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.
- 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.
- Easton K, Morgan T, Williamson M. Medication safety in the community: A review of the literature. Sydney: June 2009.
- 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.
- 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.
- 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.
- 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.