The looming question: who pays?


An Australian S8 first once again raises the question of MBS numbers for pharmacists, writes Angelo Pricolo

Patients are the real winners as Victorian pharmacists will become the first in Australia to administer Long Acting Injectable Buprenorphine (LAIB).

Importantly this will be the first non-vaccine product that pharmacists will administer in Australia and significant also in that LAIB is an S8 medicine.

But looming is the usual question. Every time pharmacists earn more responsibility we arrive at an impasse, who will pay for the service? Historically the answer, conveniently for the government, has been the patient.

It has served the government well to exclude pharmacists from a Medicare Benefits Schedule (MBS) number. It has in fact served the dual purpose of saving them money (that patients continue to pay) while reinforcing the uneven playing field with doctors.

What will the model look like if the government continues to exclude pharmacists from a Medicare Benefits Schedule (MBS) number? The same as the vaccine landscape where patients must pay, services cannot be bulk billed.

Both doctors and pharmacists receive some vaccines free of charge for administration to patients. Notwithstanding the percentage of patients choosing pharmacist administration is growing each year, only doctors get paid by the system. Patients find themselves out of pocket by selecting the pharmacist.

There are more examples. Absence from Work Certificates attract a fee at the pharmacy and effectively save the taxpayer a Medicare bulk billing. Handy.

Naloxone became an OTC medicine in 2016. But if it is purchased without a doctor’s prescription, it can cost $80 instead of $6 after the additional bulk billed visit. This extra step represents a barrier that still sees the under-prescribing of naloxone.

LAIB may become an important new drug to assist patients with Substance Use Disorder (SUD). Two brands are available as S100 drugs, Sublocade® and Buvidal®. They are both administered subcutaneously and can last depending on the formulation from one week to one month.

The long acting formulations will not suit all patients but already some very positive results have been seen. It is an exciting time in a field where changes do not come along very often. The accreditation process to administer consists of a six-minute training video.

Access to the treatment will always be a contributing factor to its success and patient choice will be limited if we rely on the already strained GP network. Pharmacist competency to administer has been demonstrated after going through various authorities.

Firstly there was advocacy at the state DHHS level to demonstrate there were not any regulatory barriers for pharmacists (providing it was on the written instruction of a prescriber).  Anthony Tassone and Stan Goma at the Guild Victoria Branch achieved much of this.

Then through the National Secretariat, we advocated to the Pharmacy Board that it could be considered within the scope of practice of pharmacists. Khin May spearheaded this in Canberra Guild office.

Following acknowledgement by the Pharmacy Board that provided there were no regulatory barriers at the state level, it could be considered within the scope of practice for pharmacists who had undertaken relevant training and deemed it within their own competency – we then advocated to PDL from an indemnity insurance perspective.

The advice from PDL is for Victoria to administer LAIB providing it is on a written instruction by a prescriber – which can be on a regular prescription that has directions as ‘To be administered by the pharmacist’.

This is very significant.  It is essentially support at a regulatory, professional practice board and indemnity level that pharmacists are able to administer a S8 substance and a medication that is not a vaccine.

Through our representations on expert advisory groups on Opioid Replacement Therapy (ORT)  – we know there are doctors who may not participate in the storage and administration of LAIB for their patients and may consider prescribing it for a pharmacist to administer.

From here, the Victorian Guild Branch has reached out to the PSA (Vic) to collaborate on some guidance for our members on its administration. This will not be extensive and we envisage it will involve the same GP six minute video.

But the model that is most likely will mean that doctors and practice nurses will be the only health professionals that can claim a MBS item number for the administration of LAIB. Pharmacists will either be forced to administer it for free or charge the patient.

Fragmentation of care, often used as a catch cry, is really code for all health matters should be funneled through GPs. Health is fragmented; everyone seeks advice and treatment from different sources. It is important to be involved in your own health and get varied opinions.

The two pivotal questions that need to be resolved are:

  1. When do we finally move towards a health system where the patient is at the centre?
  2. When will the system finally acknowledge pharmacists and assign them with MBS numbers for the services they provide?

We all hope that our scientists develop a vaccine for COVID-19. Positively thinking, when this becomes available I know pharmacists will be enthusiastically encouraged to administer doses to as many people as possible.

I sincerely hope we can do this and be fairly remunerated by an equitable health system.

Angelo Pricolo is an addiction medicine pharmacist and former National Councillor of the Pharmacy Guild of Australia.

 

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