Does anyone have HMR pharmacists’ back?


Failure to lift the cap on HMRs makes no sense, writes Karalyn Huxhagen

The recent discussion about the new Community Pharmacy Agreement rules has fuelled my ire.

When I spoke with the Pharmacy Guild of Australia about my frustration in relation to the lack of increase to the caps on Home Medicines Reviews, I was directed to this section of the 6CPA agreement which spells out that the funding is only for community pharmacies and independent accredited pharmacists are not mentioned in this agreement as being a partner for funding.

My reply was, and still is, that the next section talks about improving access to consumers in rural and remote areas.

I work closely with all of the community pharmacies who practice in these areas. We have mutual respect, good dialogue and I am providing a much-needed service.

They identify at-risk clients, organise referrals, provide dispensing histories and background information. After I perform the medication review I visit with the pharmacist and have a chat before writing my report to the doctor.

These community pharmacists are at the centre of the health and wellbeing of these clients, especially in towns relying on locum services and Royal Flying Doctor Service.

The cap restricts how many patients I can see each month, causes me increased expense as I have to travel large distances to see 20 people and then return the following month to see 20 more, and the list goes on.

The payment of $125 for one round trip to see these 20 people does not cover the fuel costs, let alone wear and tear on my vehicle or accommodation.

At a recent Guild roadshow meeting, an owner pharmacist rose from her seat to complain that I was taking business away from her pharmacy, which also performs HMRs. The Guild representative stated quite clearly that he was working towards removing people like me from the payment system. Great!

The hysterics of the night got better but the real issue is that I am not performing HMRs anywhere near this person’s catchment. On any given day I have between 50-60 HMRs sitting on my desk for rural and remote locations.

I am now taking calls from GPs asking me to support them with HMRs as the pool of HMR pharmacists has decreased in my catchment areas. My hard work has paid off as I am now recognised for the talent that I have and the efforts I make to see clients.

I have not targeted the local area that I live in, as there were other HMR pharmacists performing this role. Three of these pharmacists have now left the HMR business model as it costs you money to be a HMR pharmacist, rather than supporting your existence as a pharmacist. 

I niched my efforts elsewhere and grew my business with the help of the rural community pharmacies and rural GPs who appreciate and value my work. If this owner is not gaining many referrals, than she needs to look at her business practice and stop throwing barbs at others in the profession.

I am told that I have to wait for the evolution of the pharmacist in general practice model if I want to see a genuine return on investment for what I do.

I have already waited for two years for realism. I have put in a submission to the King Review which the Guild now damns as a piece of wild speculation. I have participated in more research programs and interviews than I can list here, and still I am in a silo of ‘who has my back’ in this fight for a right to practice and be appropriately remunerated.

Karalyn Huxhagen is a community pharmacist and was 2010 Pharmaceutical Society of Australia Pharmacist of the Year. She has been named winner of the 2015 PSA Award for Quality Use of Medicines in Pain Management and is group facilitator of the Mackay Pain Support Group.

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18 Comments

  1. Jarrod McMaugh
    19/07/2017

    I have a good relationship with the pharmacist who undertakes HMRs for my patients, and I’m very happy that he receives direct referrals.

    I want to make a specific note of this quote:
    “The Guild representative stated quite clearly that he was working towards removing people like me from the payment system”

    This is very troubling, and it does not represent my views as a Guild member. The guild should take particular note of this, and ensure that this is not the official or unofficial policy of the guild or its representatives. I’m sure I am not the only current member who would have an issue with this attitude, and would reconsider membership if this were a widely-held view.

    While it is important that funding for HMR is secured in a way that doesn’t put pressure on the CPA (ie funding should be secured via MSAC as an MBS item) this shouldn’t be done with the intent of “removing” anyone from the process.

    • JDM
      19/07/2017

      Hi Jarrod. I also feel the anger and frustration. I tried to express my view with the Guild, but in classic political fashion…they appeared to be “hiding under the desks”. As a consultant pharmacist with a view to be a pharmacy owner in the medium term, I find this to be a startling development which I’m sure that, if it succeeds, will hurt quite a few proprietors of whom the Guild is MEANT to represent! Maybe you might have better luck getting that message across. Good luck, Jarrod!

