MBS funding for pharmacists’ professional services: Is it time?


pharmacist with patient

Should there be MBS funding for professional pharmacist services? asks Manya Angley

An estimated 2% to 3% of Australian hospital admissions are medication related, representing 230,000 medication related hospital admissions per year, with associated costs of $1.2 billion. (1)

In addition, approximately 5.6% of general hospital admissions and 30.4% of hospital admissions in patients 75 years and older in Australia are related to adverse drug events (ADEs) and approximately 50% of ADE-related admissions (ADE-RAs) have been identified as potentially preventable. (2)

Further, another study found that 10.4% of General Practitioner encounters involved patients reporting an ADE. (3)

Pharmacist led medication reviews represent a key opportunity to improve medication management  and quality of life for Australians who are vulnerable to medication misadventure as well as reduce medication-related costs to the health care system.

At the moment, Home Medicines Reviews are the only mechanism whereby an accredited pharmacist’s medication management services for community dwelling patients can be remunerated. MedsChecks or Diabetes Medschecks are available for patients through their usual community pharmacy but they do not need to be undertaken by accredited pharmacists and they are not collaborative with the patient’s GP.

Like HMRs, MedsChecks are funded via the Sixth Community Pharmacy Agreement. In contrast to most other registered health professionals, there is no Medical Benefits Schedule item number for any pharmacist service.

For the past four years I have been working in a large, metropolitan Adelaide general practice that has 19 GPs, some medical specialists and employs 17 nurses. Various allied healthcare professionals are associated with the practice, which prides itself on delivering a team approach to care.

Contributions from all members of the team are acknowledged and valued but overall care is GP led.

Together with two of the practice’s principals I have developed a successful model where I conduct collaborative HMRs for patients with full access to case notes.

GPs and patients are highly satisfied with the service. Development of our general practice pharmacist model is described elsewhere. (4)

The HMR service includes a home visit lasting approximately one hour. A written report to the GP is generated and if the patient chooses, it is forwarded to their regular community pharmacy.

When the caps were introduced by the Pharmacy Guild on March 1 2014, accredited pharmacists were limited to providing 20 HMRs per month and a patient can only receive a HMR service once every two years. Therefore, I can only provide the ‘tip of the iceberg’ of patients at our practice with a HMR service.

In general GPs are receptive to the notion of pharmacists being integrated in to general practice. United General Practice Australia, which represents Australia’s peak GP bodies, made a media release in December 2015 endorsing pharmacists being further integrated into GP-coordinated primary care services. (5)

Further, the Australian Medical Association made a submission for the 2016-2017 Federal budget for a practice incentive for pharmacists in general practice. (6)

The Government subsequently announced a proposed redesign of the Practice Incentives Program (PIP) which will provide increased flexibility for general practice through Quality Improvement Incentive payments which may involve implementation of new arrangements in May 2017 that will possibly support a model for pharmacists in general practice.

Or is this yet another strategy by the Government for delaying addressing this important gap in patient care?

A potential risk to our profession is that if a practice incentive ever eventuates we will compromise our professional autonomy. Another risk is that it will perpetuate the divide between so called ‘dispensing’ and ‘non-dispensing’ pharmacists, fuelling the building disharmony between different arms of our profession.

Is it time for the pharmacy organisations to unite and prepare a submission for a MBS item number to deliver medication management services? Is it time for pharmacists to have parity with allied health professionals?

There is no doubt that the Pharmacy Guild-driven Residential Medication Management Review (RMMR) and HMR programs that were introduced in 1997 and 2001 respectively, were highly innovative and have led to many positive outcomes.

However, in the words of the great Bob Dyan, the times they are a-changin’; the health care system has changed and our profession needs to evolve with it.

My experience has revealed that although there are clear benefits associated with home visits by an accredited pharmacist and provision of a full written report, not all patients need or are willing to participate in the comprehensive home-based service.

Is the answer blowin’ in the wind? Is it time for appropriately credentialed pharmacists to be remunerated to deliver cognitive services from a range of settings including: patients’ homes, hospital outreach, general practice, medical home, community pharmacy, private rooms, aged care facilities or aboriginal health services?

Surely it is about the service and not the location. Collaboration is another key factor and the patient’s GP must be integral to the entire process and the pharmacist should have access to the patient’s health record.

One option could be to apply for two item numbers; one for a long consultation and another for a short consultation. The long consultation would be along the lines of a HMR or RMMR; a comprehensive medicines review, in a location of the patient’s choice with a comprehensive written report forwarded to the GP.

