predict their treatment preferences, and that their lifestyle prior to cancer will remain the same. Also do not assume that a patient with private health insurance will want to use it or that it will cover their treatment. Discussing your patient’s preferences and exploring these from a financial impact perspective, in addition to clinical, demonstrates your commitment to your patient’s financial welfare.

Breaking down the barrier to a conversation about costs can begin by adopting a commitment to supporting informed financial consent. A pledge has been developed for you and/or your practice to adopt and display. It communicates to your patients that you are open to discussing costs because you recognise the impact this may have and you want to provide the best care possible.

There are services, such as pathology and radiology which are critical to patient care. Patients are referred to these services or samples are taken by the treating health professional and sent off to be reviewed, making it difficult for service providers to see the patient prior to treatment or even at all. It can lead to ‘hidden’ out-of-pocket costs as patients were unaware of the service and the fee, and often report feeling confused about these costs, and that they have no choice.

However, you can still support the informed financial consent process, such as encouraging health professionals and services which routinely refer to you, to list these service items on the bill estimate and inform their patients that costs will be incurred for these additional services. Ask them to acknowledge these types of services in their discussion about out-of-pocket costs and let them know that they should tell patients to call to confirm costs. If you have standard service prices or pricing guides, these could be displayed online or provided to referring health professionals.

You are not expected to provide financial advice. In Australia, only financial advisors authorised under an Australian financial services (AFS) licence to provide financial product advice can do so.

You may not know exactly where to refer your patients for information and support about the impact of cancer on their finances. However, it is important to seek this out locally as your role is to refer your patients to services which assist in their care. Social workers are a wonderful resource for both yourself to learn from, and to refer your patients too. Financial counselling services are another option as they provide information, advice, and advocacy to people in financial difficulty. These services are free and can be found via the Financial Counselling Australia website. By contacting Cancer Council’s 13 11 20 information and support service, patients can discuss their concerns with trained staff who will provide information, support and referral to programs or services depending on the patient’s needs. Visit Cancer Council’s patient information page to find more options for your patients.