      • Greg Turnbull
        20/07/2017

        Here at the Guild we are certainly not ‘hiding under the desks.’ Not hiding behind anonymous social media posts either. So feel free to call any time. Greg Turnbull 02 6270 1821. Direct.

        • Andrew
          20/07/2017

          The communications bloke from the guild with two comments recorded on the most trafficed pharmacy forum in Australia saying that his organisation isn’t avoiding questions…..

          Guild commentary yet again not lining up with the evidence….

        • Consultant Pharmacist
          20/07/2017

          Distribute this one widely in your office Greg. You all need to read it.

          http://www.gutenberg.org/files/1232/1232-h/1232-h.htm

        • Andrew
          24/07/2017

          Hi Greg,

          I called your number yesterday – it rang out. No opportunity to leave a message.

          There was three things I wanted to discuss;

          1. Whether there are any minutes from the meetings that discussed the most recent apportioning of funds to HMR/RMMR vs MedsChek/In pharmacy services? If so, can we see them please? If not, why not?

          2. Why is the PGA – despite the clear and mounting evidence for community harm – continuing to advocate against the upscheduling of codeine? How does the guild balance community health/safety against the financial interests of its members?

          3. What is the average cost per pharmacy for all the services the Guild provides in the pharmacy space?

          I understand you have issues internet anonymity so I’ll send these questions via my private email address too. Looking forward to your response.

  2. Manya Angley
    19/07/2017

    So frustrating. Doesn’t make any sense at all. When I talk with the Guild folk about this issue the team line is “the HMR program was never intended to support stand-alone businesses for independent pharmacists”. My response is “It may never have been the intention but it is the pharmacist-delivered service that has the strongest evidence for benefit.” It has been unequivocally shown HMRs reduce admissions for specific patient groups (e.g. patients prescribed warfarin and patients with CCF) and saves the system $$. That was not known when the program was introduced but now that it is proven our professional organisations and politicians have a responsibility to tax payers and Australians at risk of medication misadventure to ensure best bang for the system’s buck and best possible health outcomes. Services need to evolve as evidence for or against them emerges and it benefits all if appropriate business models develop. That’s innovation and progress!

    To clarify, I am in favour of the Medscheck program which is modelled on the UK Medicines Use review (MUR) program and believe it is complementary to the HMR program. It has been shown that MURs have a material positive impact on patient’ understanding of their conditions and medications and this has a positive impact on adherence. Due to the range of conditions and medicines which MURs cover, it is not possible to quantify the consequent impacts on health outcomes. Furthermore, studies which have looked directly at the impact of MURs on health outcomes have not consistently been able to find a significant impact.

    Intuitively Medschecks should also improve outcomes, but that is not yet proven. I understand and am pleased that there are attempts to collect data to demonstrate the benefits of Medschecks. However, until the benefits of Medschecks are proven it beggars belief why the caps on Medschecks have been lifted and the caps on HMRs have remained. At the very least HMR caps should be more generous for groups who clearly have the greatest need such as rural and remote and ATSI people, as highlighted by Karalyn.

    Sadly I don’t believe that any of the pharmacy professional organisations have independent consultant pharmacists’ back. No doubt there are senior representatives of the various pharmacy organisations who go in to bat for independent pharmacists but at the end of the day the PSA and SHPA have too many other members who they need to appease and independent consultant pharmacists’ needs (and by extension the patients to whom they provide services) are not their priority.

    There needs to be a unified effort by the pharmacy organisations to fund HMRs (or equivalent service) outside the CPA as suggested by Jarrad. The reality is that medicines play such an important role in the health of our nation that there is plenty of work for all types of pharmacists and if we work together our impact and our value will be much greater.

