Looking behind the curtain


The reality of medication reviews is a program full of band-aids and add-ons, argues Karalyn Huxhagen

When Home Medicine Reviews (HMRs) were launched, we were promised interactive programs with GPs and patients to improve health care.

Those of us that took on that challenge had to upskill, spending a lot of money on becoming accredited, staying accredited and jumping through more hoops than anybody else in the profession to keep practising.

We were given pittance to perform an important role that has a lot of research behind it, to prove that we can make a difference to patient health with this service.

Every year the two payments – HMR and RMMR – gain CPI increases. It is a trickle of improvement.

Payments such as travel allowance have stayed at their original price while fuel, costs of maintaining a car and accommodation costs have skyrocketed. Some of the towns I visit can cost $200 a night or more in a poor-quality hotel, as they service the mining community and know they can charge a high fee for a substandard room. The reality is that I can rarely get a room anyway as mining comes first.

The money certainly does not entice anyone to this role. If you perform this role it is because you love the work, love the collaboration with the prescribers and feel you make a difference.

It has taken me 23 years to build my business to the level of respect and professional collaboration that I share with general practice in Queensland, from Biloela to Bowen and west to Springsure. You could fit Tasmania in my working territory.  I regularly take calls from GPs in more remote locations wanting me to visit but I am already stretched too thin.

Over a three- to four-day period every two to three months, I travel thousands of kilometres to see 20 patients in that month. The cap has ruined my business model more than anything else that the CPA program hackers have done.

When you travel these kinds of distances you can see eight patients a day and cover off on far more requests than 20 per month.

Now as the Pharmacy Programs Administrator (PPA) announces that it is starting to audit the programs and will be tough on rorters, I have taken time to ensure I have not missed any program changes because the last thing I need is to inadvertently have my claims rejected.

The review of my practice has led me to acknowledge another casualty of the cap system. When I receive an HMR request I must action that request within 90 days of the referral being written by the GP. That rule was fine when I could perform as many HMRs as I had in my inbox. That rule is no longer viable now that I can only see 20 patients a month.

On any given month I receive 20 referrals from each of the practices that I provide services for, plus referrals from at least five pharmacies who use my services. At last count I service 20 general practices which in turn multiplies to 80 GPs plus five regular pharmacies. On any given 1st of the month there are 90 referrals to be actioned in my in-tray.

I hear you say: “Share the work.” I do if I can find quality pharmacists wanting to “go west, young man” and perform the work. I share where I can, but only with those who perform the task at a standard that I am happy with.

So here is the dilemma: referrals for medication reviews last 90 days from writing. GPs are up in arms about having to redo HMR referrals that have expired simply because I could not get to the patient in a timely matter due to the 20-patient restriction. Meanwhile referrals they write for all other allied health practitioners last 12 months from the date of writing.

I hear you say: “if we make the time longer the information will be out of date” …so what? I am in the patient’s house with their latest medications and I update the information as part of my role.

Often the referral has so many discrepancies that timely access to a GP print-out will make no difference at all.

These GPs want to vent their anger at this system that has put restrictions of trade on their ability to assist their patients. They do not understand why the caps are in place. When you put restrictions such as caps on services in place, please look at the knock-on effect of the program detail.

The 90-day referral time was put in place to ensure the patient received a timely medication review. It is not the pharmacists that cannot meet the timeliness ideal situation, it is the restrictive trade practice of the caps that prevents the demand for service to be met.

Let me just add that the practices that I provide services to are not the ‘quick buck for service’ GPs. I weeded those out long ago and only provide services to practices where the GPs use my work constructively to improve their ability to provide excellent primary health care. I receive a return rate of medication management plans from GPs that is exceptional in terms of quality and timeliness.

So, a message to the CPA negotiating team: please think like a GP for a moment when you are reworking these rules once again.