A short consultation could focus on a specific medication-related issue including:

  • medication reconciliation for patients going to hospital for an elective admission and/or on discharge;
  • patients suspected of non-adherence;
  • patients identified as likely needing a dosage administration aid (DAA);
  • follow up after a long consult (HMR or RMMR equivalent);
  • device use;
  • falls risk analysis;
  • suspected adverse effect;
  • adverse effect monitoring for toxic medicines; and
  • smoking cessation.

 

The service could be adapted according to the setting where it is delivered. For example in a general practice a short consult would lead to a brief written report documented directly in the patient’s case notes, provision of a reconciled medication list and the option of an on-site conversation between the GP, patient and/or accredited pharmacist if deemed necessary regarding the patient’s medication management.

Regardless of whether pharmacists work in a hospital or primary care setting, and whether we are business owners or salaried, our common goal is supporting our patients to achieve best health outcomes.

Disunity within a profession is never helpful and impedes us reaching this goal. MBS item numbers for pharmacist services delivered from a range of settings is something our professional bodies should unite and strive for.

 

References:

  1. Roughhead L, Semple S, Rosenfeld E. Literature Review: Medication Safety in Australia Australian Commission on Safety and Quality in Health Care, Sydney.; 2013 [cited 2016 January 20]. Available from: http://www.safetyandquality.gov.au/wp-content/uploads/2013/08/Literature-Review-Medication-Safety-in-Australia-2013.pdf.
  2. Easton K, Morgan T, Williamson M. Medication safety in the community: A review of the literature. Sydney: June 2009.
  3. Miller GC, Britt HC, Valenti L. Adverse drug events in general practice patients in Australia. The Medical journal of Australia. 2006;184(7):321-4.
  4. Angley M, Kellie A, Barrow G. Integration of a consultant pharmacist into a general practice: development of a collaborative care model. Journal of Pharmacy Practice and Research. 2015;45:81-5.
  5. United General Practice Australia. Collaboration of GPs and pharmacists will better support patient care 2015 [cited 2016 June 8]. Available from: http://www.acrrm.org.au/rsrc/cw/151204/UGPA%20Media%20release%20-%20Collaboration%20of%20GPs%20and%20pharmacists%20will%20better%20support%20patient%20care.pdf.
  6. Australian Medical Association (AMA). AMA’s pre-Budget Submission 2016-17: Health – the best investment that governments can make 2016 [cited 2016 February 11]. Available from: https://ama.com.au/sites/default/files/budget-submission/Budget_Submission_2016_2017.pdf.

 

Manya Angley is a pharmacist and the director of Manya Angley Research & Consulting.

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9 Comments

  1. Jenny Gowan
    15/06/2016

    Some very valid points Manya. How to progress this – is the question? Prior to the caps and regulation changes I saw a number of challenging patients in the clinic where I work, and gained some valuable insights to assist with medication management issues. I work in a lower socio-economic area with many drug, alcohol and mental health issues, as well as the need for interpreters.

  2. Kevin Hayward
    15/06/2016

    I can see nothing to suggest that either potential governments would change the current status quo with regard to HMR. I believe that until we can prove beyond doubt that HMR is a costing reduction model nothing will change.

  3. Manya Angley
    15/06/2016

    Agree Jenny, those scenarios are ideal for pharmacist-patient
    encounters that are outside the home, especially when pharmacists have full
    access to case notes and are truly collaborative with GPs.

    Others have highlighted potential issues with MBS funding. The
    MBS can be restrictive and the Medicare freeze on GP rebates until June 2020 is
    a concern ……but I would argue not as brutal as the HMR caps. PHN funding is
    another option but sustainability is a concern. Private insurers and user pays
    are other options but equity of access is a key issue.

    Kevin, I think it is time to move on from the HMR/RMMR model
    which has had its day. I agree that before embarking on a full roll-out, trials
    and an economic analysis should be undertaken but with the end goal of
    obtaining MBS rebates for services delivered by appropriately credentialed
    pharmacists with the following features: accessible, patient centred, flexible
    location, collaborative with GPs, access to case notes, sustainable ….and with every measure taken to ensure it is ‘rort proof’.
    If our profession wants to embed itself in team care, a concerted effort needs to be made by our professional organisations to revise the game plan.

