Anthony Tassone refutes recent claims around longer-length prescriptions, and looks at their drawbacks
A recent article in the Medical Journal of Australia, written by Dr Evan Ackermann, cannot go unchallenged for its disingenuous approach to patient care.
Under the suitably emotive headline of Exorbitant costs of routine medication repeats, Dr Ackermann seeks to build an argument that community pharmacies are somehow responsible for high medicine costs and that having longer length prescriptions would be some sort of panacea for everything that is wrong with the health system in this country.
Never mind that through PBS reform and the ongoing impacts of price disclosure that community pharmacy is forecast to have contributed $20 billion in savings over the government forward estimates by the end of the 6th Community Pharmacy Agreement, due to expire in June 2020.
Reading the article shows that Dr Ackermann has lost none of his skills of cherry picking the ‘facts’ to support his own tenuous arguments.
In this latest instance, one of the journal articles he cites as ‘evidence’ to support his argument, found that not only were longer length prescriptions associated with more medication waste per prescription, but that the “prescriber time costs accounted for the largest component of total unnecessary costs”.
In another of the cited journal articles attempting to argue that longer prescription durations has been found to improve patient adherence to prescribed medicine regimens; the following was included in the results section;
“The available evidence was found to be at a moderate to serious risk of bias. … No evidence of the direct impact of prescription length on health outcomes was found. The cost study could investigate prescriptions issued only; it could not assess patient adherence to those prescriptions.“
Biased evidence seems to suit a biased point of view.
Contrary to what Dr Ackermann would have us believe, his own choice of cited material reveals that where costs can be addressed, they are at the prescriber end of the chain.
Expecting patients to see their doctor more frequently when starting a new medicine, as Dr. Ackermann proposes—rather than collaborating with their local pharmacist and medicines expert—hardly makes for a sustainable health system given that the MBS continues to grow at a far quicker rate than other parts of the health system including the PBS, which is shrinking in real terms.
In addition, any change along the line suggested in the article would actually have attendant costs.
Manufacturers would be confronted with obvious costs in having to change over to larger packaging for the Australian market, even if they are already doing it for overseas markets.
Given other pressure they face such as the ongoing impacts of price disclosure and PBS reform, they may well question just how attractive Australia is as a market? Would striving for longer supply to the patient paradoxically threaten continuity of supply through the supply chain?
We also have to look at the big picture and who would pay for the added costs. All Dr Ackermann’s proposal seems aimed at is pushing more people into GP waiting rooms with eventual longer consultations.
Already the system is under stress with the Department of Health’s data on Medicare showing there are more GP attendances and more benefits being paid. The Department’s figures show that in in 2017-18, patients accessed almost 155 million GP services, at a cost in Medicare benefits of $7.8 billion.
This compares to 149 million services in 2016-17 at a cost of $7.5 billion in Medicare benefits. This is an increase of 4.9%1 in service volumes and an increase in benefits of 5.5% compared to 2016-17. Cleary we have to look at every viable option at managing this growth rate, rather than finding ways to further put pressure on the system.
Who will pick up the tab for the longer duration of each visit and how will we address the already serious problem of medicines affordability if we go down Dr Ackermann’s rabbit hole?
Aside from the economic flaws in this proposal, we also must look at the clinical aspects, and the evidence is overwhelming that having patients consult regularly with their pharmacist has positive benefits.
For instance, a PROMISe study, Evaluation of Clinical Interventions in Community Pharmacies, reported that 80% of the interventions were considered to be proactive, that is they were initiated by the pharmacist and were provided in addition to dispensing medication.
“The majority of clinical interventions were one of three categories: drug selection problems (22.7%), dosage problems (19.4%) or education or information problems (17.4%),” the study found. It should be noted that drug selection problems and dosage problems are errors in the prescribing process – something unlikely to be detected by review by the same practitioner
“Drug groups commonly associated with clinical interventions were antibiotics, drugs for diabetes, cardiovascular drugs and drugs for respiratory disorders.
“Almost one-third of the clinical interventions were classified as either of moderate or severe level of clinical significance by the recording pharmacist. In almost 90% of cases, the pharmacist investigated the drug-related problem by discussing the issue with the patient or the carer.”
The study conclusions found: “The current value of Australian community pharmacists’ interventions in both health and financial terms is high. However, there is considerable scope for increasing this impact; it is likely that both the existing rate and the financial value of pharmacists’ interventions could be increased three-fold.”
The Pharmacy Board of Australia is quite clear on this issue and its Guidelines for Dispensing of Medicines states: “Dispensing multiple quantities of particular medicines (whether or not directed by the prescriber) may not be consistent with the safety of the patient.
“When not directed by the prescriber, the simultaneous supply of multiple quantities of a particular medicine (i.e. the supply of multiple repeats at once) may be contrary to the Quality Use of Medicines principles outlined in the National Medicines Policy. It does not promote regular review of therapy and effective provision of medicine information by pharmacists, which may assist in minimising medication misadventure. It may also be contrary to state or territory legislation.”
The Board’s guideline states: “Dispensing multiple quantities of any prescription should only occur at the specific direction of the prescriber on each occasion, unless exceptional circumstances exist to the satisfaction of the pharmacist. An appropriate notation should be made to that effect on the prescription, in the dispensing record and where possible, in the patient’s health record. Examples of exceptional circumstances may include a patient going away for an extended period of time, or a patient who cannot easily attend the pharmacy because of disability and/or a mobility issue. State and territory legislation must be complied with.”
Notwithstanding all of the above, there is facility in special circumstances for the prescriber to provide for a larger quantity of medicine at one dispense if they feel it is appropriate for the patient. This is achieved by issuing a “Regulation 24” prescription under which the original plus all repeats other prescription are dispensed and issued together in as one dispensing event. In this case only one dispense fee paid by the Government to the pharmacy.
But are we overcomplicating the issue? Should we not instead be arguing for the cost benefit to our system arising from giving pharmacists broader continued dispensing or supply rights? We should be really taking the opportunity to expand the role of pharmacists for medication continuance as happens in other countries which will bring benefits to not only patients but the broader health system.
This is perhaps the more common-sense approach and one which will help contain costs, ensure improved patient health outcomes, and give GPs more time to concentrate on patients’ more complex issues.
Dr. Ackermann refers to experiences in Canada where “maintenance drugs for long term conditions are encouraged and already being dispensed in 100-day supply. There is no reason Australia cannot adopt a similar policy.” Also, in certain provinces of Canada, pharmacists practice to their full scope and have a significantly expanded role compared to pharmacists in Australia including; prescribing, wider vaccination rights, pathology testing and chronic disease management.
Perhaps there is more we can learn from the Canadian experience to help best utilise our health workforce and have a more cost effective health care system?
In my engagement with consumer organisations and my own experiences, I can’t say I have heard patients complain about the frequency they need to visit a pharmacy, the most accessible and convenient primary healthcare destination compared to having to pay a consultation fee for a prescription from a doctor.
It’s time for pragmatism in looking for solutions; not the peevish pharmacy put-downs which characterise so much of Dr Ackermann’s rhetoric.
Anthony Tassone is the president of the Pharmacy Guild’s Victorian Branch.