Having a cap of 20 HMRs per month and 90 days to service every HMR referral is not providing the outcomes that the program is designed for. If we had an HMR pharmacist embedded in every GP practice, clinic and pharmacy across Australia then maybe it would work.

The reality is, for the pittance that we make delivering this program, there will not be a ground swell of newbies coming out to help. I am told caps are here to stay due to program funding limitations etc.

Fine, I will accept this even though it sticks in my craw – but let us relook at the reality of the other rules impacted by capping and adjust such things as the ‘timeliness’ rule.

Karalyn Huxhagen is a consultant pharmacist based in Queensland.

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24 Comments

  1. Christine Wise
    22/01/2020

    Well said Karalyn. We just butt our heads on that brick wall. I also service a remote area and just last week travelled 1600km round trip, 2 nights away from home, for HMR/ RMMR work. We do it for the love of it, certainly not the financial profits!! Before caps, I could spend a week and provide service to as many patients as the GP wanted me to see and still come out on top. Now, I have to limit the time away and balance the number of HMR referrals in the remote towns with those I receive closer to home. Why travel hundreds of KMs to do HMRs when I could stay home and do just as many? Certainly makes better sense financially to just work around home.

    BUT, like Karalyn, I have spent many years building the relationships. I grew up out there. I have a connection and if I don’t do the travel, this region misses out completely!! I have tried to share/ give away the region and no-one will take it on. It is all too hard and if you can get 20 HMRs in the city, why spend hard earned money on travel & motels to do the same amount of work?? Sure, RMMRs can be sucked up into the vortex of a big company… only for them to service from afar, never visiting the facilities in person and paying peanuts to the pharmacists working for them, never providing the service as it is intended. HMRs are a little harder to do. While yes, we can gain permission for a local community pharmacist to do the interview, if there is a local pharmacy, is this really going to gain the information I value for my reports? Is that betraying the GPs trust in me? The 20 cap still exists and now another pharmacist also must be paid from the HMR fee. In these areas it is not just about the medication, it is a more holistic service than that.
    There was talk of giving better access to aboriginal patients. How can this happen when majority of this population at greatest need is not in an urban environment. Sure, government sees figures for city aboriginal health services, but what about those further west?

    I have lobbied, written letters and told my story here and elsewhere numerous times as well… and I know there are a few others like Karalyn & I. What is the answer? Better funding to support us? She & I cannot continue forever, but will do so as long as we are able. What happens after that?
    Living in a rural area, it is very easy to see that no government values their constituency beyond the Great Dividing Range and the further you live from that coastal fringe, the less is the care factor.

    It still makes me angry that those few unscrupulous pharmacists who rorted the HMR funding causing the enforcement of caps got away without consequence (financial or registration), without being named & shamed, tarring us all with their dishonest brush, but effectively preventing access for so many patients who desperately need HMRs.

    I always have too many referrals in my diary for the month and yes, many go out of date before action. Even more so for the remote areas as it is not viable to travel 400km to do 1-2 HMRs and nor is it safe to be travelling that in a day. We do the best we can with what we have and sadly the profession and government does not support as much as is required.

    My 20c worth 🙂 sorry, got me going again…

  2. Debbie Rigby
    22/01/2020

    Equity of access to health services is a fundamental right for Australians and is Government policy.

    I do not accept that the caps on HMRs should continue. Caps are a blunt instrument to restrict access and contain the funding pool. The recently announced auditing of HMRs claims is a positive step to assure compliance with program rules. Karalyn highlights the challenges of the caps in delivering high quality HMRs in a timely manner, especially in rural and remote areas.

    HMRs are supported by good quality evidence forimproved patient outcomes, reduced hospital admissions and enabling medication reconciliation. After nearly 20 years of implementation the barriers, enablers and evaluation are well described. The caps were implemented as an interim measure due to small numbers of over-servicing and limited funding pool.