  3. Greg Kyle
    19/07/2017

    Alas Karalyn, you have hit the nail on the head. No professional organisation really cares much about accredited pharmacists. The guild flat out do not care as AP’s can’t become guild members, unless they are also owners, in which case they have an alternate income stream to “prop up their hobby”. PSA would probably like to but I expect feel conflicted as it means taking on the guild. Normally this may not phase them too much, but the problem is there are more guild members and other non-APs that are PSA members than APs. Therefore it is simple economics – if you are a member based organisation and reliant on annual member fees as income, you will naturally think about where the least damage can occur to your bottom line! While SHPA have made overtures towards APs, and I believe there is a natural synergy for APs with the SHPA ethos, their core business is hospital pharmacists, so see my comments about PSA!
    The only organisation that really is dedicated to APs is AACP, but its 2 owners (PSA & guild) flatly refuse to let it have any advocacy role on behalf of the very members of the profession that are seeking and need a strong voice!

    You have uncovered a major flaw in the profession – for all the words to the contrary, pharmacy in Australia does not embrace innovation in practice models unless it can be crammed into an existing paradigm.

    • Jarrod McMaugh
      19/07/2017

      Greg, your assessment of the ongoing advocacy PSA undertakes in this area is incorrect, and I’m pretty sure the same is true of your assessment of SHPA.

      From what I can remember of your recent commentary on pharmacy in Australia (ie via The Conversation, etc) you seem to be highly critical. I’m not really sure why though.

      • Greg Kyle
        20/07/2017

        Jarrod, please provide examples where PSA has mounted a sustained public campaign calling for the HMR cap to be removed (I believe SHPA could probably provide more examples). I have also had a discussion with a former PSA President who said the same thing Karalyn was told – HMR were not intended to be a full-time career option, therefore the cap is OK.
        I am a PSA member and I do not have a problem with the ideal of PSA being a peak body for pharmacy. My issue is I have not seen strong advocacy or professional leadership in the areas I have commented on – HMR caps (here) and sale of homeopathy in pharmacy (Conversation article).

        • Big Pharma
          21/07/2017

          Could not agree more Greg! PSA have done very little even to release a positive position statement about HMRs. I remember at the time of the proposed moratorium very little was said other than we must adapt and lift quality of work…..a nice slap in the face for anyone who has dedicated their life to this service. It’s interesting that the PSA/PGA continue to reap the rewards from ownership of the AACP racking up millions annually from member fees. At the same time no one represents the most valuable clinical pharmacist service available.

          At least SHPA has a very evident positive stance in support of HMRs.

  4. Kevin Hayward
    19/07/2017

    Hi Karalyn, having been in a similar position for some time now, I know how you feel. Without a strong political or professional advocate to support the HMR program, it does appear to be a service, which, from my perspective, although valued by the patients and the referring physicians, is now being allowed to wither on the vine.

    I have long since given up lobbying and writing comment, I know that we cannot fight the inevitability of Guild dominance over primary care pharmacy, my personal solution has been to utilise my skills and experience elsewhere.

  5. Manya Angley
    19/07/2017

    So frustrating. Doesn’t make any sense at all. When I talk with the Guild folk about this issue the team line is “the HMR program was never intended to support stand-alone businesses for independent pharmacists”. My response is “It may never have been the intention but it is the pharmacist-delivered service that has the strongest evidence for benefit.” It has been unequivocally shown HMRs reduce admissions for specific patient groups (e.g. patients prescribed warfarin and patients with CCF) and saves the system $$. That was not known when the program was introduced but now that it is proven our professional organisations and politicians have a responsibility to tax payers and Australians at risk of medication misadventure to ensure best bang for the system’s buck and best possible health outcomes. Services need to evolve as evidence for or against them emerges and it benefits all if appropriate business models develop. That’s innovation and progress!

    To clarify, I am in favour of the Medscheck program which is modelled on the UK Medicines Use Review (MUR) program and believe it is complementary to the HMR program. It has been shown that MURs have a material positive impact on patient’ understanding of their conditions and medications and this has a positive impact on adherence. Due to the range of conditions and medicines which MURs cover, it is not possible to quantify the consequent impacts on health outcomes. Furthermore, studies which have looked directly at the impact of MURs on health outcomes have not consistently been able to find a significant impact.