    • Kevin Hayward
      15/06/2016

      I agree the HMR/RMMR model does not meet a targeted need either in terms of cost or quality, nor does it promote collaborative service provision and enhance seamless care. But I doubt that change in the model will come from the current professional or political leadership.

  4. Angus Thompson
    15/06/2016

    Some great points here. Whilst aspects of the current system are good, the caps and location rules are not serving the needs of the most needy well; and moving outside of a funding system as part of the CPAs should be our objective.

    Whilst I agree that showing our activity is cost-effective is highly desirable and probably fundamental to getting a more sustainable funding model, it is somewhat irking that this card keeps being played. How many existing MBS items are associated with an activity that has been shown to be cost effective? Drawing a more direct parallel, is a GP referral to a medical ‘specialist’ cost effective for our health system?

    Jenny makes another good point regarding interpreters, this is an area where once again, current arrangements are a hindrance to independent pharmacists delivering services to a very needy sector of the population.

    This whole debate needs to gain momentum and move outside the domain of being ‘pharmacy-centric’ which sadly remains the focus all too often

  5. Manya Angley
    16/06/2016

    I may be overly optimistic Kevin but if our professional organisations can ignore the distraction of intra-professional politics and politicians can look beyond short term cost cutting we could rally the momentum that Angus highlights is needed to progress this debate. GPs and consumers are key partners. UGPA and CHF have already indicated they endorse pharmacists being further integrated into GP-coordinated primary care services. However, GPs are understandably currently preoccupied with their Medicare rebate freeze until 2020 so we need to be mindful that GPs may be less receptive to MBS $$ funding primary care pharmacists.

    Should sustainable funding via MBS for cognitive services in primary care be the long term goal of the Pharmacy Trials Program? Our profession needs to unite in an effort to progress and adapt to best use our skills and meet the changing health needs of Australians or we’ll find ourselves “knockin’ on heaven’s door”.
    Doing nothing isn’t an option.

  6. Oscar Klass
    19/06/2016

    It was recently recommended by my wife to see an Optometrist for an ongoing eye issue. I’ve never visited an optometrist before; I have good vision and I don’t wear glasses, so I didn’t know what to expect.

    I visited a Laubman & Pank Optometrist in a busy suburban shopping centre. I was immediately greeted by a store assistant, and I explained my situation. She confirmed that it would be beneficial for the Optometrist to assess my eye, and we made an appointment for later that morning.

    I occupied myself in the shopping centre for 30 minutes, and returned for my appointment. I was greeted by the Optometrist and taken to a private consultation room. My eye issue, vision and general eye health was assessed. No major issues were identified, and a trial of lubricating eye drops was recommended.

    I was relieved to know that there are no immediate issue with my eye and surprised when the ‘cost’ of this interaction was covered by Medicare.

    Upon reflection, my interaction with this primary healthcare provider was VASTLY different to that of a member of the public seeking the help of a community pharmacist. There was no time pressure, there was adequate staff in the store, the consultation was private and electronically documented, the Optometrist was focused on my episode of care free from external distractions, there was no suggested selling of retail products, and the cost was covered by Medicare.

    Why doesn’t a similar system exist for consultation within the pharmacy profession? I believe a mechanism of renumeration, independent of retail community pharmacy and GP referral, is a step in the right direction.

    • Manya Angley
      21/06/2016

      Your experience certainly is in stark contrast to a consumer seeking help in a community pharmacy Oscar. In particular, the electronic documentation as community pharmacists don’t usually document details of encounters in pharmacy case notes which I think can compromise the care that community pharmacists can provide, especially when a community pharmacy employs multiple pharmacists. Why not? Moreover, the payment for the optometrist’s service was likely immediate rather than a delay of around 6 weeks post HMR. It is great that optometrists can offer a Medicare funded service for self-referred patients but I am not sure if optometrists routinely communicate with patients’ GPs. I think a model for pharmacists where the GP is ‘gatekeeper’ is needed as the primary care team co-ordinator. Speaking with my GP colleagues there are issues with optometrists referring to eye specialists as information exchange falls off with the GP. Documentation and communication are key to authentic team care.

  7. Chris Freeman
    21/06/2016

    Hi Manya,
    I support the concept for funding for pharmacists to perform services outside of the community pharmacy setting, I am not sure that the MBS is the best way forward.
    1. Ask most GPs how they think the MBS is working for them – my guess is that they are not happy. Even if you ignore the freezes that are in place the monetary value place on each MBS item number is small (relative to say specalist care).
    2. The MBS is a fee for service model which has a number of issues:

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