    Ongoing negotiations for the 7CPA provide an opportunity for reflection on the value of HMRs to the funder and to patients and the health system. Refinement of the program rules can still occur. Targeting of high risk medicines has been suggested many times through numerous expensive evaluations. And yet no action has been taken to date. Other changes to the program rules have also been recommended in evaluations. And yet no action has been taken to date.

    Rural health services require exceptional rules for pragmatic implementation. Good models like Karalyn has evolved and described in this article highlight the need for modifications and enhancements to program rules to suit the needs of the rural population.

    Appropriate funding should be allocated in the next agreement.

    • Debbie Rigby
      22/01/2020

      #nomorecaps

      • David Cannalonga
        22/01/2020

        7CPA Negotiators, HMR’s are one of the most effective tools available in Australia to improve medication management and quality use of medicines. Reducing caps, extending referral life, increasing travel allowance are the only ways to see the true benefit of this service, period.

        • Debbie Rigby
          25/01/2020

          Eliminating or increasing caps to reflect quality capacity is the key. I don’t agree with extending the referral life – timeliness is important.
          Realistic travel allowance or 50% loading for rural HMRs is also important to assure equity of access

          • Big Pharma
            25/01/2020

            I also agree with not extending referral life. The only reason referrals are expiring is because of the cap. If you have a cap, referrals will expire, especially in rural areas. Prior to the cap my turnaround time was 7 days (most within 48 hours). Now I have a 3 month++ wait list. Those marked with extreme urgency still wait 2-4 weeks depending on the time of month referred…..and that is with me taking the time and effort to triage and reschedule patients to slot them in.

            The greatest benefit for a patient discharging from hospital is within a week of discharge. Visiting a high risk patient 3 months plus after discharge just seems absurd. Quite often they are frequent flyers and back in hospital within 3 months. Sadly, this is the current landscape of clinical pharmacy work in the community.

          • Jarrod McMaugh
            25/01/2020

            Extending the cap is useful for clients – for some people with complex conditions or who have impending surgery, they quite often want to wait. The GP isn’t always willing to re-issue the referral.

            Audits are a good sign that caps may be addressed… but it won’t happen within the 6CPA

  3. Vian
    22/01/2020

    Well said Karalyn.
    20 HMR per month and 90 days Referral expiry should be reviewed

    • Debbie Rigby
      25/01/2020

      If caps were eliminated or increased to 20 per week, then referral life would not be an issue. I actually think HMRs should be conducted within 30 days.

      • Karalyn Huxhagen
        27/01/2020

        I totally agree that referrals should be actioned ASAP.the GP has identified an issue and wants assistance before they next see the patient. Waiting causes the patient to lose faith in the GPs ability to help and support them.
        The cap continues with no basis in place while open faced rorting of programs such as CLinical interventions continues. The ability to control the very few bad boys in Medication review was an easy audit task. We are using a very blunt instrument with the caps. the reality is that it is causing more Division between us and GP colleagues

        • Big Pharma
          29/01/2020

          Is it all CPA programs getting audited or just HMRs? Surely all programs are receiving the same audits. The “clinical intervention” program sets some of the most vague guidelines for claiming I’ve ever seen. I’d be surprised if >10% of “clinical interventions” claimed weren’t absolute garbage. The dilution of clinical interventions with such rubbish submissions also diminishes the value of any true intervention performed. Payments for interventions need to be significantly staggered to reflect their degree of importance and time involved in resolution. Selling a probiotic for a 3 day course of trimethoprim under the guise of “undertreatment” is deemed the same as identifying a patient presenting with antidepressant discontinuation syndrome, phoning the GP, booking an urgent appointment, counselling the patient on the importance of not just stopping 200mg of desvenlafaxine etc etc .

          What exactly are they auditing with HMRs? GP sends a referral, the service is completed, a report is sent to the GP, communication occurs to implement changes…..? I am unsure what they are looking for? Do they want a copy of the report….the referral…the changes…the letter of thanks….the PBS savings?