    Intuitively Medschecks should also improve outcomes but that is not yet proven. I understand and am pleased that there are attempts to collect data to demonstrate the benefits of Medschecks. However, until the benefits of Medschecks are proven it beggars belief why the caps on Medschecks have been lifted and the caps on HMRs have remained. At the very least HMR caps should be more generous for groups who clearly have the greatest need such as rural and remote and ATSI people, as highlighted by Karalyn.

    Sadly I don’t believe that any of the pharmacy professional organisations have independent consultant pharmacists’ backs. No doubt there are senior representatives of the various pharmacy organisations who go in to bat for independent pharmacists but at the end of the day PSA and SHPA have too many other members who they need to appease and independent consultant pharmacists’ needs, and therefore the patients to whom they provide services, are not their priority.

  6. Bente Hart
    19/07/2017

    I am deeply troubled by the attitude demonstrated by the guild towards HMR/RMMR APs and the comments mentioned in Karalyn’s article upset me – it was not what I expected from the guild. Why – because I am a AP, an owner, a guild member and I work in rural Australia. I would expect the Guild to support APs – though it has not looked much like it for a while. I in particularly agree with the Karalyn that the support to providing HMRs in rural areas is appalling and I do not travel the distance that she does. As I live in the rural area that I service my travel to HMRs in round trip do not get over the 200km mark so I get no funding to travel, but a round trip of 140km to reach the further away ones happens and add to this the general poor condition of some rural roads.
    I am not impressed with the guilds action towards HMRs in resent years and I find the whole restriction placed on the program highly disappointing. My reason for keeping my accreditation is that I believe it benefits my community to have the service available and I can not say that it is compensated for via ownership. As any other AP I have several income streams to make ends meet. You can do something for love but in the end there is bills to pay and kids to feed.
    When it comes to HMRs and APs the Guild do not represent my views. I can second Jarrod in that.

  7. United we stand
    19/07/2017

    Short answer: NO. No one does.
    As for the reasons, feel free to ask any pharmacist employee.

  8. Kevin Hayward
    21/07/2017

    For too long we have lobbied the Guild to change its stance on HMR and non pharmacy based professional services. They have their viewpoint and are sticking to it.
    The time has come to lobby for professional services to be taken out of the CPA, or, for the CPA to be abandoned in favour of a system more reflective and responsive 21st century primary care pharmacy

  9. Big Pharma
    21/07/2017

    The PGA has little interest is healthcare. They are about maximum rebates for minimal input. They represent the community pharmacy owner. End of storey. Why would they advocate for a service that often diminishes sales through improved polypharmacy? They use their political strong hold to sway evidence in favour of in-house programs regardless of the evidence. This is why we see medschecks expand and “HMR follow-ups” funded with the actual clinical review and collaboration with the GP a distant memory. This is why it is essential to have HMRs funded separately to the CPA. Quite happy for the CPA utilised as a prop up for diminishing PBS rebates for community pharmacy…just not at the expense of evidence based clinical pharmacist services.

  10. Big Pharma
    22/07/2017

    Well said Karalyn!
    I have conducted rural HMRs for up to a decade. I too have been waiting for common sense to prevail and the cap be lifted. A very obvious conflict of interest in funding allocation has resulted in the execution of rural HMRs. I previously travelled to some of the most remote areas of Australia to conduct my services. It is hard work. These are the most vulnerable people in the country so it is very rewarding to see regular health improvements.
    When you include flights, accommodation, car hire and fuel you need 10-15 HMRs to break even. $125 rural allowance for a “round trip” (for me was usually 10 days) is a joke. Obviously, these services were discontinued the moment caps were introduced. Some community pharmacies I liaise with also tried finding alternative funding sources for my travel (with no benefit to them other than community health) however with my cap reached in the city I am still unable to visit anyone.
    The GP network spent 10 years promoting and advocating these rural services persuading GPs to involve clinical pharmacists in patient care (initially funding my expenses because the service is so valuable and cost effective). It took a little over a fortnight for the PGA to undo a decade of hard work. Sadly there is still no resolution and these patients are left with nothing. Blind Freddie could see the value of rural HMRs. Just not the PGA as they have ulterior motives.

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