          I’m all for auditing. Hopefully this will result in cap removal. However, anyone that was rorting the program is surely long gone. The program is capped. What possibly can people be doing fraudulently?

          • Jarrod McMaugh
            30/01/2020

            Every program is being audited

      • Angelica Rostov
        29/01/2020

        Absolutely agree. Cap should be removed, not a referral life increased. We should attend patients ASAP, this would be the most beneficial service.

  4. Red Pill
    22/01/2020

    How about using technology to overcome the need to travel the vast distances. Maybe the government can provide funding for video conferecing equipment that can be stationed in rural and remote medical centres and the HMR pharmacist can simply schedule a time to do it via skype etc
    I believe some medical centres already have this equipment that allows them to access a cardiologist in metropolitan areas when there’s an emergency

    • Jarrod McMaugh
      22/01/2020

      Agreed, but consider that many people who would most benefit from an HMR may not have access to these facilities.

      Where they do, it should be funded… with consideration about the benefits to an HMR report that come from being present in the person’s home.

    • Karalyn Huxhagen
      22/01/2020

      Red Pill I would welcome skype and telehealth for follow up but right now, in this lifetime, pharmacists are one of the FEW providers who cannot be paid for a service if they use any form of telehealth etc. I love the model of people such as Dr Claire Barrett who runs succesful rural clinics. She sees each patient in teh flesh for initial review then skype after that. We have skype set up in many pharmacies in rural Qld for every other HP to use except us cos we are not paid if we use technology-go figure the vagrancies of the system!

      • Red Pill
        22/01/2020

        Oh right! So we should be pushing for tele-HMRs if patients are living remote areas. Who is representing accredited pharmacists at the 7CPA?

        • Karalyn Huxhagen
          22/01/2020

          That is the big question. Who is fighting for this section of the phcy family. I know PSA is but are there any practicing accredited pharmacists on the Guild team? I do not who is on each team

          • Big Pharma
            23/01/2020

            Nobody. Otherwise a cap would have never occurred in the first place. Blind Freddy could have resolved the situation without a cap. We are on our own. SHPA is the only real advocate for clinical pharmacy and they are not involved in CPAs. PSA is weak as water. Unless the PGA approves it, which they won’t as they need more $$ for their members, no change will be made.

            HMRs/RMMRs should have nothing to do with a CPA.

          • Red Pill
            23/01/2020

            I’m curious to see what the Guild will pull out of their hat this time around.

          • Big Pharma
            23/01/2020

            A large novelty cheque to all political parties. This is the only way to influence funding direction. Public health, patients lives, clinical evidence, common sense….all come second to the almighty dollar.

            The façade that the PGA is representative of the entire profession is amusing. This is what the laymen and the politician believes.

            I remember a prominent clinical pharmacist trying to set up an organisation for accredited pharmacists so they would be actually represented at these negotiations….so they weren’t smashed every 5 years. Unfortunately, very few people worked in these roles fulltime. In the PGA’s own media release in 2014 they stated only 97 accredited pharmacists would be impacted by the cap (only 97 pharmacists across the entire country were performing >20 HMRs/month). I’m still yet to see any figures from HMR “rorts”. It would seem an audit of the 97 full-time/part-time pharmacists would be pretty simple. The PGA remains the only organisation who has had access to these “rort” numbers.

  5. Big Pharma
    26/01/2020

    Spot on Karalyn!

    I feel your pain! I serviced the Kimberley region in WA for 5+ years until total funding abandonment in 2014. I remember the time of GP Networks and how eager they were to implement HMR services. It was a no brainer. Rural isolated high risk patients to have a medication assessment in the home. The GP Networks actually paid for flights, accommodation and car hire, out of their own funding pool, as it was clearly an exceptional return on investment. The reduction in polypharmacy and PBS expenditure alone would pay for this outlay >10 times over.

    Then came a time when the GP Networks disappeared and that funding was unavailable. I agreed to continue the service out of my pocket 3-4 times a year as I was aware of the extreme need for this service. I expanded my role beyond the local medical centre to include BRAMS (visiting high risk Indigenous patients). It would take at least 10 HMRs per visit just to break even once you include costs of accommodation, flights, fuel, car hire etc. Despite this, I continued to take the 3000km round trip (not including ground travel upon arrival) just to maintain the relationships I took so long to build.

    How many times have you tried to explain the cap to a GP? The explanation itself is ludicrous. Like saying some are rorting item numbers so we’ll delete them altogether….the equivalent of a GP being able to see 2 patients a day. Makes sense doesn’t it? People rort things in every essence of life. A solution is not to remove a program but audit those with insanely high claim numbers. From my understanding this was very few people and an audit could have been done with little time and cost. Unfortunately this is what happens when Accredited Pharmacists have no representation. I’m still waiting for an AACP position statement regarding rural HMRs and caps.

    “Sharing the load” also makes no sense as it is you that has gained the trust of the GP and built the rapport. I can not guarantee another Accredited Pharmacists work. Nor am I aware of their experience or clinical exposure. In fact I have had GP colleagues vent to me about the poor quality reports they have received and some have stopped referring as a result. As you mention no one wants to travel to these regions. It is both time consuming and expensive. You have to really want to make a difference. Rural HMRs are pretty much now a volunteer service.

    Sad to say all HMR services in this area have been discontinued since the cap. A region with a population of ~15,000 left with nothing. Pretty disappointing really when you consider the cost involved just to transport a patient to the city when a tertiary hospital is not readily available.

    I have documentation of many many many interventions. I have letters of thanks from both patients and GPs when a life is potentially saved. I have documentation of support from medical centres who were desperate to retain these services when the caps were announced. I have documentation of hospital admissions as a result of medication misadventure due to a patient HMR being delayed due to the caps.

    I too find it interesting that those rorting the programs have got off without punishment. One well known banner group bragged about the number of “medscheks” done in a week and to not take the foot off the “medschek” accelerator in their in-house newsletter. Reports of people doing “medscheks” when patients handed in a script for Augmentin with no other medical history were frequent. The mind boggles. Just the other day during a HMR the patient pulled out 6 GTN sprays and said “my use of this is seldom, my old one expired so I went to replace it and the pharmacy insisted I take all 6, can you discard them” (yes indeed she had reached the safety net). 2 weeks later the same thing, trying to reconcile medication for a patient who presented to hospital and it was apparent clopidogrel was getting dispensed (and not supplied), due to the patient reaching the safety net, despite therapy ceasing 6 months earlier. Should we limit dispensing to 2 scripts per pharmacy per day? Of course not.

    Anyway I digress….HMRs should be uncapped. Pure common sense applied which has been absent over the past 5 years. Patients should have access to a preferred provider in a timely fashion. Rural patients should be no different. Currently this specialised area of pharmacy is a hobby at best. Hilariously, the program is looking to expand to include hospital medicos and specialists to the list of those that can prescribe..which demonstrates the value of a HMR and is needed…yet no one will be able to do them.

    #nomorecaps

  6. Big Pharma
    23/01/2020

    Spot on Karalyn!

    I feel your pain! I serviced the Kimberley region in WA for 5+ years until total funding abandonment in 2014. I remember the time of GP Networks and how eager they were to implement HMR services. It was a no brainer. Rural isolated high risk patients to have a medication assessment in the home. The GP Networks actually paid for flights, accommodation and car hire, out of their own funding pool, as it was clearly an exceptional return on investment. The reduction in polypharmacy and PBS expenditure alone would pay for this outlay >10 times over.

    Then came a time when the GP Networks disappeared and that funding was unavailable. I agreed to continue the service out of my pocket 3-4 times a year as I was aware of the extreme need for this service. I expanded my role beyond the local medical centre to include BRAMS (visiting high risk Indigenous patients). It would take at least 10 HMRs per visit just to break even once you include costs of accommodation, flights, fuel, car hire etc. Despite this, I continued to take the 3000km round trip (not including ground travel upon arrival) just to maintain the relationships I took so long to build.

    How many times have you tried to explain the cap to a GP? The explanation itself is ludicrous. Like saying some are rorting item numbers so we’ll delete them altogether….a GP can now see 2 patients a day. Makes sense doesn’t it? People rort things in every essence of life. A solution is not to remove a program but audit those with insanely high claim numbers. From my understanding this was very few people and an audit could have been done with little time and cost. Unfortunately this is what happens when Accredited Pharmacists have no representation. I’m still waiting for an AACP position statement of rural HMRs and caps.

    “Sharing the load” also makes no sense as it is you that has gained the trust of the GP and built the rapport. “Sharing the load”when I am indeed available, just capped, is ridiculous. I cannot guarantee another Accredited Pharmacists work. Nor am I aware of their experience or clinical exposure. In fact I have had GP colleagues vent about the quality of some of the reports. As you say no one wants to travel to these regions. It is both time consuming and expensive. You have to really want to make a difference. Rural HMRs are pretty much now a volunteer service.

    Sad to say all HMR services to this area have been discontinued. A region with a population of ~15,000 left with nothing. Pretty disappointing really when you consider the cost involved when a tertiary hospital is not readily available.

    I have documentation of many many many significant interventions. I have letters of thanks from both patients and GPs when a life is potentially saved. I have documentation of support from medical centres who were desperate to retain these services when the caps were announced. I have documentation of hospital admissions as a result of medication misadventure due to a patient review being delayed due to the caps. Where do I send these? Any ideas? No one cares.

    #no more caps

  7. Angelica Rostov
    26/01/2020

    Well written, Karalyn. I am an accredited pharmacist for 12 years. In my first few years I did a lot of “leg job”- walking around GP practices, pharmacies, introducing myself and explaining about HMR serivice. I moved a few doctor’s mentality from “I hate an accredited pharmacist, to “I love an accredited pharmacists and HMR is a great program”. After starting my job I was receiving phone calls from practice managers and doctors just to say “thank you for your job. A patient was so happy after your visit, he/she learned a lot. And your report is very valuable”. Now we have to “share a job”. Why? Salaries at the retail pharmacies and hospital pharmacies would be very different for inexperience (or grade 1 in a hospital system) pharmacist to experience (grade 2-3 pharmacist). Why in accredited world we have all be the same? Why after may years of providing good service I have to give my job to someone else so he/she would earn the same money? And to be honest I did share a job, as I could not cope with 20 HMRs per months. I did it until I have received a few phone calls from different doctors who were not happy with the job. Plus patients complains. I been told not to share my job. If referral was done for me it means I have to do it, full stop. Not my rules, the doctors were unhappy. I feel that accredited pharmacists are the only discriminated medical professional in Australia. If I am a good physiotherapist, or psychologist, or DE, ets- I would have more clients that someone across the road only because I provide a better service. It calls competition. This is when a person always tries to improve himself/herself to provide a better business to build a reputation. We had a news that from January this year a government gives more money for HMR business. And what we heard: the referrals could be written by specialists as well- grate, it means more referrals, when most of us are already sitting on a files of referrals. It would be a follow up for HMR service- grate. But nothing about a cap. May be instead of inventing a bicycle someone needs to thinks about the cap (or at least increas the cap limit to a reasonable number). When it was introduced we have been told that it is just for a short period of time due to money issue. It is 6 years now since the caps was introduced. May be after so many trials regarding value of HMR services for patients it should be removed. Plus we can safe a lot of taxpayers money if we would be able to attend a patient ASAP, not after three months of the referral was written due to our limits to provide the HMR. By that time patient could spend a lot of time at the hospital due to medications issue. And a bed/day in hospital cost much more that a single HMR.

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